Know Your Coverage
Your monthly premium is determined by your age, where you live, and whether you use tobacco. Depending on your family's income, you may qualify for a tax credit to help you pay for coverage. When shopping for or renewing a plan, you should make sure the premium is affordable. If you don't pay your premium on time, you have a grace period before your plan is canceled. If the company cancels your plan, you probably won't be able to enroll in a new plan until the next open enrollment period and you might owe a tax penalty for being uninsured.
Learn more about finding affordable health coverage
Benefits and Exclusions
Health care benefits vary by plan. This means that some plans might cover a particular treatment or service, while another plan might not. All Texas plans, however, must cover 10 essential health benefits:
- ambulatory patient services (outpatient care you get without being admitted to a hospital);
- emergency services;
- hospitalization (including surgery);
- maternity and newborn care;
- mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy); (Learn more about Coverage for Mental and Substance Use Disorder Services.)
- prescription drugs;
- rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills);
- laboratory services;
- preventive and wellness services and chronic disease management; and
- pediatric services, including oral and vision care.
What are My Benefits and Exclusions?
To learn what your plan covers, read your plan's summary of benefits and coverage (starting on Page 2). This outlines the plan's benefits, cost-sharing, and exclusions. If you want more detail, such as the prescription drug formulary or the full list of plan exclusions, read your policy or EOC.
What is a Network?
A network is a group of providers - doctors, hospitals, and other health care professionals - that have entered into agreements with health plans to treat their members at discounted rates. The health plan will pay a larger percentage of your covered health expenses when you use providers in its network. Therefore, you'll have lower out-of-pocket costs if you stay in the network. Also, your costs for in-network services are predictable since the provider and your health plan have negotiated the charges in advance. If you use providers that aren't in your network, you might have to pay the full cost of your care yourself.
An in-network provider is also called a preferred provider.
Who is in My Network?
Refer to Page 1 of a plan's summary of benefits and coverage to find out how to get the plan's preferred provider directory. Before seeking care, you should use your plan's provider directory to make sure you are treated by a preferred provider.
Balance billing -- or surprise medical bills -- often occurs when you get health care outside of your plan's network. Out-of-network providers haven't agreed to treat a health plan's members at discounted rates. Therefore, their rates are higher than the rates negotiated between a health plan and its preferred providers. Even if your health plan pays for some out-of-network services, it will only pay the allowed amount as determined by the insurer's selected methodology. You will have to pay the difference between what your plan will pay and what the out-of-network provider charges you. This is called balance billing. Out-of-network providers can bill you for these charges; preferred providers cannot.
There are some exceptions. In an HMO or EPO, you typically won't have to pay any balance-billed charges if you received out-of-network care because of a medical emergency or if there weren't any preferred providers available to treat you. In a PPO, you may be balance billed even for emergency services, but your expenses will count toward your in-network deductible and out-of-pocket maximum. If your balance-billed charges from a hospital-based provider are more than $500, you may request mediation.
For more information, visit the Avoiding Surprise Bills page.
Understand the Plan's Network
It's important to understand a plan's network to avoid unnecessary costs:
- understand the rules and protections associated with the plan type (preferred provider organization, exclusive provider organization, HMO, point-of-service plan)
- search the preferred provider directory to see which doctors are available in any specialty category you think you might need
- look at the plan disclosures to see if the plan has an adequate network in your area, or whether the plan has an active local market access plan for any provider area of practice
- use the preferred provider directory to identify whether the in-network hospitals near you have agreed to help assign preferred providers to your care
- for a preferred in-network hospital, look at how often an insurer's enrollees get care from out-of-network providers
- understand the methodology the plan uses to develop an allowed amount used to pay nonpreferred providers
For more information contact:
Last updated: 10/21/2016