November 19, 2017 (512) 246-9955
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Frequently Asked Questions

Select a question below to find the answer

Unable To Acquire Private Health Insurance?

The Texas Health Insurance Risk Pool is for people who have been denied coverage by private insurance providers. These plans are robust and supply an inexpensive-albeit higher-than-average-price-alternative.

The Texas Health Insurance Risk Pool is administered by Blue Cross Blue Shield. You can check out their site www.txhealthpool.org to see if this choice is an option for you.

Is Preventive Care Covered?

As a result of Patient Protection and Affordable Care Act (PPACA) Preventive Care Coverage was added to most all individual Texas Health Insurance plans with effective dates of September 23, 2010 or later.

For adults with most individual Texas health insurance carriers these benefits are now covered as a first dollar expense by the carrier. This means that with most plans you have no deductible, coinsurance, copays, or waiting periods for adult preventive care coverage(for in network care). Prior to healthcare reform most health insurance carriers had limits around $300 to $500 per covered adult.

Are There Aggregate Lifetime Dollar Maximums?

As a result of Patient Protection and Affordable Care Act (PPACA) the following benefit was added to most all individual Texas Health Insurance plans with effective dates of September 23, 2010 or later:

No Aggregate lifetime dollar maximum: Most Individual Texas health insurance carriers have done away with the limitations to the lifetime maximum coverage per person. For example, before the reform most carriers had either a $3 or $5 million lifetime maximum per person. After reform, most Texas health insurance plans have an unlimited lifetime maximum per person while covered under that plan.

Is There an Annual Dollar Limit on Prescriptions?

As a result of Patient Protection and Affordable Care Act (PPACA) the following benefit was added to most all individual Texas Health Insurance plans with effective dates of September 23, 2010 or later:

Prescription Drugs: Most Texas health insurance carriers have done away with any annual dollar limit for prescriptions. Prior to healthcare reform most carriers had $3000 to $5000 annual limits per person.

Can I Get Health Insurance with a Preexisting Condition?

As a result of Patient Protection and Affordable Care Act (PPACA) the following benefit was added to most all individual Texas Health Insurance plans with effective dates of September 23, 2010 or later:

Children with Preexisting conditions: children under age 19 will have no preexisting condition exclusions. This is required on a state-by-state basis, that dependent children under the age of 19 will not be declined based on medical history. Prior to healthcare reform most Texas health insurance plans could decline a child with a preexisting condition and forcing them to take coverage through the Texas Health Insurance Risk Pool.

How Long will my Dependents be Covered?
Dependent Children: dependent children will be allowed to stay on their parent/legal guardian plan until age 26
What is an HMO?
HMO (Health Maintenance Organization) Prepaid health plans in which you pay a monthly premium and the HMO covers your cost of care to see doctors within their network at pre-negotiated rates. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. If you are an HMO member and you do not use the doctors, hospitals and clinics that participate in your plan's network, you will usually bear the cost of those medical services
How does Indemnity Traditional Health Insurance Work?
Indemnity Traditional health insurance that usually covers a percentage of the cost of care (often 80%) after the consumer pays a deductible. Insureds with indemnity coverage can choose any doctor or hospital for their care.
What is a Health Savings Account (HSA)?
HSA (Health Savings Account) A tax-advantaged personal savings account used in conjunction with a high deductible health policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual deductibles and copayments.
What is a POS Plan?
POS (Point-of-Service) A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge.
What is a PPO?
PPO (Preferred Provider Organization) A network of health care providers that have agreed to provide medical services to a health plan's members at negotiated costs. PPO members typically make their own decisions about their health care rather than going through a primary care physician like HMO member. The cost to use physicians within the PPO network tends to be less than using a non-network provider.
What is a Deductible?
A deductible is the amount of money paid by the insured each year to cover eligible medical care expenses before the insurance policy starts paying. Deductibles shown are for network when applicable. Select higher amounts to lower monthly premiums.
What is Coinsurance?
Coinsurance is the amount shared by the insured and insurer for eligible medical care in a fee-for-service plan, an indemnity plan or a preferred provider organization (PPO) after the deductible has been met. It is usually expressed as a percentage of eligible charges. For example, if the insurance company pays 80 percent of the claim, the insured pays 20 percent.
What are Co-pays?
Co-pay is a specific amount an insured pays for a specific medical service. For example, the insured may pay $35 for an office visit or $15 for a prescription and the health plan may cover the rest of the eligible charges. Select a higher amount to reduce monthly premiums.
What is a Premium?
The monthly premium is the amount paid each month in exchange for health insurance coverage. Typically, if a person pays more in monthly premiums they will pay less for routine doctor visits and other services. Note: The estimated monthly premium may change based on medical history, the underwriting practices of the health plan, occupation (where allowed), or other factors as determined by the health insurance company.
What is a Prescription Deductible?
Some plans have a prescription deductibles (usually $250-$500) for brand name prescriptions before you begin paying your brand prescription copay.
What is Maximum Out Of Pocket?
Your Maximum Out of Pocket includes your deductible and coinsurance. For example, If you have a $2500 deductible with 80/20 coinsurance that you are responsible for another $2500 in coinsurance which gives you a Maximum out of pocket of $5000.
Can you keep your coverage and what is qualifying coverage?
Yes if you have a current coverage, you can keep that plan into 2014 with most major Texas health insurance carriers. Qualifying coverage is considered Employer provided insurance, government programs like Medicare, Medicaid, CHIP, COBRA, privately purchased insurance, or coverage you purchase on the Texas marketplace or through a Texas health insurance agent.
Will I pay a tax or penalty in 2014 for not having health insurance?
Yes, in 2014 all individuals are required to have health insurance coverage. The penalty for not having health insurance coverage in 2014 will be $95 per year or 1% of your annual income whichever is greater.
What are “Exchanges” or “Marketplaces”?

Starting October 1st 2013 there will be Marketplaces(also known as "exchanges") for those who do not have insurance and for small business with up to 50 employees. The state and federal governments are not providing the coverage, they are gathering all the information for consumers through one platform called the "Marketplace". The Marketplace is like using Travelocity to shop various airlines versus visiting each airline's website to find the same information.

Texas is one of 27 states that has not agreed to partner with the federal government and Texas will have federally managed marketplaces run by the carriers where individuals can shop for coverage.

What are my plan choices and what are metallic plans?

Individuals can choose amount 4 plans: bronze, silver, gold and platinum, which are intended to cover 60 to 90 percent of health costs that a plan would pay for an average person. Insurers do not have to offer all four plans, but within the health insurance marketplaces, all insurers must offer at least one silver and one gold plan. Cost of each type of plan vary by state and carrier.

What are penalties for NOT having coverage?

In 2014: $95 per uninsured adult in the household, capped at $285 per household or 1 percent of the household income whichever is greater.

In 2015: $325 per uninsured adult in the household, capped at $975 per household or 2 percent of the household income whichever is greater.

In 2014: $695 per uninsured adult in the household, capped at $2085 per household or 3 percent of the household income whichever is greater.

Are there exemptions from penalties?
Yes, for economic hardship(income below 100% of poverty level, those who are unable to pay for coverage that is more than 8 percent of household income), religious objections, American Indians, those without coverage for less than 3 months, undocumented immigrants and incarcerated individuals.
What are subsidies and how can they help?

Tax credits/subsidies for individuals and families making between 100 and 400 percent of the federal poverty level which is direct offset of premiums of the plans to purchase through the Marketplaces. For example if someone qualifies for a credit of $250 per month and the plan they choose is $500 per month then that plan would them $250 per month. You cannot qualify for subsidy if you or your spouse has access to a group health insurance plan, you are covered by a government plan, Medicare, or Medicaid. Listed below are the limits of income to qualify for a credit:

$11,490 (100%) up to $45,960 (400%) for one individual

$15,510 (100%) up to $62,040 (400%) for family of two

$23,550 (100%) up to $92,200 (400%) for one individual

If you are eligible for the credit, you can choose to have all or some of the credit paid in advance directly to your insurance company to lower what you pay out-of-pocket for your monthly premiums during 2014; or you wait to get all of the credit when you file your 2014 tax return in 2015.

Tax credits will also be available for small businesses with up to 25 employees that have an average wage of less than $40,000.

The government will also help low income people with out-of-pocket (unreimbursed) expenses. If income is between 100 percent and 250 percent of the federal poverty line($23,550 to $58,875 for a family of four), you can qualify but only if you enroll in a silver plan.

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