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Health Insurance Information for a

People age 50 to 64 frequently have difficulty obtaining health care coverage because carriers may consider an applicant's age and health condition when determining whether to issue a policy. However, seniors often have more coverage options than they realize. People age 65 who have worked for at least 10 years, or their spouses, generally qualify for Medicare, the federal health insurance program for seniors. Medicare may not cover all of your health-related expenses, however, and you may need additional coverage.

The following steps can help you obtain the health care coverage you need as a senior:

1. Seek coverage through your employer or past employer
2. Locate other group coverage
3. Determine whether you qualify for Medicare
4. Determine whether you qualify for Medicaid
5. Buy an individual policy from a private carrier
6. Apply for coverage through the Texas Health Insurance Pool
7. Find low-cost health services in your area

1. 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.

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2. Locate other group coverage

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.

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3. Determine whether you qualify for Medicare

Medicare is the federal health insurance program for seniors and people with disabilities. You qualify if you are over age 65 and have worked full-time for a total of at least 10 years, or have received Social Security disability income for a total of at least two years. Also, individuals with Lou Gherig's disease or end stage kidney disease automatically qualify for Medicare. If you have a qualifying spouse, you are also eligible for coverage under his or her Medicare plan.

Medicare typically pays a large portion of participants health care costs, but not all of them. "Medicare Supplement" policies are coverages that help cover out-of-pocket costs that Medicare does not cover. Insurance companies generally must automatically accept you for Medicare supplement coverage if you apply during the six-month "open enrollment period" beginning on the day you join basic Medicare coverage. However, if you apply for a supplement policy more than six-months after joining Medicare, a carrier may decline to cover you if you have any existing medical conditions. It is important to note that not everyone needs a Medicare supplement policy. There are other health coverage that may also pay for Medicare's out-of-pocket costs, such as group health coverage from an employer or as part of a retirement benefit, a Medicare Advantage plan, Medicaid, or a Medicare savings program.

Resources that can help you obtain Medicare coverage include:

• 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.
• Medicare.gov is the official U.S. government site for people with Medicare. The online Medicare Eligibility Tool can help you determine whether you qualify for Medicare.
• TDI's Medicare Supplement Insurance Handbook and Rate Guide explains the basics of Medicare coverages and can help you shop for a supplement plan.
• TDI's Medicare Advantage-Plan Options for Medicare Beneficiaries explains some of the plan options that are available other than original Medicare
• The Health Information Counseling and Advocacy Program (HICAP) is a network of Texas state and local government programs and non-profit groups that can assist you in applying for Medicare and appealing denials for Medicare Supplement Coverage.

Beginning in 2006, Medicare will contract with private sector drug plans to provide prescription drug coverage to persons eligible for Medicare. Everybody who is on Medicare is eligible for the new benefit. It is important to learn about the Medicare drug benefit now because not enrolling at the time of eligibility may make a person subject to a penalty for enrolling later. For the latest information about the new drug benefit, contact Medicare.

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4. 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 limited income and high medical bills they can't pay
• Families and individuals that leave TANF as a result of finding employment
• 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.

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5. 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.

To verify an agent and company's licensing status, use the Agent Look-Up feature or view the company profiles on our website.

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6. 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 website provides more information.

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7. Find low-cost health services in your area

If you are unable to obtain any health coverage, certain federal, state, and county health services programs may be able to help.

Federally Qualified Health Centers (FQHCs) are designated by the federal Bureau of Primary Health Care (BPHC) to provide comprehensive primary health, oral, and mental health/substance abuse services to all individuals regardless of their ability to pay. FQHCs charge for services based on a person's income as a percentage of Federal Poverty Index Guidelines.

• The BPHC Provider Locator can help you find a low-cost provider in your area.
• Access the list of Hill-Burton facilities that provide free or reduced-cost health care services.

Community Health Services are other provider groups, often affiliated with city or county assistance programs, that strive to meet the health care needs of the uninsured and underinsured.

• 2-1-1 Texas provides free information about services in your area. Call 2-1-1 or search the website at www.211texas.org.
• The Texas Association of Community Health Centers (TACHC) offers a search tool to find low-cost providers in your area.
• Unite For Sight is a nonprofit group that specializes in helping Americans obtain free or low-cost vision care services. The group also maintains a comprehensive directory of free clinics that provide health services of all types.

Prescription drug assistance is available from a variety of companies and organizations.

• The Partnership for Prescription Assistance provides a link to programs that provide free or low-cost health clinics and mediations.

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