Advocates Urge Care in Choosing a Health Insurance Plan

health professional holding a mini shopping cart

Texans can shop for health insurance through the federal marketplace until March 31, 2014. To have coverage when it first starts on Jan. 1, you must enroll by Dec. 15.

Most Texans can buy private insurance through the federal Health Insurance Marketplace, although advocates are urging people to take their time and consider the options before making a decision. The initial enrollment period started on Oct. 1, 2013, and continues through March 31, 2014. To get coverage when it first starts on Jan. 1, you must sign up by Dec. 15.

Most Americans are required to have health insurance in 2014 or risk tax penalties under the Affordable Care Act (ACA). There is also a health insurance marketplace for small businesses that want to purchase coverage. Employers with 50 or more workers will be required to provide affordable coverage or pay fines starting in 2015.

How Does the Health Insurance Marketplace Work in Texas?

Eleven companies are offering Texans a variety of health insurance plans through the marketplace, with at least two plans in each part of the state. Texans can choose from an average of 54 health plans, with different deductibles, co-payment rates, covered benefits, network size and participating providers.

How Do Changes Affect People with Disabilities?

Starting in 2014, most health insurance companies cannot deny you coverage, charge more because of a pre-existing condition, or set lifetime dollar limits on health benefits. You can switch to a marketplace plan if it would provide better coverage for your needs. Individuals who are eligible for Medicare, Medicaid or the Children’s Health Insurance Program (CHIP) are not eligible for the marketplace, but continue to receive their same health care services.

Automatic Referral to Medicaid and CHIP Delayed

The federal marketplace was intended to identify applicants who are eligible for programs like Medicaid and CHIP and refer those individuals directly to these programs. This feature is not working yet. People who may be eligible for those programs should apply for them at YourTexasBenefits.com.

What Do the Insurance Plans Cover?

Each plan in the Health Insurance Marketplace provides coverage for essential health benefits. These include regular doctor visits; emergency care; prescription drugs; lab tests; mental health treatment; rehabilitation and habilitation, and other benefits.

How Do I Choose an Insurance Plan?

There are four main levels of coverage which determine how much your out-of-pocket expenses will be for the essential health benefits, after you reach your deductible. The bronze level covers 60 percent of the cost of essential health benefits; silver covers 70 percent; gold 80 percent and platinum 90 percent. A fifth, catastrophic level, is designed for young adults, 26 and 30, who are no longer covered by their parents and cannot afford better insurance.

The level you choose affects the cost of your monthly premium, as well as out-of-pocket costs such as co-payments and deductibles. As premiums go up, the co-payments go down. But, if you use a lot of prescriptions or health care services, plans that have lower premiums could end up costing more in the long run. You should also consider if the doctor or clinic that you want is on a plan, and if it gives you access to any additional benefits of value to you. Many doctors, hospitals and other providers are still deciding what plans they will join and this can affect which plan works best for you.

What Does Insurance Cost?

Monthly premiums vary based on where you live, your age and your subsidy level. Deductibles, co-pays and items that are not covered also vary with each plan. The lowest-cost bronze plan for all Texas markets averages about $210 per month for an individual. The lowest silver plan averages $287 a month. Premiums may be significantly reduced by income tax credits. You may qualify for a tax credit if you earn 100 to 400 percent of the federal poverty level. For 2013, that’s $11,490 to $45,960 for an individual, and $23,550 to $94,200 for a family of four.

Some People Fall through the Cracks

As passed by Congress, the ACA would have expanded Medicaid coverage to include Americans who earn between 100 and 138 percent of the federal poverty level. However, in June 2012, the U.S. Supreme Court ruled that state participation in Medicaid expansion is optional. About half of the states chose not to participate, including Texas. Individuals who were targeted for Medicaid expansion are now “falling through the cracks” in states that opted out of the expansion. These individuals make too much money to qualify for Medicaid benefits in those states, but not enough to be eligible for insurance subsidies. This means many adults who earn less than 138 percent of poverty receive little assistance in paying for health insurance, although they will not be fined for not having insurance. For example, to be under 138 percent of poverty level in 2013, an individual must earn less than $15,856. For a family of four, it is less than $32,429.

What if I Don’t Get Insurance?

Most people are required to have health insurance starting in 2014 unless the cost is more than 8 percent of your household income, your income is so low you do not have to file a tax return or you qualify for and receive another exemption. Otherwise, people without insurance will be charged an “individual shared responsibility payment” on their tax return.

How Do I Enroll in the Health Insurance Marketplace or Get Help?

To enroll in the Health Insurance Marketplace or get more information, you can:

  • Go to the HealthCare.gov website or the Spanish site at CuidadodeSalud.gov.
  • Call (800) 318-2596 anytime, with translation available in 150 languages, or call (855) 889-4325 if you are deaf or hard of hearing.
  • Use an online chat or find local resources on the marketplace’s Contact Us web page. Local resources include trained “navigators” who can walk you through the process in person. The navigators have at least 20 to 30 hours of training that includes accommodating people with mental, physical, sensory or cognitive disabilities.

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