Health Care Coverage for Texas Children
(January 2012)
Health care coverage helps make it possible for your child to receive the checkups, shots, and medicine he or she needs to stay healthy and active.
There are several ways you can buy health care coverage for your child. Many parents add their children to their group health plan at work or through an association. If this isn’t an option for you or is too expensive, consider these other ways to insure your child:
- private health care coverage from an insurance company or health maintenance organization (HMO)
- coverage through Children’s Medicaid
- coverage through the Children’s Health Insurance Program (CHIP)
- coverage through the Texas Health Insurance Pool.
Also visit TexasHealthOptions.com to learn more about health coverage and the options available for your children. TexasHealthOptions.com is a comprehensive online resource for health care coverage information and is a free service of the Texas Department of Insurance (TDI).
Private Health Care Coverage
If you’re unable to get insurance through your employer or another group, you may be able to add your child as a dependent on your individual health plan or buy a child-only policy.
Individual policies may be either indemnity or managed care plans. Insurance companies and HMOs sell managed care plans, but only insurance companies sell indemnity plans. Typically, managed care plans are more affordable than indemnity plans. However, indemnity plans give members more flexibility when choosing doctors or getting care. The trade off is essentially choice versus cost.
For lists of HMOs and insurers writing individual health policies in Texas, call the TDI Consumer Help Line or visit our website
1-800-252-3439
463-6515 in Austin
www.tdi.texas.gov
Indemnity Plans
Indemnity plans – also called fee-for-service plans – allow you to take your child to see the doctor of your choice. Typically you pay for the service out of pocket and then you complete reimbursement forms. You must pay a deductible each year before the insurance company will reimburse you. Once you meet the deductible, indemnity plans pay a percentage of the charge for the covered service.
The indemnity plan generally pays 80 percent of costs and you pay 20 percent. In Texas, health plans must pay at least 50 percent of the costs. This cost-sharing is called coinsurance. As with deductibles, the higher the amount you pay in coinsurance, the lower your premium will be.
If the doctor or hospital charges more, you will be responsible for the coinsurance amount and the excess charges. For example, if the fee for a doctor’s visit is $100, the indemnity plan will pay $80 and you will pay $20. However, if your doctor charges $125, the indemnity plan will still pay $80 and you will be responsible for $45.
Managed Care Plans
Managed care plans require you to use the plans’ networks of doctors and hospitals. You generally have less paperwork and lower out-of-pocket costs in a managed care plan, but your choice of doctors is limited. There are two types of managed care plans in Texas: preferred provider organizations (PPOs) and health maintenance organizations (HMOs).
PPOs
You can take your child to any doctor or provider you choose – even if the doctor or provider isn’t in the PPO’s network – but your out-of-pocket costs will be lower if you use network providers.
PPOs typically require you to pay a monthly premium, coinsurance, and a copayment each time you receive medical care.
HMOs
HMOs normally require you to use doctors and hospitals in their networks. You must select a primary care physician to oversee your child’s health care. If you want to go to a specialist or another doctor, your PCP must give you a referral before you go.
HMOs usually don’t pay for services your child gets outside the network, except in medical emergencies or in certain other situations. You will most likely have to pay the full amount of the bill.
With an HMO, you will pay a monthly premium and a copayment each time you or your child goes to the doctor or receives medical care. Generally you will not be responsible for a deductible. An in-network doctor or hospital cannot charge you any balance after your copayment is met.
Federal Health Reform
The Patient Protection and Affordable Care Act – the federal health care reform law – provides significant additional coverages and strengthens consumer protections beginning with health insurance policies issued or renewed after September 23, 2010. For more information and regular updates, visit TDI’s Federal Health Care Reform Resource Page at www.tdi.state.tx.us/consumer/cpmhealthcare.html.
Two provisions impacting health care coverage for children took effect September 23, 2010. The first allows children who can’t get health care coverage from their employers to stay on their parents' plans until age 26. The other provision prohibits insurers from denying coverage to a dependent child under age 19 because of preexisting conditions. The same will be true for adults and dependent children age 19 and older beginning in 2014.
Children’s Medicaid and CHIP
If you can’t afford private health care coverage, you may be able to get coverage through Children’s Medicaid or CHIP. Both programs provide health coverage to eligible children through age 18.
Both programs offer a lot of benefits that are often better than private health plan benefits. Benefits include:
- choice of doctors, regular checkups, and office visits
- prescription drugs and vaccines
- dentist visits, cleanings, and fillings
- eye exams and glasses
- hospital care and services
- mental health care
- treatment of special health needs
- medical supplies, X-rays, and lab tests.
To qualify for Children’s Medicaid or CHIP, a child must be
- a Texas resident
- a U.S. citizen or permanent resident (parents’ citizenship or immigration status does not affect a child’s eligibility and is not reported on the application form)
- under age 19
- living in a family that meets the income requirements.
For more information or to apply for Children’s Medicaid or CHIP, call the Texas Health and Human Services Commission (HHSC) or visit its website. You use the same application to apply for both programs.
1-877-KIDS-NOW (543-7669)
www.chipmedicaid.org
Children's Medicaid
Children’s Medicaid is a state and federal assistance program that provides free health care coverage for eligible low-income Texans. A family’s home and personal property are not included when determining assets, but all or part of the value of a vehicle may be included. Children’s Medicaid defines family as any adults – parents, grandparents, relatives, legal guardians, or adult siblings – who are living and caring for uninsured children.
HHSC determines Medicaid eligibility for most children. Children in families receiving Temporary Assistance for Needy Families (TANF) automatically qualify. HHSC usually reviews a family’s financial situation every six months to determine if participating children are still eligible.
CHIP
CHIP is a federal and state health coverage program for families who earn too much money to qualify for Medicaid but can’t afford private health care coverage. Private insurance companies and HMOs sell CHIP statewide.
Participating families usually pay a fee that covers all of the family’s children in the plan. The fee is based on income and is $50 or less per family every 12 months. Most families also have copayments ranging from $3 to $10 for doctor visits, prescription drugs, and emergency care.
There is a 90-day waiting period for children who were insured in the 90 days before applying for CHIP for the first time. There are several exceptions, including one for children who lost coverage because a parent was laid off, a parent’s plan no longer pays for dependents, or the parent’s marital status changed. After enrolling, families must renew CHIP coverage every year.
Note: CHIP also provides a CHIP perinatal program for Texas residents who are pregnant, uninsured, and not eligible for Medicaid. Coverage starts before the child is born and lasts for 12 months. Benefits include 20 prenatal visits; hospitalization that results in delivery; and regular checkups, vaccines, and prescriptions for the baby.
Texas Health Insurance Pool
The Health Pool is a last resort for Texans who can’t obtain health care coverage because of their preexisting medical conditions. Coverage through the Health Pool can be twice as expensive as plans in the standard market. To be eligible for Health Pool coverage, a child must be one of the following:
- rejected for similar individual coverage for health reasons
- diagnosed with a medical condition that automatically qualifies for Health Pool coverage
- unable to find similar individual coverage, except at rates higher than those charged by the Health Pool
- certified by an agent as unable to obtain similar private health care coverage from a licensed insurance company or HMO that the agent represents because of the child’s medical condition
- a dependent of an adult covered by the Health Pool.
Health Pool plan benefits are similar to benefits in private health care plans. Benefits cover hospital stays, physician services, and prescription drugs. The Health Pool also provides coverage for serious mental illness but does not cover treatment for chemical dependency or drug abuse.
For more information, call the Health Pool or visit its website
1-888-398-3927
www.txhealthpool.org
Other Options
Ask someone at your child’s school if the school offers an affordable health plan for its students. Schools may also be able to tell you about other ways to receive health care coverage, such as any partnerships with local health care providers to provide free or low-cost services.
If none of these options work for you and your family, you and your children may be eligible for indigent health care. For information on indigent care options in your county, contact your county courthouse.
For More Information or Assistance
For answers to general insurance questions or for information on filing an insurance-related complaint, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website
1-800-252-3439
463-6515 in Austin
www.tdi.texas.gov
For printed copies of consumer publications, call the 24-hour Publications Order Line
1-800-599-SHOP (7467)
305-7211 in Austin
Help us prevent insurance fraud. To report suspected fraud, call our toll-free Fraud Hot Line
1-888-327-8818
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hot Line
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.
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