Most insured Texans are covered by private insurance, or through government programs like Medicare (for the elderly), Medicaid (for low-income pregnant women and children), the Children’s Health Insurance Program (for children whose families’ incomes exceed Medicaid limits) or a county’s program for poor residents. Slightly more than half of Texas employers offer health care coverage to their employees.
The Texas Department of Insurance has an online resource, Your Health Care Coverage, which provides general information about health care coverage available in Texas. If you have insurance, your health plan’s policy or benefits booklet has detailed information about covered services, networks and your responsibilities for payment. Certain terms are defined in the “Basic Health Coverage Terms” section.
You should contact your health plan if you have questions about your coverage and out-of-pocket costs.
The Patient Protection and Affordable Care Act of 2010 – often called “Obamacare” – has made health insurance available to more Americans. The federal legislation’s ultimate goals are to reduce the nation’s uninsured population and to make health care coverage more accessible and affordable for everyone. Key provisions require insurers:
to provide coverage without regard to an individual’s pre-existing medical conditions,
- to remove lifetime and annual maximum caps on benefits provided,
- to eliminate waiting periods for coverage to begin, and
- to guarantee renewal or continuation of coverage for all individuals.
A provision in the law requiring every individual to have health insurance coverage took effect Jan. 1, 2014. Penalties for failing to obtain coverage are included. After a fine of $95 per person or 1 percent of taxable income – whichever is higher – in 2014, the penalties gradually increase to 2.5 percent of the individual’s taxable annual income.
The PPACA envisioned two ways to help uninsured individuals purchase insurance:
- A federal Health Insurance Marketplace where individuals without access to affordable health insurance coverage can compare policies and those between 100 percent and 400 percent of poverty can obtain subsidies in the form of tax credits to help purchase insurance; and
- Expansion of state Medicaid programs to cover those below 100 percent of poverty and up to 133 percent of poverty. (Note: The Texas Legislature chose not to expand Medicaid coverage.)
The law also has provisions to encourage small businesses with fewer than 50 full-time employees to provide coverage. The Small Business Health Options Program Marketplace offers small employers the opportunity to compare qualified health plans, and qualifying small businesses may obtain tax credits of up to 50 percent of an employer’s contribution toward employees’ premium costs.
Those with insurance – usually some type of group policy, such as through an employer – may see a few changes in their covered benefits, plus potential premium increases. Those currently covered by Medicare or Medicaid likely will see few changes.
The Texas Department of Insurance and the Office of Public Insurance Counsel offer information to help you learn about health insurance coverage.