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.
Finding Health Insurance
briefly covers special health plans for small employers, coverage available through the Texas Health Insurance Risk Pool, the Children’s Health Insurance Program and employers’ self-funded health plans.
Private Insurance Coverage
Self-employed individuals and workers who do not have access to health insurance through their employers may purchase individual and/or group health policies. The following resources may help you:
- A Consumer Guide for Getting and Keeping Health Insurance – State-by-state information on your rights under federal and state law that will protect you when you seek to buy, keep, or switch your health insurance (Georgetown University Health Policy Institute)
- Questions and Answers About Health Insurance – Describes the different kinds of health insurance plans available. (America’s Health Insurance Plans)
- Managed Care Answer Guide – Guide to assist you in choosing, understanding, and utilizing your health plan. (Patient Advocate Foundation)
TDI’s Web site may help you understand health insurance options. TDI has lists of:
- Companies authorized to offer consumer choice benefit plans;
- Companies offering small employer accident and health coverage;
- Insurance companies authorized to sell individual health policies;
- Insurance companies authorized to offer Preferred Provider Organization health plans;
- Insurance companies authorized to offer medical savings accounts; and
- Insurance companies authorized to offer dental plans.
If you cannot obtain health insurance as a result of a pre-existing medical condition, or qualify as a “Federally Eligible” individual, you may be able to purchase insurance through the Texas Health Insurance Risk Pool.
If you have insurance through your employer and leave the company, a federal law allows you to continue your insurance coverage through your former employer for up to 18 months, although you will have to pay the entire premium. Get more information about COBRA continuation of coverage.
Medicare is a federal health insurance program that covers those age 65 and older, as well as disabled individuals. Supplemental insurance may be purchased to help offset the costs not covered by Medicare. These resources will help you learn more about Medicare coverage:
- Medicare Personal Plan Finder – Allows you to identify and compare Medicare health plans that are available in your area. (Centers for Medicare & Medicaid Services)
- Understand Your Health Insurance and Medicare Options – Information to help you understand Medicare, Medicare supplemental insurance (Medigap), managed care, and other health insurance options. (American Association of Retired Persons)
- Your Medicare Coverage and Frequently Asked Questions – Provide information about health care benefits in the Original Medicare plan. (Centers for Medicare & Medicaid Services)
Medicaid provides access to health care for qualified low-income pregnant women and children as well as people who are elderly or who have a disability. Applications for Medicaid and other services for low-income families are taken at local Medicaid offices, or may be made online. Call the toll-free Texas Medicaid Hotline at 800/252-8263 between 7:30 a.m. and 5:30 p.m., Monday through Friday for assistance, or visit the Texas Medicaid Web. Additional information is available here.
The Children’s Health Insurance Program provides coverage for children whose family income exceeds the amount to qualify for Medicaid but do not earn enough to buy private health insurance. Families pay premiums and share the cost of services based on their income for doctor visits, prescription drugs and emergency care. To find out more, call toll-free 800/647-6558 or visit the CHIP Web site. Additional information is available here.
Resources are available to help individuals find coverage if they cannot obtain it from their employer. In addition, public programs are available to help those unable to afford to buy private insurance coverage.
Quality And Performance
Resources are available to help you compare health maintenance organizations. The Office of Public Insurance Counsel publishes reports that compare HMOs on various measures, including provision of preventive care services and client satisfaction. The Texas Health Care Information Collection also publishes comparative data about health plans in Texas.
Consumers have a right to know in advance an estimate of what a medical procedure or treatment will cost. The charge for the procedure or treatment is the “retail”price. If you have insurance, your health plan has negotiated a discount, and your out-of-pocket costs will depend on your policy’s deductible and copayment requirements. If you do not have insurance, you may qualify for a government program or for free care. If not, your provider may offer a discount. More detailed information is available in the Hospitals section.
Texas PricePoint is an online tool to help you compare average charges among hospitals for certain conditions or inpatient and outpatient procedures.
Getting Your Claims Paid
If you have insurance, the hospital and/or physician likely will file a claim with your insurer. You will be billed for your deductible and copayment amount. Your health plan will send you an Explanation of Benefits that shows the amount billed, the amount paid by the health plan and the patient’s responsibility. The following resources may assist you in understanding how claims are filed and paid.
- Interpreting Your Explanation of Benefits – This Patient Advocate Foundation webpage helps you understand the explanation of benefits you receive from your insurance administrator.
- Understanding Your Insurance Plan – The Patient Advocate Foundation has an online publication to help you understand usual, customary and reasonable charges, and how your deductible/co-pay amounts work with charges.
- Understanding Your Bill in the “Hospitals” section provides more information.
The Texas Department of Insurance assists consumers with insurance-related complaints. TDI’s web page, “Helping You With Your Insurance Complaint” explains how TDI can help you with your insurance problem as well as how to file a complaint.
If you are an employee or family member of an employee who receives health benefits from a health plan provided through employment in the private sector, the federal Employee Retirement Income Security Act protects you. Among the protections, ERISA sets standards for administering these plans. Those standards require plans to give you important information and to have a fair process for handling benefit claims. These claims and complaints are not handled by the Texas Department of Insurance, but are handled by the U.S. Department of Labor. Information on how to file a benefits claim or appeal a denied claim may be found here.
If you have a complaint about your bill, first contact the provider of the service. Additional information about making complaints about hospital services is available under the “Hospitals” tab.