Texas Health Pool Benefits Outlined as of 1/1/2011

[This is only a summary of information. This summary is NOT a legal document.
Refer to the Health Pool's Outline, Contract (Policy) and Application for complete information.]

Health Pool Plan Benefits Summary as of 01/01/2011

[see Outline and Policy for specifics related to each benefit]
Please note all benefits, applications and rates are as shown on TEXAS HEALTH POOL SITE on the date above, please refer to the Texas Health Pool for the most accurate information. We are not an agent for the pool and the pool does not have agents.

Here is a link to an application for the pool
Here is a link to the rates for the pool

Medical
Deductibles/
Coinsurance

Plan I
(Insured Pays)

Plan II
(Insured Pays)

Plan III
(Insured Pays)

Plan IV
(Insured Pays)

Plan V
HDHP/
HSA Qualified
(Insured Pays)

Deductible
(Calendar Year)

$1000

$2500

$5000

$7,500

$3,000

Coinsurance for
PPO Providers

20%

Coinsurance for
Non-PPO
Providers

40%

Coinsurance
Maximum
for PPO Providers
(Calendar Year)

$3000

$5,000

Annual PPO Medical Maximum Out-of-Pocket
Amounts

Plan I
(Deductible
+
Coinsurance)

Plan II
(Deductible
+
Coinsurance)

Plan III
(Deductible
+
Coinsurance)

Plan IV
(Deductible
+
Coinsurance)

Plan V
HDHP/
HSA-Qualified

$1000 + $3000
= $4000 Annually

$2500 + $3000
= $5500 Annually

$5000+$3000
=$8000 Annually

$7,500+$5,000
=$12,500 Annually

$3,000
Annually

Annual Pharmacy Deductible/Copays

$200
(No Copay limit)

$500
(No Copay limit)

$1,450/
$1,500 Copay Maximum

NOTES:

The Coinsurance Maximum for Non-PPO Providers for all plans is $10,000 in a Calendar Year.
The Lifetime Maximum benefit for all plans is $3,000,000.
Plans III, IV and V are not available to individuals eligible for Medicare. Plans I & II are available to supplement Medicare Disability. Plans I and II do not provide outpatient prescription drug benefits to Medicare-eligibles due to the availability of Medicare Part D.
The Calendar Year Deductible, the Emergency Care Deductible, Physician Office Visit Copayments, and Charges for Outpatient Prescription Drugs DO NOT COUNT toward the Coinsurance Maximums.
After the insured pays the medical deductible for the policy, the policy pays the amount of Covered Expenses in excess of the Coinsurance Amount subject to policy limits. For Covered Expenses from a Preferred Provider, once you have paid your Coinsurance Maximum, the policy pays 100% of Covered Expenses from Preferred Providers for the rest of the Calendar Year. In no event will the policy pay more than the Lifetime Maximum for each Insured Person.
The deductible amount selected may not be changed to a lower amount after the Policy is issued. You may request to change to a higher deductible, if offered, but only one such change will be allowed in a calendar year. The change will be effective on the first of the month following the date your written request is received, or a later date if requested.

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These are the benefits as shown on http://www.txhealthpool.org/benefits.html please refer to Texas Health Pool for the accurate information, we are not an agent for the pool and the pool does not have agents that work for it

Summary-Health Pool Plan Benefits

[see Outline and Policy for specifics related to each benefit]

Hospital	Average semi-private room rate. No more than one visit per physician per day
Intensive Care or Cardiac Care Unit	No more than 3 times the average semi-private room rate
Assistant Surgeon or Surgical First Assistant	One assistant, no more than 25% of the primary surgeon's fee
Hospital or other facility for Emergency Care	Subject to additional $100 deductible per visit (not credited toward coinsurance maximum). Does not apply to Plan V
Physician Office Visits-for covered illness or injury	PPO Plan: $30 copayment per visit, for first 6 visits per calendar year. Thereafter, visits are subject to Calendar Year Deductible & Coinsurance. Non-PPO Plan: Subject to Calendar Year Deductible and/or Coinsurance
Home Health Care	Lesser of 60 visits or $5,000 per calendar year
Skilled Nursing Facility	45 days per calendar year
Hospice Care	Lesser of 180 days or $10,000 lifetime maximum
Named Transplants	Subject to a lifetime combined maximum benefit for all transplants of $300,000. Transplants covered include: kidney, pancreas, heart, liver, lung and bone marrow. Includes preparation and transportation.
Physical, Speech, Occupational Therapy	$5,000 per calendar year
Serious Mental Illness	Calendar year maximum benefit of 30 inpatient days and 50 outpatient visits.
Preauthorization Provisions	If a preauthorization requirement is not met, benefits for covered services and supplies will be reduced 50%. Preauthorization required for: inpatient admissions, skilled nursing facility admissions; home health care services, home infusion therapy, hospice care, transplants, and durable medical equipment over $2,000.
Outpatient Prescription Drugs	See Pharmacy Program page of website.

These are the benefits as shown on http://www.txhealthpool.org/benefits.html please refer to Texas Health Pool for the accurate information, we are not an agent for the pool and the pool does not have agents that work for it.