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 insurance helps you get the care you need and protects you and your family financially if you get sick or injured.

How do I get health insurance?

You can get health insurance:

  • through your job, if your employer offers it;
  • by buying a plan offered by a group like a membership association, union, or church;
  • by buying it from an insurance company or agent;
  • by buying it through the federal health insurance marketplace; or
  • through a government program like 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 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 members of a particular group. For lists of companies and health maintenance organizations (HMOs) that sell individual health insurance in Texas, visit the Lists of Companies and HMOs page on our website at www.texashealthoptions.com//cp2/index.html.

How do I get coverage for my family?

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 covers only you, or you and 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.

You usually must buy health insurance during the open enrollment period

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 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.

You can’t be turned down if you have a preexisting condition

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.

Cost of health insurance

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:

  • your age;
  • where you live;
  •  whether you smoke or use tobacco; and
  • whether the coverage is for one person or a family.

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 percent or more. For more information, visit HealthCare.gov’s Rate Review page at
https://ratereview.healthcare.gov/.

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.

You and your health plan share the cost of your care

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.

  • A deductible is the amount you must pay before your plan will pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 yourself. You’ll have to meet a deductible each year. Some plans have more than one deductible. For instance, you might have one deductible for in-network care and another for out-of-network care. If your plan covers your family, you’ll have a separate deductible for each family member and a deductible for the family. Some plans don’t have deductibles.
  •  Copayments are fees you pay each time you get a covered health service. For example, you might have to pay $25 when you go to the doctor and $15 when you fill a prescription. You’ll also have a copayment if you go to the emergency room or see a specialist. The amounts vary by plan.
  • Coinsurance is an amount you pay for a covered service after you’ve met your deductible. It’s usually a percentage of the cost of the service. For example, your health plan might pay 80 percent of the cost of a surgery or hospital stay. You pay the other 20 percent. The percentage you pay in coinsurance varies by plan. You usually don’t 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 limits are $7,900 for one person and $15,800 for a family. 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.

Types of health plans

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:

  • HMO plans;
  •  exclusive provider (EPO) plans;
  • preferred provider (PPO) plans; and
  • point-of-service plans.

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.

HMO plans

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.

EPO plans

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.

PPO plans

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.

Point-of-service plans

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.

How health plans compare

HMO EPO PPO Point-of-service
What’s the cost? Generally lowest of all plans Usually lower than PPO Generally highest of all plans Usually lower than PPO
Do I have to use providers in the network? Yes (except for emergencies and for care that isn’t available in network) Yes (except for emergencies and for care that isn’t available in network) No (but you’ll have to pay more if you go out of network) No (but you’ll have to pay more if you go out of network)
Do I have to choose a primary care physician? Yes No No Usually
Do I need a referral to a specialist? Yes No No Usually