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Texas health insurance purchases can be very confusing. There are many questions to ask as you compare companies selling health insurance in Texas . Even though these companies’ coverage options appear different there are some circumstances that are controlled by Texas laws and regulations and therefore the same. For example …

What about pre-existing conditions?

Let’s talk about what you need to know about pre-existing conditions before purchasing health insurance in Texas.

First let’s get HMO’s out of the way. This one is simple! In Texas individual health plans offered by HMOs cannot contain a pre-existing condition exclusion period. But, now it gets really complex…

When determining if a claim is for the treatment of a pre-existing condition, an individual non-HMO health plan can look back 5 years. Non-HMO individual health plans in Texas are allowed to exclude coverage for your pre-existing conditions for up to 2 years. However, if the individual health plan does not ask you questions about your health or medical treatment history when you apply for health coverage and it does not exclude a condition by name on your policy, it can only exclude pre-existing conditions for 12 months. Okay that seems simple enough; all you have to do is read all of the applications until you find one with your pre-existing condition not listed.

You finally find one, so you apply! Your new policy arrives. You decide to read all of the fine print and what do you find? It has an elimination rider which is an amendment that puts a permanent exclusion on coverage for a health condition which pre-existed.

So this isn’t the policy for you! As you looking for another coverage option, here are a few things to consider If you have a pre-existing condition…
pregnancy can be considered a pre-existing condition in individual health plans, but genetic information cannot.

Who do you trust?

This will make you feel real comfortable! It’s called the prudent person rule. In an individual health plan, the definition of a pre-existing condition is a condition for which you actually received care, as well as one that the insurer thinks that most people in your situation would have gotten care for during the 5-year period before you applied for health coverage. 63 Days - where did that come from?

Individual health plans have to give you credit for your prior continuous coverage if your most recent coverage was under a group plan. Continuous coverage means the gap between health plans is less than 63 days. If you have 18 months of continuous creditable coverage, you will not face a pre-existing condition exclusion period.

If your gap in health coverage was 63 days or more and your most recent coverage was under a group plan, you must be given credit for any creditable coverage in effect at any time during the 18 months preceding your application for coverage. This means that although you will have a pre-existing condition exclusion period, it will be shorter than by the amount of credit you earned.

Whew! Okay you give up yet?

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Texas Health Insurance