(October 2006)
Nearly four million Texans have some type of mental or physical disability. Besides often having difficulty obtaining insurance, Texans with disabilities may experience other insurance-related problems, such as claim denials, higher premiums, cancellations, and refusals to renew their policies.
This publication explains your basic rights under Texas insurance law and the actions you can take if you believe you have been improperly denied coverage or unfairly discriminated against. It also provides state and federal resources for Texans with disabilities.
Disability and the Law
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.
To determine whether to issue a policy, insurance companies usually evaluate certain information about you to determine how likely you are to have a claim. This is called "underwriting." For a health policy, for instance, a company might consider your age, occupation, current health status, and your medical history. 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.
Risk Factors That Could Affect Coverage
If... You recently had cancer.
And... You're trying to get a health insurance policy.
And... Statistics show you&'re more of a risk for a claim.
Then... You might not be able to get a policy, may have to pay more, or may only be able to get limited coverage.
If... You have permanent vision impairment.
And... You're trying to get an auto policy.
And... Statistics show your functional impairment makes you a greater risk as a driver.
Then... You may not be able to get coverage, or you may have to have someone else drive your car to get coverage.
Risk Factors That Would Not Affect Coverage
If... You have vision impairment.
And... You're trying to get a health insurance policy.
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 policy as someone without a vision impairment.
If... You have diabetes.
And... You are trying to get a homeowners policy.
And... There's no statistical evidence that people with diabetes pose a higher risk for a homeowners claim than anyone else.
Then... You should be given the same consideration for a policy as someone without diabetes.
Your Rights
The 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
1-800-949-4232 (voice and TTY)
www.adata.org/
Unfair Discrimination
It might be difficult to determine whether you've been discriminated against because you don't know how companies treat policyholders or applicants without disabilities. You should, however, be wary if a company engages in any of the following actions:
- refuses to issue you a policy that is unrelated to your disability
- refuses to renew your coverage
- cancels your policy
- refuses to pay a valid claim
- charges you a higher premium
- imposes large annual rate increases.
If a company declines to cover you 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.
Pre-Existing Conditions
If you are seeking a health insurance policy and you have a current or past health problem, you must disclose it on your insurance application. 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 and 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. If you move from a group, government, or church health plan to an individual policy with 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.
Health maintenance organizations (HMOs) cannot exclude treatment for pre-existing conditions once your enrollment is effective. HMOs must cover all health conditions.
Health Benefit and Claim Issues
If an HMO 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 Health Maintenance Organizations decision, the denial must include the medical reasons.
If you have unsuccessfully exhausted an HMO, preferred provider organization (PPO), or insurance policy appeal process on a claim denial for services you believe are medically necessary, you can ask for a review by an Independent Review Organization (IRO). For more information, call the Texas Department of Insurance (TDI) IRO Information Line
1-888-TDI-2IRO (834-2476)
322-3400 in Austin
If an HMO or PPO terminates your doctor, treatment with the doctor can be extended 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.
Individual HMO and PPO plans and hospital medical-surgical insurance policies are guaranteed renewable. Your plan cannot be terminated as long as you pay your premiums.
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.
How to Get Help
File a complaint. If 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 TDI.
You also can file an ADA complaint. Obtain a complaint form and more information by contacting your nearest office of the U.S. Department of Justice, the U.S. Equal Employment Opportunity Commission, or by calling the ADA Technical Assistance Center.
Note: If your health insurance is through your employer, you must file your ADA complaint with the Texas Commission on Human Rights.
You also can report the problem to the Office of Public Insurance Counsel (OPIC), which represents the interests of Texas insurance consumers. When individual complaints suggest a wide pattern of unfair or discriminatory practices in the business of insurance, OPIC may become involved. For more information, call OPIC
512-322-4143
Seek Legal Advice. You 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 directory for listings in your area or call local bar associations and legal referral services.
Medicare Health Plan Options
Medicare is a federal health insurance program for people 65 or older, some people under 65 with disabilities, and people with end-stage renal disease. If you are on Medicare, it will pay for much - but not all – of your health care.
People on Medicare may have an option to get coverage under the original (or traditional) Medicare plan or under Medicare Advantage plans. Original Medicare is a fee-for-service plan and frequently works with employer group plans, including TRICARE for Life, and with Medicare supplement policies. Medicare Advantage plans are private companies that contract annually with Medicare. These plans may include managed care plans, such as HMOs and PPOs, Medical Specialty Plans and other health plans.
For more information about Medicare health plan options, call Medicare
1-800 Medicare (633-4227)
Open Enrollment Rights for Medicare Supplement Policies
There are 12 standardized Medicare supplement insurance plans that work with original Medicare. They are labeled "A" through "L." Each plan offers a different level of benefits. You must have both Medicare Part A and Medicare Part B to buy Medicare supplement insurance. In Texas, companies that sell Medicare supplement insurance must sell at least Plan A to people with disabilities. Companies may choose to sell other plans to people with disabilities if the company chooses.
People under age 65 who receive Medicare because of disabilities have a six-month open enrollment period beginning the day they enroll in Medicare Part B. This open enrollment right is only applicable to Plan A. Open enrollment means a company cannot deny you a policy because you have pre-existing conditions.
An insurer may, however, decide not to cover your pre-existing conditions for up to the first six months you have the policy. If you have had certain kinds of health coverage, called creditable coverage, the company must shorten the waiting period or eliminate it entirely.
At age 65, the standard Medicare open enrollment period begins. If you are already enrolled in Medicare Part B when you turn 65, you have the right to purchase any Medicare supplement plan offered by any insurer in Texas within six months after you 65th birthday. Any time you have been covered under your current policy will be counted toward meeting any pre-existing condition waiting period in your new policy.
For more information about eligibility requirements for Medicare, contact the U.S. Social Security Administration
1-800-772-1213
1-800-325-0778 (TTY)
http:/www.ssa.gov/reach.htm
Medicaid Buy-In Program for Workers with Disabilities
Medicaid, a health care assistance program for people with limited incomes, was expanded in 2005 to include the Medicaid Buy-In Program for workers with disabilities. The program allows Texans with disabilities to work jobs that pay more than the traditional income limits and still retain their Medicaid benefits. The legislation increases the Medicaid benefits income cap for a person with a disability from $604 per month to $2,042 per month.
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.
For information about Medicaid and eligibility, call 2-1-1 for free access to health and human services information in your community or visit the Texas Health and Human Services Commission
www.yourtexasbenefits.com/wps/portal/
Other Health Care Coverage Options
If 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 Risk 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
1-888-398-3927
1-800-735-2989 (TDD)
- 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
1-800-647-6558
State and Federal Agencies for Texans with Disabilities
The following state and federal agencies may have information helpful to Texans with disabilities:
Texas Department of Aging and Disability Services
512-438-3011
www.dads.state.tx.us/
Texas Department of Assistive & Rehabilitative Services, including Rehabilitation Services, Deaf and Hard of Hearing Services, and Blind Services
1-800-628-5115
www.dars.state.tx.us
Texas Governor's Committee on People with Disabilities
512-463-5739
512-463-5746 (TDD)
www.governor.state.tx.us/disabilities/
Texas Department of State Health Services, including Mental Health and Substance Abuse Crisis Services
1-888-963-7111
458-7111 in Austin
1-800-735-2989 (TDD)
458-7708 (TDD) in Austin
www.dshs.state.tx.us/
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.
1-877-787-8999
1-888-425-6889 (TDD)
www.hhsc.state.tx.us/
U.S. Department of Justice Americans with Disabilities Act
1-800-514-0383 (TTY)
www.usdoj.gov/crt/ada/
U.S. Equal Employment Opportunity Commission
1-800-669-4000
1-800-669-6820 (TTY)
www.eeoc.gov/
U.S. Department of Veterans Affairs
1-800-827-1000
1-800-829-4833 (TDD)
www.va.gov/
For More Information or Assistance
For answers to general insurance questions or for information on filing an insurance-related complaint, visit our website or call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday
www.tdi.state.tx.us
1-800-252-3439
463-6515 in Austin
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 Hotline
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: ConsumerProtection@tdi.state.tx.us
Last updated: 11/28/2006
