Health Services Coverage Guide

by Alex Musk

Getting sick can be very expensive. Even minor illnesses and injuries can cost thousands of dollars to diagnose and treat. Health insurance helps you get the care you need and protects you and your family from financial loss if you get sick or injured.

How can I get health insurance?

You can get health insurance:

  • through your job, if your employer offers it;
  • buying a plan offered by a group such as a membership association, union, or church;
  • buying it from an insurance company or agent;
  • buying it through the federal health insurance marketplace; or
  • through a government program such as Medicare or Medicaid.

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

Insurance that you buy directly from a company or the marketplace is called individual coverage because it is sold directly to individuals, not to members of a particular group.

How can I get coverage for my family?

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

You can keep your dependent children on your plan until they turn 26. They do not have to live at home, be enrolled in school, or be claimed as dependent on your tax return. You can keep children who are married on your plan, but you can’t add a spouse or children.

If you have dependent grandchildren, you can keep them on your plan up to age 25. 

Generally, you must purchase health insurance during the open enrollment period

The open enrollment period for individual and marketplace plans is November 1 through December 15 of each year. You can buy health insurance at other times of the year only if you lose your coverage or have a life change, such as getting married, divorced, having a baby, or adopting a child.

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

You cannot be denied coverage because of a pre-existing condition

Insurance companies must sell a plan to anyone who asks for it during the open enrollment period. Insurance companies cannot deny you coverage or charge you more because of a pre-existing condition or disability.

Health insurance cost

The cost depends on your circumstances. You will have to pay for insurance premiums and part of the cost of your health care. The insurance premium is the monthly amount you pay for coverage. In deciding your insurance premium, insurance companies will consider:

  • your age,
  • the place where you live,
  • if you smoke or use tobacco, and
  • whether the coverage you are buying is for an individual or a family.

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

Insurance premiums for individual plans are locked in for one year. Prices generally increase when you renew your plan to reflect your age and the rising cost of health care. Federal law requires companies to justify price increases of 10 percent or more.

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

Insurance premium tax credits can help you pay for coverage

Tax credits are amounts that are deducted from what you owe in taxes. You can use these savings to pay your health insurance premiums. To get a tax credit, you must buy a health plan through the Marketplace. Your income must be between 100 percent and 400 percent of the federal poverty level. In 2019, this means an income of between $12,140 and $48,560 for an individual or between $25,100 and $100,400 for a family of four.

You can’t get a tax credit if your employer offers low-cost health insurance or if your income is less than the poverty level.

You and your health plan share the cost of your health care

All health plans require that you pay part of the cost of your health care. This is called cost-sharing. In addition to insurance premiums, you generally must meet a deductible and pay copays and coinsurance.

  • The deductible is the amount you must pay before your plan begins to pay. For example, if your deductible is $1,000, your plan will pay nothing until you have paid $1,000 out of pocket. You will have to meet the deductible payment each year. Some plans have more than one deductible. For example, you may have a deductible for in-network care and a separate deductible for care that is provided out-of-network. If your plan covers your family, you will have a separate deductible for each family member and a deductible for the family. Some plans do not have deductibles.
  • Copayments are the amount you pay each time you receive a covered health service. For example, your plan might charge you $25 when you see your doctor and $15 when you fill a prescription. You will also have a copay if you go to the emergency room or see a specialist. Amounts vary by plan.
  • Coinsurance is the amount you pay for a covered service after you’ve met your deductible. It is usually the percentage of the cost of a service. For example, your health plan might pay 80 percent of the cost of surgery or a hospital stay. You pay the remaining 20 percent. The percentage you pay in coinsurance varies by plan. You generally do not have to pay coinsurance in an HMO.

Federal law sets limits on the amount you have to pay out of pocket in a plan year. In 2019, the cap amount is $7,900 for an individual and $15,800 for a family. Some plans have lower limits that you pay out of pocket. After you reach the limit, you don’t have to pay copays or coinsurance for the rest of the plan year. However, you still have to pay for insurance premiums. A plan year is the 12-month period from the date your coverage began. For example, if your coverage began on September 1, your plan year runs through August 31.

Your rights in health insurance

Companies cannot set dollar limits on your health care. Insurance companies cannot stop paying your claims just because they have already paid a certain amount for your health care.

Your policy cannot be voided.  Insurance companies cannot rescind your policy if you unintentionally made a mistake on your insurance application. Companies can rescind a policy only if you commit fraud or submit false information on your application. Rescind means to cancel a policy up to the effective date as if it had never been issued.

Coverage renewals are guaranteed. Most individual health plans have a renewal guarantee. This means that your insurance company cannot 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 from your home or office. Health plans must also:

  • Have enough providers to meet the needs of its members.
  • Allow you to continue seeing your doctor for some time after your doctor leaves the network. To do this, you must have a terminal illness, disability, life-threatening condition, or be pregnant. The doctor must agree to continue treating you at the plan’s contract price.
  • Pay for care to stabilize your condition after an emergency. If you receive emergency care at a facility outside of your network, you may be transferred to an in-network hospital when your condition is stable.
  • Pay for care outside of your network if you need medical care that is not available in the network.

Employers are required to 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 haven’t done so before. You can also use it to cancel or change your coverage.

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