Insurance for Texans with Disabilities
Fourteen percent of Texans have a mental or physical disability. A disability is a physical or mental impairment that limits a person’s ability to walk, breathe, hear, see, learn, work, or perform tasks.
In the past, people with disabilities often faced insurance denials, higher premiums, cancellations, and policy renewal refusals. But beginning in January 2014, federal law generally prohibits insurance companies from denying you health coverage or charging you more because of your health status, including a preexisting condition or disability.
When deciding what to charge you for comprehensive health insurance, carriers may consider only your age, where you live, whether you use tobacco products, and whether the coverage you are buying is for an individual or a family. They may not charge you more because you have a disability.
The Texas Insurance Code prohibits life, auto, and homeowners insurance companies from denying, refusing to renew, limiting, or charging more for coverage because of a disability, unless the company can show that the disability increases the chances that you’ll have a claim.
The federal Americans with Disabilities Act (ADA) provides additional protections. For more information, call the ADA Technical Assistance Center at 1-800-514-0301 or 1-800-514-0383 (TTY) or visit its website at www.ada.gov/taprog.htm.
If a company won’t sell you a policy, cancels, or refuses to renew your policy, ask why. Most auto and homeowners companies must give you their reasons in writing. The company must explain exactly what incident, circumstance, or risk factor they used to make the decision. The company must also give you its sources of information.
Life insurance companies that issue individual policies aren’t required to give a written explanation of their decision.
How to Get Help
If you think an insurance company has treated you unfairly or won’t answer your questions, you may file a complaint with the Texas Department of Insurance. For more information, call TDI’s Consumer Help Line at 1-800-252-3439 or 512-463-6515 in Austin or visit our website at www.tdi.texas.gov.
You can also file a complaint with the ADA Technical Assistance Center,
Note: If you receive health insurance through your employer, you must file your ADA complaint with the Texas Workforce Commission’s Civil Rights Division. For more information, contact the division at 1-888-452-4778 or 512-463-2642 in Austin or visit its website at www.twc.state.tx.us.
For concerns about the federal health care reform law or the health insurance marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Get Legal Advice
You may find inexpensive or free legal assistance through local or government programs in your area.
The Texas Legal Services Center is a nonprofit organization that has legal resources for Texans. Its TexasLawHelp.org website offers free information and helps people who can’t afford attorneys find free and low-cost legal aid. TLSC also operates the Legal Hotline for Texans at 1-800-622-2520 for people who are over age 60 or on Medicare.
Check the phone book or Internet or call local bar associations and legal referral services to find attorneys willing to help. Some attorneys may accept your case on a contingency basis, which means they will receive a percentage of any judgment you win.
Appeals and Independent Review
A managed care plan will only pay for treatments that are medically necessary. Your plan will review a treatment either before or after you receive it to determine medical necessity. You can get information about how to appeal a carrier’s decision, including how to get an independent review of the carrier’s decision in the Independent Review Organizations publication at www.tdi.texas.gov/pubs/consumer/cb057.html.
Health Care Coverage Options
Beginning in 2014, most people must have health insurance that meets minimum federal coverage standards or pay a tax penalty. Health benefit plans provided by your employer and most state or federal government health plans (Medicare, Medicaid, CHIP, TRICARE, and some veterans’ health programs) will usually satisfy the requirement. The IRS covers many tax penalty issues on its website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision.
If you don’t have access to employer- or government-sponsored health coverage, you can buy an individual plan to cover yourself, or yourself and your family. You can buy directly from companies or through insurance agents. You can also buy coverage through the federally operated online insurance marketplace at www.HealthCare.gov, or by calling the marketplace toll-free at 1-800-318-2596. You can only buy individual coverage during open enrollment periods, with some exceptions.
You might be able qualify for subsidies to help pay for your coverage and your out-of-pocket costs if your employer doesn’t offer affordable insurance and your income is between 100 percent and 400 percent of the federal poverty level. In 2013, this would mean a gross annual income between $11,490 and $45,960 for an individual, and between $23,550 and $94,200 for a family of four. Subsidies are only available when you buy a health plan through the marketplace.
If your income is less than 100 percent of the federal poverty level, you aren’t eligible for a subsidy. However, you won’t have to pay the tax penalty for not having insurance if you get a hardship exemption from the federal marketplace. (Non-citizens in the United States lawfully who are not eligible for Medicaid may still qualify for a subsidy, even if their income is below the poverty level.)
Medicare is a federal health insurance program for people 65 or older, some people under 65 with certain disabilities, and people with end-stage renal disease or Lou Gehrig’s disease. If you are on Medicare, it will pay for much – but not all – of your health care needs. Medicare eligibility is determined by the Social Security Administration.
Medicare benefits include:
- Medicare Part A hospital or inpatient care
- Medicare Part B medical services and supplies
- Medicare Part D prescription coverage.
For more information about Medicare eligibility requirements, call Medicare at 1-800-Medicare (1-800-633-4227) or visit the Medicare website at www.Medicare.gov.
Medicare Advantage Plans
Medicare Advantage plans are alternatives to original Medicare. If you join a Medicare Advantage plan, the plan will provide your Medicare parts A and B benefits, but you will still be in the Medicare program. Medicare Part D (prescription drug coverage) is only available through approved Medicare drug plans.
Medicare Advantage plans may include HMOs, preferred provider plans, Medicare special needs plans, and private fee-for-service plans. The special needs plans serve special populations, including people with Medicare and Medicaid, people living in some types of institutions, and people with chronic illnesses. To be eligible to join a Medicare Advantage plan, you must live in a plan’s service area, be enrolled in Medicare Part A and Part B and, in some plans, not have end-stage renal (kidney) disease.
For more information about Medicare health plan options, call Medicare.
Medicare Supplement Plans
You may buy Medicare supplement insurance to help pay some health care costs that Medicare doesn’t pay. Because it helps cover some of the “gaps” in Medicare coverage, Medicare supplement insurance is often called Medigap insurance.
The 10 Medicare supplement plans (plans A, B, C, D, F, G, K, L, M, and N) offer a different combination of benefits, but they all cover these benefits:
- Pays your daily copayments for hospitalization expenses from the 61st through the 90th day of the Medicare benefit period.
- Pays the Medicare Part A copayments for any hospital confinement beyond the 90th day in a benefit period, up to an additional 60 days during your lifetime. (These are your inpatient reserve days. You may use these days when you require more than 90 days in the hospital during a benefit period. When you use a reserve day, it is subtracted from your lifetime total and can’t be used again.)
- Pays the Medicare Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Hospice: Pays the copayment for outpatient drugs and the coinsurance for inpatient respite care. Plans K and L pay this cost at a different rate. You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
Medical expenses: Pays your portion of the 20 percent Part B coinsurance for Medicare-eligible expenses for medical services -- including doctor bills, hospital or home health care, and specified higher payments for certain services under the prospective payment system -- after you have met your Part B deductible. Plans K, L, and N require you to share in the payment of coinsurance.
Blood: Pays the reasonable cost of the first three pints of blood each year under Medicare parts A and B.
People under age 65 who receive Medicare because of a disability may buy a Medicare supplement policy during the six-month open enrollment period beginning the day they enroll in Medicare Part B. You may have a guaranteed issue right to buy a Medicare supplement policy outside of your open enrollment period if you lose certain types of health coverage.
You must have Medicare Part A and Part B to buy a Medicare supplement policy. Companies that sell Medicare supplement plans in Texas may not deny you a Plan A policy because you have preexisting conditions. Companies may offer the other plans to Texans with disabilities, but they are not required.
The wait time before a Medicare supplement policy will cover preexisting conditions may not be longer than six months, but may be shorter if you’ve had prior coverage.
For more information about Medicare supplement insurance, read TDI’s Medicare Supplement Handbook and Rate Guide.
Note: Medicaid, an employer group plan (including TRICARE for Life), or a Medicare Advantage plan might also cover the gaps in Medicare coverage.
Medicaid Buy-In Program for Employees with Disabilities
Medicaid, a health insurance program for low-income Texans, has a buy-in program for employed people of any age with disabilities. The program allows Texans with disabilities to keep their Medicaid benefits, even if they earn more than the traditional Medicaid income eligibility limits. To be eligible for the program, you can’t earn more than $2,328 per month.
People in the buy-in program pay monthly premiums based on income and other factors. They will receive the same services as other people with Medicaid, including office visits, hospital stays, X-rays, vision and hearing services, and prescriptions.
For information about Medicaid and eligibility, call the Texas Health and Human Services Commission’s Texas Medicaid Client Hotline at 1-800-252-8263 or visit its website at www.yourtexasbenefits.com/. You can also call 2-1-1 for information about free access to health and human services information in your community.
State and Federal Agencies for Texans with Disabilities
The following state and federal agencies may have information helpful to Texans with disabilities:
Federal health insurance marketplaces
The Office of Public Insurance Counsel (OPIC) advocates for consumers and represents them at rule hearings, legislative hearings, and court proceedings. OPIC also promotes policyholder interests and rights in matters concerning insurance rates and coverage. OPIC can’t represent individual consumers or resolve individual consumer complaints, but it can provide tools to help you understand insurance products.
322-4143 in Austin
Social Security’s Supplemental Security Income (provides basic needs assistance for certain people with little or no income)
Texas Department of Aging and Disability Services
Texas Department of Assistive & Rehabilitative Services, including Blind Services, Early Childhood Intervention Services, and Disability Determination Services
Texas Governor’s Committee on People with Disabilities
Texas Department of State Health Services
458-7111 in Austin
512-458-7708 (TDD in Austin)
Texas Health and Human Services Commission
2-1-1 is the national abbreviated dialing code for free access to health and human services information. The alternative number is 1-877-541-7905.
U.S. Department of Justice Americans with Disabilities Act
U.S. Equal Employment Opportunity Commission
U.S. Department of Veterans Affairs
For More Information or Assistance
For answers to general insurance questions, for information about filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line at 1-800-252-3439 or 512-463-6515 in Austin between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website at www.tdi.texas.gov.
For printed copies of consumer publications, call the 24-hour Publications Order Line at 1-800-599-SHOP (7467) or 512-305-7211 in Austin.
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hotline at 1-877-4FIRE45 (434-7345).
The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.
For more information contact: