Carriers often evaluate a policy applicant's health status and other risk factors when deciding whether to issue health coverage and what rate to charge. Therefore, people with disabilities or uninsurable medical conditions may have difficulty obtaining the coverage they need. However, the law places strict limits on how carriers may use information about a disability. Denying coverage or charging a higher rate based on an improper use of information may qualify as illegal discrimination. If you have a disability or a health condition, it is important to understand your rights so that you can protect yourself.
The following steps can help you obtain health care coverage if you have a disability or a serious medical condition:
- Know your rights
- If you're seriously disabled, apply for Social Security Disability Income, which can also qualify you for Medicare
- Seek coverage through your employer
- Locate other group coverage
- Determine whether you qualify for Medicaid
- Buy an individual policy from a private carrier
- Apply for coverage through the Texas Health Insurance Pool
- Find low-cost health services in your area
1. Know Your Rights
Texas law prohibits carriers from using a person's disability as the sole reason for declining or limiting coverage or charging more for coverage, unless the carrier can show evidence that the disability increases risk for a claim. However, if you have a disability that is likely to require future treatment, a carrier may refuse to cover you, limit your coverage, or charge you a higher rate for coverage.
If you believe your health or disability information has been used as a factor in a decision about your insurance coverage, ask the carrier for an explanation. If you believe the information has been used improperly, file a complaint with the Texas Department of Insurance. You also may have grounds for a civil rights complaint under the federal Americans with Disabilities Act.
Most policies have a "pre-existing condition waiting period" for new plan members. During this period, which can be as long as one year for group coverage and up to two years for individual coverage, you will not receive coverage for any specific health conditions for which you received advice, diagnosis, or treatment during the year prior to joining the plan. You will have full coverage for any new illnesses or injuries that you incur subsequent to joining the plan, however.
Any pre-existing condition rules must apply equally, and for an equal period of time, to all members of any group plan, regardless of any individual health conditions or disabilities. Individual health carriers may have a standard period for all policies, or may be willing to negotiate the terms of the period on a policy-by-policy basis.
2. If you're seriously disabled, apply for Social Security Disability Income, which can also qualify you for Medicare
Most people know Social Security as the federal program that pays benefits for most Americans upon their retirement. In addition, the Social Security Disability Income (SSDI) program pays replacement income for workers who become seriously disabled and are unable to work. SSDI eligibility standards are quite high, however. The program pays only for "total disability" - no payments are provided for partial or short-term disability.
If you become seriously disabled and are unable to work, you should apply for SSDI as soon as possible. SSDI provides lost income and does not pay for any medical costs. However, if you remain eligible to receive SSDI for 24 months, you will become automatically eligible for early enrollment in Medicare, the federal health insurance program. Typically, Medicare is only available to people without disabilities after reaching age 65. Medicare will cover most, but not all, of your health care costs.
Approval of an SSDI application typically takes several months. The 24-month waiting period before you become Medicare eligible begins on the date of approval. Therefore, it's important to apply for SSDI as soon as possible in order to avoid going without coverage any longer than necessary.
SSDI pays only for total disability. No benefits are payable for partial disability or for short-term disability. Medicare will likely cover most, but not all of your health care costs. However, during the first six months that you receive Medicare, you will also become automatically eligible for a Medicare Supplement insurance policy that can help make up the difference. For more information about these policies, refer to TDI's Medicare Supplement Insurance Handbook and Rate Guide.
In order to qualify for Medicare disability coverage, you must:
- Be unable to do work you did before or any "substantial work" because of your medical condition(s). In 2004, substantial work was defined as performing any job providing earnings of $810 or more per month. This amount may change each year.
- Be disabled by a condition that is expected to last for at least a year or result in death.
Furthermore, you must also have worked long enough, and recently enough, in jobs covered by Social Security to be eligible. Generally, this means you must have worked a total of 10 years in jobs where a Social Security contribution is deducted from your paycheck. However, younger workers who become disabled may qualify after working fewer years.
To qualify, you will have to submit an application to the Social Security Administration (SSA), which you may do either online, or at your local SSA office. You will than have to participate in an interview with a Social Security claims representative, which you may do either over the telephone or at your local SSA office, and submit medical records and other information needed to make a determination of your eligibility. The process typically takes 3 to 5 months.
To contact the Social Security Administration Disability Office:
The following resources can also assist you in obtaining SSDI:
- The online Office Locator can help you find the Social Security Office nearest you.
- SSA's "Adult Disability Start Kit" (PDF) provides the information on how to apply and will guide you through the process.
- The Social Security Disability Income application form can be completed and submitted online.
- Completing the SSA Adult Disability and Work History Report form in advance of your interview with an SSA claims representative can expedite your application.
- The SSA Work Schedule can help you determine whether you have worked a sufficient amount of time in Social Security covered jobs in order to qualify for disability income.
3. Seek coverage through your employer
If you're employed, your first step should be to determine whether your employer offers an employee group health plan, and if so, find out the details. If you're retired, find out whether you can obtain coverage through your employer's retirement plan. Group health coverage through an employer is typically the easiest to qualify for and is often the most affordable option.
Employers may place certain restrictions on plan membership, however by law these rules must be applied to all employees equally. A plan may therefore only be offered to employees who are above a certain pay grade, work within a particular division, or work a minimum number of hours per week. Arbitrary eligibility rules - such as only offering coverage at a manager's discretion- are never legal however. In addition, health risk factors, such as your current health status or medical history, may never be used as a requirement for plan membership. Therefore, an employee health plan may be a good option for coverage if you have a pre-existing condition. Be aware, however, that you may have to wait a certain period of time before pre-existing conditions are covered.
Employees are typically eligible to join a plan on their date of hire or the time they become members of the class of employees to which the plan is offered. However, if you do not join within 30 days of the time you first become eligible, you may have to wait until the next "open enrollment" period. Group plans have an open enrollment period each year which lasts for 30 days.
Employee health plans may be indemnity coverage, meaning you may use any health care provider you choose; managed care plans, meaning you usually must obtain services from within a particular "network" of providers; or preferred provider plans that combine various features of the two.
One drawback of joining an employer-sponsored plan is that you probably won't have a great deal of choice in deciding the terms of coverage. You typically must either accept a health plan or reject it, although some employers may offer you the choice of multiple plans at varying rates. The rules governing which coverages an employee health plan must include and which are optional can be complex. Whether your company is a large employer - defined as having more than 50 full-time workers - or a small employer, and whether a plan is managed care or indemnity will have a significant impact on the coverage available and the cost of the plan.
If employer-sponsored group coverage isn't an option, you may be able to find other group coverage. Trade unions, religious institutions, professional associations, and fraternal organizations sometimes offer health coverage as a membership benefit.
Group health plans offered by entities other than employers typically provide coverage that is narrower in scope. They typically cover fewer conditions and have higher deductibles than employer-sponsored plans. It is also less likely that a non-employer group sponsoring a plan will contribute to the cost of coverage. This means you'll have to pay the entire premium yourself. Non-employer group plans are usually more expensive than employer-sponsored plans, although they are still often less expensive than an individual policy, particularly if you have existing health problems.
Groups must make their health plans available on equal terms to all members. However, a plan might only be offered to members who have belonged for a certain period of time, achieved a certain rank within the group, or meet particular underwriting standards. Health risk factors may not be used to determine eligibility for plan membership. Therefore, group coverage may be a good option if you have a pre-existing health condition. Be aware, however, that you may have to wait a certain period of time before pre-existing conditions are covered.
Group members who do not join a plan within 30 days of the time they first become eligible may have to wait until the plan's annual 30-day open enrollment period in order to join.
Before joining a non-employer group plan, you should ask other participating members in the group about their experience with the coverage. Most plans are reputable, although fraud schemes have been known to operate under the pretense of offering coverage through a non-employer group. Such an operation will likely collect your premium but disappear if you have a claim.Back to Top
5. Determine whether you qualify for Medicaid
The Health and Human Services Commission (HHSC) determines Medicaid eligibility in Texas. People who receive Temporary Assistance for Needy Families (TANF), also commonly known as welfare, automatically qualify for Medicaid. Other people also may qualify based on their income and resources, including:
- Families that have high medical bills they can't pay
- Families and individuals that leave TANF for work or whose time limits have expired
- Low-income children under age 19 and pregnant women
- Youths aging out of foster care
Different eligibility requirements apply to each group. In order to find out if you qualify, you need contact your local HHSC Eligibility Office.
- Call 2-1-1, the national abbreviated dialing code for access to health and human services information, to reach a Health and Human Services representative who can determine whether you qualify for Medicaid.
- Go online to the State of Texas Assistance Referral System (STARS) for an interactive map to help you locate a Medicaid assistance office in your area.
6. Buy an individual policy from a private carrier
If you're unable to obtain a group policy and exceed the income requirements for Medicaid, you may be able to buy individual coverage directly from a Texas-licensed health carrier. View a list of carriers offering individual plans on TDI's website.
Individual policies can be expensive, and carriers will evaluate an applicant's health risk factors before making a decision to issue coverage. That means that if you have a serious medical condition, or are predisposed toward a certain condition, a carrier may decline to issue coverage. However, if a carrier declines to cover you, keep shopping. Each carrier has different criteria for accepting customers.
Individual coverage may be purchased as either an indemnity or managed care plan. Indemnity plans are sold exclusively by insurance companies, and will generally cover services from any licensed health provider as long as treatment is consistent with the terms of the policy. Managed care plans can be sold by both insurance companies and HMOs.
Typically, managed care plans are more affordable than indemnity plans, but indemnity plans provide members with the most flexibility in obtaining health services. The trade off is essentially choice versus cost.
Both carriers and agents must hold a valid Texas insurance license to legally sell insurance in the state. Before purchasing any individual health plan, it is important to verify that the carrier and agent are licensed. Verifying that the carrier is licensed protects you against fraud. In addition, a state guaranty association will pay some or all of the claims of a licensed carrier should it become insolvent. If you buy from an unlicensed entity, you may have to pay the costs of any claims yourself. For many health care services, this cost could be significant.Back to Top
7. Apply for coverage through the Texas Health Insurance Pool
If you are unable to obtain coverage through any other source, you can apply to join the Texas Health Insurance Pool (Health Pool). The Health Pool is a program primarily intended for Texans who are unable to obtain insurance from licensed private insurers because of their health condition.
Health Pool coverage is similar to that included in employer-sponsored or private insurance plans. Benefits cover hospital stays, physician services, and prescription drugs. The Health Pool also provides coverage for serious mental illness, subject to calendar year maximums for inpatient and outpatient treatment. The Health Pool does not cover treatment for chemical dependency or drug abuse.
Coverage through the Health Pool can be expensive - premiums are twice the rate charged in the standard market, as required by state law.
To qualify for Health Pool coverage, you must be one of the following:
- a federally defined eligible individual (HIPAA)
- rejected for substantially similar individual coverage for health reasons
- unable to find substantially similar individual coverage, except with riders that exclude coverage for medical conditions.
- a dependent of an adult covered by the Health Pool
- certified by an agent as unable because of a medical condition to obtain substantially similar individual coverage from a licensed insurance company or HMO that the agent represents
- diagnosed with a medical condition that automatically qualifies a person for coverage from the Health Pool.
If you are still eligible to continue an employer-sponsored health plan after separation from a job under the terms of federal COBRA regulations, you may be eligible for the Health Pool, but with a pre-existing condition waiting period.
The health pool has a premium subsidy program to help enrollees whose household incomes are at or below 300 percent of the federal poverty level. If you are in the health pool and would like to know if you qualify for a premium subsidy, please fill out the application form.
For more information about premiums, visit the health pool's rate information webpage.
The Health Pool website provides more information.Back to Top
8. Find low-cost health services in your area
For more information about other options and programs that may be able to help, visit our Resources page.
For more information contact: