If you're a parent or guardian, you'll want to ensure that your child has access to health care, including immunizations, preventive care, and routine and emergency health services.
The following steps can help you shop for the health coverage your child needs:
- Seek coverage through your employer
- Locate other group coverage
- Check out state or federal health coverage programs
- Buy an individual policy from a private carrier
- Apply for coverage through the Texas Health Insurance Pool
- Find low-cost health services in your area
If you're employed, your first step should be to seek coverage through your employer. Many employers offer group health coverage as part of their employee benefits packages. Most employers that offer a health plan also extend coverage to their employees' spouses and dependent children. The cost of dependent coverage is usually paid by the employee. Group health coverage through an employer is typically the easiest to qualify for and is often the most affordable option.
Employers must offer health coverage on equal terms to all members. 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. Health risk factors, such as you or your child's health status, may not be used to determine eligibility for group plan membership. Therefore, group membership may be a good option if your child has 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.
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. Newborn children may always be added within 31 days of birth regardless of any open enrollment period requirements.
Employee health plans may be indemnity coverage, meaning you may have to pay for services and file a claim for reimbursement; 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 indemnity coverage and managed care.
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 (defined as having between 2 and 50 full-time workers) and whether a plan is managed care or indemnity will have a significant impact on the coverage available and the cost of the plan.
2. Locate other group coverage
If employer-sponsored group coverage isn't an option, you may be able to find other group coverage. For instance, you may be able to obtain group health coverage for a child through your child's school. Check with the school or school district to find out if health coverage is available to students.
Also, trade unions, religious institutions, professional associations, and fraternal organizations sometimes offer health coverage as a membership benefit. Often these groups extend coverage to members' spouses and dependent children in the same manner as employer-sponsored plans.
Group health plans offered by entities other than employers typically provide coverage that is narrower in scope. These plans often 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 your child has 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 or have achieved a certain rank within the group. Health risk factors, such as your child's health status, may not be used to determine eligibility for plan membership. Therefore, group coverage may be a good option if your child has 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 will typically have to wait until the plan's annual 30-day "open enrollment" period in order to join. Newborn children can be added at any time during the year, however.
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. It is illegal in Texas to form a group for the sole purpose of providing health coverage. Also, a group cannot legally require you to join a health plan as a condition of membership.
3. Check out state or federal health coverage programs
If coverage through your employer or an association or other group isn't available to you, you may qualify for state or federal assistance programs.
Medicaid is a federal/state program that provides health care coverage for children in need. Coverage is provided at no cost for children who qualify. The benefits provided are extensive and often better than those of other health plans. To qualify for Medicaid, a child must be
- a Texas resident
- a U.S. citizen or permanent resident (parents' citizenship or immigration status does not affect a child's eligibility and is not reported on the application form)
- under age 19
- living in a family with financial resources, assets, and income that meet Medicaid's requirements.
A family’s home and personal property are not included when determining assets, but all or part of the value of a vehicle may be included. Children’s Medicaid defines family as any adult or adults – parents, grandparents, relatives, legal guardians, or adult siblings – who are living and caring for uninsured children.
HHSC determines Medicaid eligibility for most children. Children in families receiving Temporary Assistance for Needy Families (TANF) automatically qualify. HHSC usually reviews a family’s financial situation every six months to determine if participating children are still eligible.
Children's Health Insurance Program (CHIP)
CHIP is a federal and state health coverage program for families who earn too much money to qualify for Medicaid but can’t afford a private health plan. Private insurance companies and HMOs offer CHIP statewide.
CHIP benefits are comparable to most private health plans. Benefits include hospital care, surgery, X-rays, physical and speech therapy, prescription drugs, limited mental health services, emergency services, regular health checkups, and immunizations.
Participating families usually pay a fee that covers all of the family’s children in the plan. The fee is based on income and can range from $0 to $50 every 12 months. Most families also have copayments for doctor visits, prescription drugs, and emergency care. There is a 90-day waiting period for children who were insured in the 90 days before applying for CHIP. After enrolling, families must renew CHIP coverage every year.
To qualify for CHIP, a child must be
- a Texas resident
- under age 19
- a U.S. citizen or legal permanent resident (parents’ citizenship or immigration status does not affect a child’s eligibility and is not reported on the application form)
- living in a family that meets CHIP income requirements (there are some stipulations based on the child’s age, but net family income can never be more than twice the federal poverty level).
Applying for Children's Medicaid and CHIP
One application covers both programs. The state will look at your information and let you know if your children qualify for the Children's Medicaid or CHIP. To apply:
- Call 1-877-KIDS-NOW, Monday-Friday, 8 a.m. to 8 p.m. (Central standard time), except federal holidays.
- Go to the following website: www.chipmedicaid.org and print an application.
Other State and Federal Resources
- To self-screen for state benefits, or to locate a Medicaid assistance office in your area, go online to https://www.yourtexasbenefits.com/wps/portal
- 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 your family qualifies for either Medicaid or CHIP. To research options, online, visit https://www.211texas.org/211/.
- Visit the Texas Health and Human Services Commission website at www.hhsc.state.tx.us. To view Your Health Care Guide, go online to http://www.hhsc.state.tx.us/QuickAnswers/TradMedHandbook.pdf.
4. Buy an individual policy from a private carrier
If you're unable to obtain a group policy and exceed the income requirements for Medicaid and CHIP, you may be able to buy individual coverage directly from a Texas-licensed health carrier.
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 your child has serious medical condition, or is predisposed toward a certain condition, a carrier may decline to issue coverage. However, if a carrier declines to cover your child, keep shopping. Each carrier has different criteria for accepting customers.
Some carriers will only issue coverage for children as the dependents of an insured adult. In this case, a parent's health status could impact the child's ability to obtain coverage from that carrier. However, many carriers offer children's only coverage.
For additional carrier information, use our individual health policy search tool or view a list of carriers offering individual plans on TDI's website.
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.
5. 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 has a premium subsidy program to help enrollees whose household incomes are at or below 300 percent of the federal poverty level. If you are in the health pool and would like to know if you qualify for a premium subsidy, please fill out the application form.
For more information about premiums, visit the health pool's rate information webpage.
The Health Pool website provides more information.
For more information contact: