Website SurveyInsurance for Texans with Disabilities(April 2009) Fourteen percent of the Texas population has a mental or physical disability. Texans with disabilities often have difficulty obtaining insurance and can experience insurance-related problems, such as claim denials, higher premiums, cancellations, and policy renewal refusals. The Texas Administrative Code defines a disability or “handicap or partial handicap” as a physical or mental impairment that substantially limits one or more of a person’s major life activities. These impairments can include medical, mental, or physical conditions that limit your ability to walk, breathe, hear, see, learn, work, or perform manual tasks. Insurance companies consider an individual’s “risk factors” when deciding whether to issue a policy. This decision process is called “underwriting.” For a health policy, for instance, a company might consider your age, occupation, medical history, and your current health status, including your disability. If your individual risk factors indicate you are likely to have a claim, the company may charge you more for your policy or refuse to cover you. For example, if you recently had cancer and statistics show you’re more of a risk for a claim, then you might not be able to get a health insurance policy, you may have to pay more, or you may only be able to get limited coverage. Similarly, if you have permanent vision impairment and statistics show your functional impairment makes you a greater risk as a driver, then you may not be able to get an auto policy or you may have to have someone else drive your car to get coverage. Not all disabilities will preclude you from obtaining certain types of insurance. For example, if you have vision impairment and there’s no statistical evidence that people with vision impairment pose a higher risk for a health insurance claim than anyone else, then you should be given the same consideration for a health insurance policy as someone without a vision impairment. Your RightsThe Texas Insurance Code prohibits insurance companies from denying, refusing to renew, limiting, or charging more for coverage because of a disability, unless the company’s actions are “based on sound underwriting or actuarial principles reasonably related to actual or anticipated loss experience.” The Texas Administrative Code also specifically prohibits the same types of discrimination solely because of blindness or partial blindness. The federal Americans with Disabilities Act (ADA) may also provide additional protections. For more information, call the ADA Technical Assistance Center
Unfair DiscriminationIt might be difficult to determine whether you’ve been discriminated against because you don’t know how companies treat policyholders or applicants without disabilities. However, you should be wary if a company engages in any of the following actions:
If a company declines to issue you a policy or cancels or nonrenews your policy, ask why. If you request an explanation, most auto and homeowners companies must explain in writing their reasons for declining, canceling, or not renewing your policy. This explanation must include the precise incident, circumstance, or risk factor that violated the company’s underwriting guidelines and the insurer’s sources of information. Life and health insurance companies are not required to provide you with a written explanation if they decline to issue you a policy. How to Get HelpIf you think an insurance company has treated you unfairly, or if you cannot get answers to your questions, you have the right to file a complaint with the Texas Department of Insurance (TDI). Call TDI’s Consumer Help Line or visit our website
You can also file an ADA complaint. To obtain a complaint form or get more information, call 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
After you file a complaint, you can report the problem to the Office of Public Insurance Counsel (OPIC), which represents the interests of Texas insurance consumers. OPIC often becomes involved when individual complaints indicate a pattern of unfair or discriminatory practices in the business of insurance. For more information, call OPIC or visit its website
Seek legal adviceYou may find inexpensive or free legal assistance through local or government-sponsored assistance programs in your area. Some attorneys may accept your case on a contingency basis, which means they’ll receive a percentage of any judgment you win. Check your telephone book or the Internet for listings in your area or call local bar associations and legal referral services. Pre-Existing Conditions and Creditable CoverageIf you are seeking a health insurance policy and you have a current or past health problem, you must disclose it as a pre-existing condition on your insurance application. Carriers may define a pre-existing condition as any condition for which you’ve received medical advice, care, diagnosis, or treatment during a specified period of time before the plan takes effect. Failure to disclose “pre-existing conditions” could jeopardize future claims or invalidate the policy. Insurance companies issuing some types of policies may completely exclude coverage for pre-existing conditions by attaching an “exclusion rider” to your policy. If you list pre-existing conditions in your application but the company issues you coverage without attaching an exclusion rider, the company must begin covering your pre-existing conditions when the policy’s pre-existing waiting period expires. Waiting periods can be a maximum of two years on individual or group association policies if an exclusion rider is not attached to the policy. Employer group policies can have a pre-existing condition waiting period of up to one year. Medicare supplement and long-term care policies can have a waiting period of up to six months. Employer group, Medicare supplement, and long-term care policies cannot have exclusion riders. If you move from a group, government, or church health plan to an individual health policy, you will not be subject to a new pre-existing condition waiting period if you had 18 months of prior coverage with no more than 63 days lapse in coverage. This prior coverage is referred to as “creditable coverage.” If you had less than 18 months of coverage or a lapse in coverage greater than 63 days, you will receive credit on the new policy’s pre-existing condition waiting period for the time you were covered during the preceding 18 months. When you change from one job to another, you may not be subject to a new pre-existing condition waiting period if you have 12 months of prior coverage with no more than 63 days lapse in coverage. If you have less than 12 months of coverage or a lapse in coverage greater than 63 days, you will receive credit on the new policy’s pre-existing condition waiting period for any time you were covered during the preceding 12 months. Managed care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), cannot exclude treatment for pre-existing conditions once your enrollment is effective. Managed care plans must cover all health conditions. Health Benefit and Claim IssuesIf a managed care plan denies you a particular treatment, it must send the denial to an appropriate physician or other health care provider to determine whether the services are medically necessary. If the physician agrees with the managed care plan’s decision, the denial must include the medical reasons. If you are not satisfied with your insurer’s or managed care plan’s decision, you may file a complaint or an appeal with the insurer or plan. If you have unsuccessfully exhausted the appeal process on a claim denial for services you believe are medically necessary, you can ask for an Independent Review Organization (IRO) to review the decision. For more information, call TDI’s IRO Information Line
If a managed care plan decides to no longer include your doctor in its network, you can continue to receive treatment with the doctor up to 90 days if you have a disability or life-threatening condition that requires it. If you are beyond the 24th week of pregnancy, care extends through the delivery with follow-up care for up to six more weeks. Care can be extended up to nine months if you are terminally ill. HMOs and PPOs are prohibited from adopting rules that prevent or discourage physicians from giving information or opinions to patients about their medical conditions, treatment options, provisions of their health care plans, or the status of a health care provider with the HMO. HMOs and insurance companies can be sued for medical malpractice. Companies that receive notice of a potential suit also can ask for a review of the claim by an IRO. Health Care Coverage OptionsMedicare Health Plans Each part of Medicare can include out-of-pocket costs, such as premiums, deductibles, and coinsurance or set copayments. Some of these costs or gaps in coverage might be covered by an employer group plan, including TRICARE for Life, Medicaid, or a Medicare Supplement policy. These costs are different in original Medicare versus Medicare Advantage plans. People have an option to receive Medicare coverage through the original (or traditional) Medicare health plan or through private Medicare Advantage plans. The Medicare Part D benefit is only available through approved Medicare drug plans. Medicare Advantage plans may include managed care plans such as HMOs and PPOs, Medicare special needs plans (SNP), private fee-for-service (PFFS) plans and Medicare savings account plans (MSA). The special needs plans serve special populations, such as people with Medicare and Medicaid or those living in certain institutions, and people with certain chronic illnesses. To be eligible to join an MA plan, you must live in a plan’s service area, be enrolled in Medicare Part A and Part B, and, in certain plans, not have end-stage renal (kidney) disease. Original Medicare offers the greatest freedom to see providers without referrals or network restrictions. Claims are automatically submitted to other insurance plans, such as an employer plan, TRICARE for Life, Medicaid, or a Medicare supplement policy. For more information about Medicare health plan options, call Medicare
Medicare Supplement Policies You must be enrolled in Medicare Part A and Part B to buy Medicare supplement insurance. In Texas, companies that sell Medicare supplement insurance must sell at least Plan A to people under age 65 with disabilities. Companies may offer to sell more than Plan A to people with disabilities if the company chooses. Medigap Plan A will pay for Part A hospital coinsurance and coverage for 365 additional days after Medicare Part A benefits end. Medigap Plan A pays for Part B coinsurance (usually 20 percent) or set copayments that apply to certain services such as ambulance or outpatient care. It also pays for the first three pints of blood each year. Medigap plans B through L cover deductibles, allowable excess charges, and certain services not covered by Medicare. Basic Medigap Plan A benefits are included in plans B through J. People 65 and older on Medicare have the right to buy Medigap plans during their initial open enrollment period. This period is the first six months from when a person begins Medicare Part B coverage. There are other guaranteed issue rights to buy Medigap usually tied to involuntarily losing other coverage. Texas requires companies selling Medicare Supplement plans to sell at least Medigap Plan A to people under age 65 during their initial open enrollment period or under guaranteed issue rights. Additionally, at age 65, you will have another open enrollment period to buy any of the 12 plans available. Although you may have a right to buy a Medicare supplement policy, Medicare allows no more than a six-month waiting period for pre-existing conditions, if you did not have creditable coverage. For more information about Medicare supplement insurance, read TDI’s Medicare Supplement Handbook and Rate Guide. For more information about Medicare eligibility requirements, contact the Centers for Medicare and Medicaid Services
Medicaid Buy-In Program for Workers with Disabilities People taking part in the Buy-In Program will pay monthly premiums based on income and other factors for Medicaid benefits. They will receive the same services available to other Medicaid recipients, including office visits, hospital stays, X-rays, vision and hearing services, and prescriptions.
Other Health Care Coverage OptionsIf you are unable to find health insurance because of a pre-existing condition, you may be able to obtain coverage for you or your family through one of the following: The Texas Health Insurance Pool (Health Pool) is for people who are unable to obtain health care coverage, their dependents or family members, and certain individuals who lose their employer-sponsored health coverage. The premiums may be up to twice the standard rate in the individual health insurance market. For more information, call the Health Pool
The Children’s Health Insurance Program (CHIP) provides health care to children of many low-income Texas families who are not eligible for Medicaid. For more information, call CHIP
State and Federal Agencies for Texans with DisabilitiesThe following state and federal agencies may have information helpful to Texans with disabilities: Social Security’s Supplemental Security Income (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
Texas Health and Human Services Commission
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 AssistanceFor 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
For printed copies of consumer publications, call the 24-hour Publications Order Line
Help us prevent insurance fraud. To report suspected fraud, call our toll-free Fraud Hot Line
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hot Line
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: |
Texas Department of Insurance Home Page · www.tdi.state.tx.us · Consumer Helpline: 800-252-3439
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