Between high premiums and a limited enrollment period, buying a plan on the Affordable Care Act (ACA) marketplace can be challenging. If you don’t have access to an employer-sponsored plan, your best option might be to purchase an individual plan from the marketplace. However, they are not available for purchase year-round and can get expensive, so you should explore alternatives like short-term Texas health insurance plans. Let’s look at some of the plan types available.
Comprehensive major medical plans
ACA plans
What makes a plan ACA compliant? All major medical insurance plans created since 2014 must meet the law’s requirements. They must cover 10 “essential health benefits,” such as preventive care at no cost, emergency services, hospitalization, maternity care, mental health and substance abuse, and prescription drugs. They can cover any legal residents regardless of any pre-existing conditions. Additionally, the plans have no annual or lifetime limit. The only way you can enroll in an ACA health plan outside the annual open enrollment, however, is if you qualify for a Special Enrollment Period.
Grandfathered plans
Many healthcare plans created before the ACA was implemented on March 23, 2010, are grandfathered. Those plans have stayed the same, which means they did not add some benefits required of ACA plans. For example, a grandfathered plan might not cover preventive health exams, may make them subject to a deductible, or may charge the same copays for them as doctor or lab visits. Grandfathered plans can exclude people with pre-existing conditions and charge premiums based on health status and/or gender. If you have a grandfathered plan, you can add dependents. (Employers offering grandfathered health plans can add new employees.) However, the plans are not available for new purchasers.
Texas Health Insurance plans
Providing health insurance for your employees can be a big decision in Texas. Here’s a breakdown to help you navigate the options:
Types of Plans:
HMO (Health Maintenance Organization): More affordable premiums, with a designated primary care physician (PCP) who coordinates care and provides referrals to specialists within the HMO network. Out-of-network coverage is usually limited.
PPO (Preferred Provider Organization): Offers more flexibility in choosing in-network and out-of-network providers. You don’t typically need referrals for specialists, but out-of-network care comes with higher costs.
High-Deductible Health Plan (HDHP) with Health Savings Account (HSA): Lower premiums with a higher deductible. HSAs allow tax-advantaged savings for qualified medical expenses.
Individual Coverage Reimbursement Account (ICHRA): A new option where you contribute a fixed amount towards employee’s individual health insurance premiums, tax-free.
What to Consider When Choosing:
Budget: HMOs typically have lower premiums, while PPOs offer more flexibility at a higher cost.
Employee Needs: Consider your workforce’s demographics and health care preferences. Younger employees might prioritize flexibility (PPO), while older employees with established doctors might prefer HMOs.
Network Availability: Ensure the plan offers adequate coverage in your employees’ locations.
Why Doctors Prefer PPOs:
Doctors generally receive higher reimbursement rates from PPO plans compared to HMOs. PPOs also involve less administrative hassle for doctors as referrals aren’t always required.
Additional Resources for Texas Health Insurance Plans:
Texas Department of Insurance: Texas small employer health insurance guide ON Texas.gov tdi.texas.gov
Blue Cross and Blue Shield of Texas (BCBSTX): BCBSTX health insurance for small groups ON bcbstx.com
Remember: Consultant with a qualified insurance broker to find the best Texas Health Insurance Plan for your specific needs and budget.
Other plans to consider
Some plans aren’t considered major medical insurance and don’t fall under ACA regulation. There are indemnity plans and short-term insurance options that might meet your needs and protect you in between jobs, until annual enrollment time, or at other times.
Indemnity plans
Indemnity insurance coverage pays a portion of your medical costs at the doctor or clinic of your choice. They operate on a fee-for-service basis. There may be a deductible to satisfy. After that, the plan pays the remainder of your health care costs based on the “Usual, Customary, and Reasonable (UCR) rate” in your area up to plan limits.
A variation of these plans is indemnity plans tied to specific diseases or situations, such as plans for cancer, other critical illnesses, or accidents. These plans usually pay lump-sum benefits directly to you to help cover deductibles and medical expenses. Others have specific benefit levels to reimburse some of your out-of-pocket costs for doctor visits, urgent care, hospital admission, and medications.
Short-term insurance plans
Short-term health insurance policies were developed as stopgap plans to provide coverage for urgent and emergency medical care. Since they aren’t intended to cover you for years, they don’t include all the ACA requirements, such as maternity or preventive care.
The terms and details vary for different short-term health plans. One important advantage to these plans is their availability at any time of year for a period of your choosing. It is usually easy to enroll, and many plans can take effect the next day. Another advantage is the fact they often cost less than other options because of their exclusions and intention to cover you for less than a year. They ensure you are not going without insurance if you are self-employed or between jobs.
Things to consider
Insurance plans vary greatly, so it is important to shop around. Prices can vary a lot from one provider to another. Additionally, make sure to review each plan’s Summary of Benefits and Coverage (SBC) so you can clearly compare options based on price, benefits, providers who take the coverage, and other features that may be important to you.
There are plenty of options for purchasing Texas health insurance. However, working with a broker who knows your market can help you assess which plan is best for your needs and your budget. If you are looking for Texas health insurance plans, Custom Health Plans are experts in the state market. Even better, all services are free and are covered by Insurance Carriers. They have more than six decades of experience serving individuals, the self-employed, and others in the Texas market. Contact Custom Health Plans today to help you find the right plan.
