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Jul 25, 2023

Health care coverage guide

Español Getting sick can be expensive. Even minor illnesses and injuries can cost thousands of dollars to diagnose and treat. Major illnesses can cost many times that. Health care coverage helps you

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Getting sick can be expensive. Even minor illnesses and injuries can cost thousands of dollars to diagnose and treat. Major illnesses can cost many times that. Health care coverage helps you get the care you need and protects you and your family financially if you get sick or injured.

You can get it through:

Insurance you get through your job or an association is called group insurance. You must be a member of the group to get coverage. Most people get health insurance through their job, but not all employers offer it.

Insurance you buy directly from a company or the marketplace is called individual insurance because it’s sold to individuals, not to a group. For lists of companies and health maintenance organizations (HMOs) that sell individual health insurance in Texas, visit the Companies that sell health plans page on our website.

To buy through the marketplace, visit HealthCare.gov or call 800-318-2596.

You must meet eligibility requirements for government health care programs. For more information about government programs, visit Benefits.gov.

Learn more: Health insurance: 5 things you may not know | Watch: Are you suddenly needing health insurance?

You can add your family to a work health plan. If you buy from an insurance company or the marketplace, you can buy a plan that also covers your family.

You can keep your dependent children on your plan until they turn 26. They don't have to live at home, be enrolled in school, or be claimed as a dependent on your tax return. You can keep married children on your plan, but you can’t add their spouses or children to it.

If you have dependent grandchildren, you can keep them on your plan until they turn 25.

The open enrollment period for marketplace and individual plans is from November 1 to December 15 each year. You can buy at other times only if you lose your coverage or have a life change. Life changes include things like getting married or divorced, having a baby, or adopting a child.

You can sign up for a work health plan when you’re first hired or have a major life change. You have 31 days to decide whether you want to join the plan. You might have to wait up to 90 days for your coverage to start. If you join your work plan, you must wait until the next open enrollment period if you decide to drop out or change your coverage. The open enrollment period for work plans might be different from the marketplace period.

Insurance companies must sell to anyone who applies during the open enrollment period. They can’t deny you coverage or charge you more because of a preexisting condition or disability.

The cost depends on your circumstances. You’ll have to pay premiums and part of the cost of your care. A premium is a monthly fee you pay to have coverage. To decide your premium, insurance companies will consider:

They may not consider your gender or health factors, including your medical history or whether you have a disability.

Premiums for individual plans are locked in for one year. Rates usually go up when the plan is renewed to reflect your age and higher health care costs. Federal law requires companies to justify rate increases of 10% or more. For more information, visit HealthCare.gov’s Rate Review page.

If you get health insurance at work, the insurance company will base premiums on the whole group. You might have to pay more if you use tobacco. Your employer might pay all or some of your premiums. If you include your family on your health plan, your employer usually won’t pay their premiums.

Tax credits are amounts taken off what you owe in taxes. You can use this savings to pay your health insurance premiums. To get a tax credit, you must buy through the federal marketplace. Your income must be between 100% and 400% of the federal poverty level.

You can't get a tax credit if your employer offers affordable health insurance or your income is below the poverty level.

For more information about tax credits, visit HealthCare.gov’s Saving Money on Health Insurance page.

All health plans require you to pay some of the cost of your health care. This is called cost-sharing. In addition to premiums, you usually must meet a deductible and pay copayments and coinsurance.

Federal law sets limits on the amount you pay out of pocket in a plan year. Some plans have lower out-of-pocket limits. After you reach the limit, you don't have to pay copayments or coinsurance for the rest of the plan year. You still have to pay premiums, though. A plan year is the 12-month period from the date your coverage started. For instance, if your coverage started on September 1, your plan year lasts until August 31.

Learn more: How to save money at the doctor | Care options and costs

There are four types of major medical health plans in Texas. Major medical plans cover a broad range of health care services. The four types are:

All four types are managed care plans. This means they contract with doctors and other health care providers to treat their members at discounted rates. These providers make up a plan’s network. Managed care plans limit your choice of doctors or encourage you to use doctors in their networks. In return, you pay less out of pocket for your care. The plans differ in the extent to which you can use doctors outside the network and whether you must have a doctor to oversee your care.

You must use providers in the HMO’s network. If you don’t, you might have to pay the full cost of your care yourself. There are exceptions for emergencies and if you need care that isn’t available in the network.

You must choose a doctor to oversee your health care. This doctor is called your primary care physician. You usually must get a referral from your primary care physician to go to a specialist. Women don’t need a referral to go to an OB/GYN if the doctor is in the HMO’s network. Under some circumstance, you can use a specialist as your primary care physician. To do this, you must have an ongoing, disabling, or life-threatening condition.

You must use providers in the network. If you don’t, you might have to pay the full cost of your care. There are exceptions for emergencies and if you need care that isn’t available in the network.

EPO plans usually don’t require you to have a primary care physician. You also don’t need a referral to go to a specialist.

You can go to any doctor you choose, but your out-of-pocket costs will be lower if you use doctors in the PPO’s network. You don’t have to choose a primary care physician, and you don’t need a referral to go to a specialist.

Like PPO plans, point-of-service plans let you go to any doctor you choose. But your out-of-pocket costs will be lower if you use doctors in the plan’s network. You usually must have a primary care physician and get referrals to specialists. Women don’t need a referral to go to an OB/GYN.

These types of health insurance provide only limited coverage. Companies selling them can deny you coverage or charge you more if you have a preexisting condition. They also usually limit the amount they will pay for your care.

Learn more: Alternative health plans

Coverages vary by plan. Coverage requirements are different for plans you get at work and those you buy directly from an insurance company. Even among plans you get at work, the requirements are different depending on whether you work for a small employer or a large one. If you ask, your plan must give you a Summary of Benefits and Coverages.

Federal law requires individual and small-employer plans to cover 10 types of health care services, called essential health benefits. In addition, Texas requires some plans to include certain health benefits. Some plans might cover more services, like adult dental and vision care and weight management programs.

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Federal law requires health plans to cover many preventive services at no cost to you. You might be able to get free check-ups, blood pressure and diabetes testing, contraceptives, mammograms, cancer screenings, and flu shots. Visit HealthCare.gov's Preventive Health Services page to see the full list of free services. You must go to a doctor in your network to get the free services.

Most plans require you to get approval before some covered services. For instance, you might need approval before having surgery or going into the hospital. Check with your plan to find out whether you need approval. If you don’t get approval, the plan might not pay.

If you disagree with a decision your health plan made, you have several options. You can appeal a decision, file a complaint, or ask for an external review of your case.

For more information about appeals and external reviews, visit our page, How to file an appeal or ask for an external review.

Learn more: Understanding an explanation of benefits

We can help you with issues involving insurance companies and health plans and people we regulate. We don’t regulate most health plans.

To learn if we can help you with a health insurance complaint, visit our page, How to file a health insurance complaint.

Patients get surprise medical bills if they get care outside their health plan’s network without realizing it. For example, you will probably pick a surgeon in your plan’s network. But you may not be asked to pick the anesthesiologist. If the anesthesiologist is out of your health plan’s network, you will get a surprise bill.

This is also known as “balance billing.” State and federal laws protect you from surprise medical bills. Find out what bills are covered by surprise billing laws on our page, How consumers are protected from surprise medical bills

For more information about getting help with a surprise bill, visit our page, How to get help with a surprise medical bill.

Companies can’t put dollar limits on your care. Insurance companies can’t stop paying your claims just because they’ve already paid a certain amount for your health care.

Your policy can’t be rescinded. Insurance companies can’t rescind your policy if you unintentionally made a mistake on your application for insurance. Companies may rescind a policy only if you commit fraud or lied on your application. Rescind means to cancel a policy back to the start date as if you’d never had coverage.

Coverage renewals are guaranteed. Most individual health plans are guaranteed renewable. This means your insurance company can't cancel your policy if you get sick.

Plans must have adequate networks. Texas law requires HMOs, PPOs, and EPOs to make covered services available within a certain distance of your home or office. Health plans also must:

Employers must have an open enrollment period each year. If your employer offers a health plan, the employer must have a 31-day open enrollment period each year. You can use this period to join the plan if you didn’t earlier. You can also use it to drop or change your coverage.

Use our Health plan shopping guide to shop smart for health coverage.

Guaranty associations pay claims for licensed insurance companies that go broke. There are separate guaranty associations for different lines of insurance. The Texas Life and Health Insurance Guaranty Association pays claims for health insurance. It will pay claims up to a dollar limit set by law.

It doesn't pay claims for HMOs and some other types of plans. If an HMO can’t pay its claims, the commissioner of insurance can assign the HMO's members to another HMO in the area.

Insurance companies may decide to stop offering a plan. If your company drops your plan, it must offer you another plan it sells. If it doesn’t sell any other plans, you’ll have to shop for new coverage.

You can usually continue your coverage temporarily under COBRA (the Consolidated Omnibus Budget Reconciliation Act).

Learn more: Need health insurance? How to find a new health plan now.

COBRA is a federal law that lets employees continue their health coverage for a period of time after they leave their job. It applies to coverage from employers with 20 or more employees. It doesn’t apply to plans offered by the federal government or some church-related groups.

You can get COBRA coverage if:

If your family was on your health plan, you can continue their coverage under COBRA. Your spouse and children also can continue their coverage if you go on Medicare, you and your spouse divorce, or you die. They must have been on your plan for one year or be younger than 1 year old. Their coverage will end if they get other coverage, don’t pay the premiums, or your employer stops offering health insurance.

You have 60 days after you leave your job to decide whether you want COBRA. You must tell your employer in writing that you want it. If you continue your coverage under COBRA, you must pay the premiums yourself. Your employer doesn’t have to pay any of your premiums.

Your COBRA coverage will be the same as the coverage you had with your employer's plan. If you continue HMO coverage and move out of the service area, the HMO will pay only for emergency care. COBRA coverage will end if your employer stops offering health insurance.

For more information about COBRA, call the Employee Benefits Security Administration at 866-444-EBSA (3272).

Texas law requires some group plans to continue your coverage for six months after COBRA coverage ends. Your plan must be subject to Texas insurance laws. State continuation doesn’t apply to self-funded plans since the state doesn’t regulate them.

State continuation lets you keep your coverage even if you can’t get COBRA. If you aren’t eligible for COBRA, you can continue your coverage with state continuation for nine months after your job ends. To get state continuation, you must have had coverage for the three months before your job ended.

You usually can’t get state continuation if you were fired.

Your employer must tell you about continuation of coverage within 30 days from the date your job ended.

These programs provide health care services. Some services might be free or low-cost.