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Insurance: Health

Find information on health insurance coverage requirements for people with disbilities. This page also includes information about health insurance services provided through the state for people with disabilities. Nothing on this page is intended as legal advice.

On this page:

Insurance for Children

Children's Health Insurance Program(Texas Health and Safety Code, Chapter 62)
STAR Kids Managed Care Program (Texas Government Code, Sec 540.0851)
Transitioning to STAR+PLUS Managed Care Program(Texas Government Code, Sec 540.0854)
Children with Special Health Care Needs Program (Texas Health and Safety Code, Sec. 35.0022)

  • Establishes a Children's Health Insurance Program (CHIP) offering low cost health care to Texan families if the child:
    • is younger than 19 years old
    • is not eligible for medical assistance under Medicaid
    • is not covered by a health benefits plan providing adequate benefits
    • has a household income that is at or below 200% of teh federal poverty level
    • satisfies any other eligiblity standard imposed under the child health plan program.
  • Provides the STAR Kids Program dedicated to provide Medicaid benefits to children with disabilities. Requires care management, care needs assessments, immediate interventions for transitioning care, and monitoring outcomes for quality of life, recipient satisfcation, and other financial and clinical metrics.
  • The Health and Human Services Commission must ensure there is a plan for transitioning from STAR Kids to STAR+PLUS when recipients become 21 years old.
  • Establishes the Children with Special Health Care Needs program. Eligible children with chronic illness, developmental disabilities, and individuals of any age with cystic fibrosis may receive medical services. Services include early identificaiton of children with special health care needs, diagnosis and evaluation, rehabilitation services, development and improvement of standards and servcies, case management servcies, other family support services, and access to health benefits plan coverage.

Health Maintenance Organizations

Texas Health Maintenance Organization Act (Texas Insurance Code, Chapter 843)
Continuity of Care (Texas Insurance Code, Sec. 843.362)

  • Establishes the ability for insurance carriers to organize and become larger insurance companies called Health Maintenance Organizations (HMOs). The Texas Health Maintenance Organization Act establishes general operational rules for these organizations. 
  • Requires a HMO to extend services for an additional 90 days for a physician's patients with disabilities or individuals recieving treatment for life-threatening illnesses when the HMO terminates a contract with a physician.

Coverage for Mental Disorders

(Texas Insurance Code, Sec. 1355.004)

  • Requires that group health benefit plans must provide coverage on treatment of serious mental illness for up to 45 days of inpatient treatment and 60 days of outpatient treatment (including group and individual) per calendar year without any llifetime limits. The amout limitations, deductibles, copayments, and coinsurance factors must be the same as for any other covered physical illness.

Coverage for Autism

(Texas Insurance Code, Sec. 1355.015)

  • Requires health benefit plans to provide coverage for screening a child for autism at the ages of 18 to 24 months. At a minimum, the health benefit plan must provide coverage for treatment of autism from the date of diagnosis up to the child's tenth birthday. Covered services include evaluation and assessment services, applied behavior analysis, beahvior training and management, speech therapy, occupational therapy, physical therapy, or medications and nutritional supplements used to address symptoms of autism.

Coverage for Traumatic Brain Injury

(Texas Insurance Code, Sec. 1352.003)

  • Provides that health benefit plans must include coverage for cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing and treatment, neurofeedback therapy, and remediation required for and related to treatment of an acquired brain injury.

Coverage for Loss of Speech or Hearing

Coverage of Treatment (Texas Insurance Code, Sec. 1365.003)
Hearing Aid Coverage(Texas Insurance Code, Sec. 1365.053)

  • Requires a group health benefit plan to offer and make available coverage for the necessary care and treatment of loss or impairment of speech or hearing. Coverage may not be less favorable than coverage for physical illness covered by the plan and must be subject to the same durational limits, dollar limits, deductibles, and coinsurance factors.
  • Requires a health benefit plan that provides coverage for hearing aids to allow the recipient their choice of hearing aids. Prohibits denial of a claim for a hearing aid solely on the basis that the price of the hearing aid is more than the benefit available under the health benefit. This does not require the health benefit plan to pay an claim for a hearing aid in an amount more than the benefit available under the health benefit plan.
  • Requires professional expertise when fitting prescribed wheelchair mobility systems for Medicaid recipients, including children with disabilities.

Medicaid

Tailored Benefit Packages for Medicaid Populations (Texas Government Code, Sec. 532.0351)
Waiver Program for Individuals with Chronic Health Conditions(Texas Government Code, Sec. 532.0352)
Employment Assistance and Supported Employment for Waivers (Texas Human Resources Code, Sec. 32.075)
Medicaid Buy-in Program for People with Disabilities (Texas Government Code, Sec. 532.0353)

  • Allows the Health and Human Services Commissioner to seek waivers to implement tailored benefit packages designed to provide customized Medicaid benefits for specific populations that will improve health outcomes and access to services, achieve cost containment and efficiency, and reduce administrative complexity. Eligible recipient categories must include children with special health care needs and may include individuals with disabilities or special health care needs. Other eligible groups include elderly individuals, children, and working-age parents and caretaker relatives.
  • Permits the Health and Human Services Commission to apply for waivers from the Centers for Medicare and Medicaid Services or another appropriate federal agency to more efficiently leverage the use of state and local funds to maximize the receipt of federal Medicaid matching funds for individuals that meet eligibility criteria and are eligible to receive services from the county for chronic health conditions.
  • Requires employment services and supported employment to be provided to specific medical assistance waiver programs including the community based alternatives program, the community living assistance and support services program, the deaf-blind with multiple disabilities program, the home and community-based services program, the medically dependent children program, the STAR+PLUS Medicaid managed care program, the Texas home living program, and the youth empowerment services program.
  • Establishes a Medicaid buy-in program for people with disabilities that are working as authorized under the Ticket to Work and Work incentives Improvement Act of 1999. Children with disabilities whose family incomes do not exceed 300% of the federal poverty limit are also eligible for Medicaid buy-in. Individuals receiving Medicaid through the buy-in program are required to pay monthly premiums according to a sliding scale based on family income.
  • Requires professional expertise when fitting prescribed wheelchair mobility systems for Medicaid recipients, including children with disabilities.

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