The following steps can help you obtain the individual health coverage you need:
- Seek coverage through your employer or past employer
- Locate other group coverage
- Determine whether you qualify for Medicaid
- Buy an individual policy from a private carrier
- Apply for coverage through the Texas Health Insurance Pool
- Find low-cost health services in your area
1. Seek coverage through your employer
If you're employed, your first step should be to determine whether your employer offers an employee group health plan, and if so, find out the details. If you're retired, find out whether you can obtain coverage through your employer's retirement plan. Group health coverage through an employer is typically the easiest to qualify for and is often the most affordable option.
Employers may place certain restrictions on plan membership, however by law these rules must be applied to all employees equally. A plan may therefore only be offered to employees who are above a certain pay grade, work within a particular division, or work a minimum number of hours per week. Arbitrary eligibility rules - such as only offering coverage at a manager's discretion- are never legal however. In addition, health risk factors, such as your current health status or medical history, may never be used as a requirement for plan membership. Therefore, an employee health plan may be a good option for coverage if you have a pre-existing condition. Be aware, however, that you may have to wait a certain period of time before pre-existing conditions are covered.
Employees are typically eligible to join a plan on their date of hire or the time they become members of the class of employees to which the plan is offered. However, if you do not join within 30 days of the time you first become eligible, you may have to wait until the next open enrollment period. Group plans have an open enrollment period each year which lasts for 30 days.
Employee health plans may be indemnity coverage, meaning you may have to pay for services and file a claim for reimbursement; managed care plans, meaning you usually must obtain services from within a particular "network" of providers; or preferred provider plans that combine various features of indemnity coverage and managed care.
One drawback of joining an employer-sponsored plan is that you probably won't have a great deal of choice in deciding the terms of coverage. You typically must either accept a health plan or reject it, although some employers may offer you the choice of multiple plans at varying rates. The rules governing which coverages an employee health plan must include and which are optional can be complex. Whether your company is a large employer (defined as having more than 50 full-time workers) or a small employer (defined as having between 2 and 50 full-time workers) and whether a plan is managed care or indemnity will have a significant impact on the coverage available and the cost of the plan.
2. Locate other group coverage
If employer-sponsored group coverage isn't an option, you may be able to find other group coverage. Trade unions, religious institutions, professional associations, and fraternal organizations sometimes offer health coverage as a membership benefit.
Group health plans offered by entities other than employers may provide coverage that is narrower in scope. They typically cover fewer conditions and have higher deductibles than employer-sponsored plans. It is also less likely that a non-employer group sponsoring a plan will contribute to the cost of coverage. This means you'll have to pay the entire premium yourself. Non-employer group plans are usually more expensive than employer-sponsored plans, although they are still often less expensive than an individual policy, particularly if you have existing health problems.
Groups must make their health plans available on equal terms to all members. However, a plan might only be offered to members who have belonged for a certain period of time, achieved a certain rank within the group, or meet particular underwriting standards. Health risk factors may not be used to determine eligibility for plan membership. Therefore, group coverage may be a good option if you have a pre-existing health condition. Be aware, however, that you may have to wait a certain period of time before pre-existing conditions are covered.
Group members who do not join a plan within 30 days of the time they first become eligible may have to wait until the plan's annual 30-day "open enrollment" period in order to join.
Before joining a non-employer group plan, you should ask other participating members in the group about their experience with the coverage. Most plans are reputable, although fraud schemes have been known to operate under the pretense of offering coverage through a non-employer group. Such an operation will likely collect your premium but disappear if you have a claim.
3. Determine whether you qualify for Medicaid
The Health and Human Services Commission (HHSC) determines Medicaid eligibility in Texas. People who receive Temporary Assistance for Needy Families (TANF), also commonly known as welfare, automatically qualify for Medicaid. Other people also may qualify based on their income and resources, including:
- Families that have high medical bills they can't pay
- Families and individuals that leave TANF for work or whose time limits have expired
- Low-income children under age 19 and pregnant women
- Youths aging out of foster care
Different eligibility requirements apply to each group. In order to find out if you qualify, you need contact your local HHSC Eligibility Office.
- Call 2-1-1, the national abbreviated dialing code for access to health and human services information, to reach a Health and Human Services representative who can determine whether you qualify for Medicaid.
- Go online to the State of Texas Assistance Referral System (STARS) for an interactive map to help you locate a Medicaid assistance office in your area.
4. Buy an individual policy from a private carrier
If you're unable to obtain a group policy and exceed the income requirements for Medicaid, you may be able to buy individual coverage directly from a Texas-licensed health carrier. View a list of carriers offering individual plans or search for an individual health plan on TDI's website.
Individual policies can be expensive, and carriers will evaluate an applicant's health risk factors before making a decision to issue coverage. That means that if you have a serious medical condition, or are predisposed toward a certain condition, a carrier may decline to issue coverage. However, if a carrier declines to cover you, keep shopping. Each carrier has different criteria for accepting customers.
Individual coverage may be purchased as either an indemnity or managed care plan. Indemnity plans are sold exclusively by insurance companies, and will generally cover services from any licensed health provider as long as treatment is consistent with the terms of the policy. Managed care plans can be sold by both insurance companies and HMOs.
Typically, managed care plans are more affordable than indemnity plans, but indemnity plans provide members with the most flexibility in obtaining health services. The trade off is essentially choice versus cost.
Both carriers and agents must hold a valid Texas insurance license to legally sell insurance in the state. Before purchasing any individual health plan, it is important to verify that the carrier and agent are licensed. Verifying that the carrier is licensed protects you against fraud. In addition, a state guaranty association will pay some or all of the claims of a licensed carrier should it become insolvent. If you buy from an unlicensed entity, you may have to pay the costs of any claims yourself. For many health care services, this cost could be significant.
5. Apply for coverage through the Texas Health Insurance Pool
If you are unable to obtain coverage through any other source, you can apply to join the Texas Health Insurance Pool (Health Pool). The Health Pool is a program primarily intended for Texans who are unable to obtain insurance from licensed private insurers because of their health condition.
Health Pool coverage is similar to that included in employer-sponsored or private insurance plans. Benefits cover hospital stays, physician services, and prescription drugs. The Health Pool also provides coverage for serious mental illness, subject to calendar year maximums for inpatient and outpatient treatment. The Health Pool does not cover treatment for chemical dependency or drug abuse.
Coverage through the Health Pool can be expensive - premiums are twice the rate charged in the standard market, as required by state law.
To qualify for Health Pool coverage, you must be one of the following:
- a federally defined eligible individual (HIPAA)
- rejected for substantially similar individual coverage for health reasons
- unable to find substantially similar individual coverage, except with riders that exclude coverage for medical conditions.
- a dependent of an adult covered by the Health Pool
- certified by an agent as unable because of a medical condition to obtain substantially similar individual coverage from a licensed insurance company or HMO that the agent represents
- diagnosed with a medical condition that automatically qualifies a person for coverage from the Health Pool.
If you are still eligible to continue an employer-sponsored health plan after separation from a job under the terms of federal COBRA regulations, you may be eligible for the Health Pool, but with a preexisting condition waiting period.
The health pool has a premium subsidy program to help enrollees whose household incomes are at or below 300 percent of the federal poverty level. If you are now in the Health Pool, or are considering the Health Pool for coverage, and would like to know if you qualify for a premium subsidy, please review the subsidy application form.
For more information about premiums, visit the health pool's rate information webpage.
The Health Pool website provides more information.
6. Find low-cost health services in your area
For more information about other options and programs that may be able to help, visit our Resources page.
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