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Affordable Texas health insurance  2016 Open Enrollment

Open Enrollment: Round 3

Open Enrollment has rolled around again. The next Open Enrollment period for the Affordable Care Act (ACA) begins on November 10. And it’s time to get ready! At Stateside, we have monitored healthcare reform since it was signed into law in March 2010 and will be ready to explain all the options available to Texans. As in previous years we’ll be writing applications for On Marketplace and Off Marketplace coverage and plan to have premiums and plan descriptions available for quoting by mid-October for the January 1 effective date.

What About Subsidies?

Thanks to the Supreme Court’s King v. Burwell decision, On Marketplace plans remain eligible for premium subsidies and will be available through Stateside. Apply from the 10 Minute Subsidy Application. Our new online On Marketplace enrollment will allow for smoother, speedier enrollment, with subsidy applications completed in less than 10 minutes – versus the previous 45-90 minutes.

Individuals and families who meet defined income requirements will be able to receive premium subsidies and financial assistance for out-of-pocket expenses. The goal of the subsidies is to help consumers who cannot access affordable coverage from employers or the private insurance market.

Income Eligible for Subsidy

In order to be eligible for the subsidies and assistance with out-of-pocket expenses, an individual or family’s gross income will be compared to the federal poverty level (FPL). The level of assistance will be determined by the percentage of gross income to the FPL as determined by number of family members. For example, in 2016 the FPL is $11,770 for a one-person household and rises by $4,160 for each additional family member. The FPL for a four-person family is $24,250. The FPL benchmark is adjusted for inflation each year.

Subsidies will be available according to ACA rules for individuals and families with incomes ranging from 100% to 400% of the FPL. The subsidies will be used to reduce the premium cost for health insurance coverage offered within the health insurance exchanges. Cost sharing assistance will be available for out-of-pocket expenses for those with incomes ranging from 100% to 250% of the FPL. Examples of out-of-pocket costs for which assistance will be provided are copays and deductibles that would typically be the responsibility of the policyholder.

Health insurance plans offered within the exchange consist of four levels of coverage designated as metallic plans because they are titled platinum, gold, silver and bronze. Each plan has a different actuarial value, which is the percentage of costs each plan will cover. For example, platinum plans will have an actuarial value of 90%, which means the plan will cover 90% of healthcare costs, and the remaining 10% will be the responsibility of the insured. Gold plans will provide an actuarial value of 80%, silver plans 70% and bronze 60%.

The premium for the silver plan will establish the level at which subsidies will be accessed. Since healthcare costs vary from state to state, silver premiums will also vary depending on the state. The percentage of premium paid by the insured will be tied directly to the individual’s actual income as a percentage of the FPL. For example, individuals and families with incomes at 133% of the FPL will be required to pay 2% of their income toward the health insurance premium.

The following is a list of FPL percentages and the percentage of income that the policyholder must pay for health insurance premium.

Income Level Annual Premium Not To Exceed Percentage of Income

Income Level

Annual Premium Not To Exceed Percentage of Income

Up to 133% FPL

2% of income

133 to 150% FPL

3 to 4% of income

150% to 200% FPL

4 to 6.3% of income

200 to 250% FPL

6.3% to 8.05% of income

250 to 300% of FPL

8.05% to 9.5% of income

300% to 400% FPL

9.5% of income


To illustrate the health insurance premium cost for plans in an exchange, assume a family of three had an income of $40,180. The FPL for this family would be $20,090 so their income places them at 200% of the FPL. The family would be required to pay 6.3% of their income or $2,531 towards the premium cost of the plan. Using the silver plan annual premium of $12,000 as the benchmark, the premium paid by the family would be $2,531 and the remaining $9,469 would be paid as a subsidy. The family can purchase any plan available from the exchange and use the $9,469 of earned subsidy to reduce the annual premium cost.

In addition to assistance with premiums, financial support for out-of-pocket expenses such as copays and deductibles are available to individuals and families whose incomes do not exceed 250% of the FPL. The financial support is known as cost sharing. In order to qualify for cost sharing the individual or family will be required to purchase at least a silver plan within the exchange. The amount paid by the insured for out-of-pocket expenses is based on a scale from 6% of out-of-pocket expenses for the lowest income levels up to 27% of out-of-pocket expenses for income levels up to 250% of the FPL.

Financial Assistance Summarized

Individuals and Families Up To 250% FPL

  1. Premium cost capped to be between 2% and 8.05% of income based on amount earned.
  2. Financial support for out-of-pocket expenses to be between 65% and 27% based on amount earned.

Individuals and Families with Income From 250% to 400% FPL

  1. Premium cost capped to be between 8.05% and 9.5% of income based on amount earned.

The Congressional Budget Office estimates that a combination of the two benefits – premium subsidy and out-of-pocket expense assistance – will result in average subsidy of $5,000 a year for individuals and families participating. Benefits will be much higher for families with lower incomes or several children.

Need-to-Know Info

Open Enrollment this year will be shorter than the last two years. This year’s Open Enrollment will be just 90 days long, including the Thanksgiving, Christmas and New Year holidays. In addition to Open Enrollment for health insurance, there’s Medicare Part D enrollment, which runs from October 15 to December 7. As a further complication, Blue Cross Blue Shield’s announcement that they won’t offer individual PPO plans for 2016 means significant changes for these policyholders. All of these factors will create an enrollment process that will resemble the first year enrollment when application delays were the norm not the exception.

The major difference between PPO plans and HMO plans concerns provider access. With PPO plans the insured member can go to any provider, but if they see providers in the PPO network the benefits are much more extensive. For example, an insurance plan can have an in-network deductible of $3,000 with an out-of-network deductible of $6,000. Out-of-network claims are filed against the higher deductible which means the coinsurance benefit is not available until the higher deductible is met. Most PPO benefits reflect similar changes when you compare in-network to out-of-network services.

HMO plans have more restrictive networks. In fact, most HMO plans do not even offer out-of-network benefits unless they are received during an emergency. Emergency is defined by insurance carriers as the potential loss of life or limb. HMO plans also require the insured member to select a primary care physician that serves as a gatekeeper for healthcare services. The primary care physician is the contact point for the initial consultation regarding any medical question. The primary care physician will make the initial diagnosis and if necessary refer you to a specialist in the HMO network.


How You Can Prepare: Early is Best!

Last year’s Open Enrollment was much smoother than in 2014, but we’re anticipating the shorter window to cause some logjams, especially around the holidays, when everyone’s rushing to meet the deadlines. Start early. To help you better manage Open Enrollment, email your information to us at

• Health insurance. Tell us about your healthcare providers. What physicians and hospitals are important to you? This information will allow our Stateside Team to identify health insurance that provides the strongest network participation.
• Prescription Information. Send us your ongoing prescription requirements. As you may know, carriers maintain formularies – lists of prescriptions eligible for benefits under their insurance plans. Our team will analyze your prescription requirements to determine the coverage providing the most favorable prescription benefit.

The sooner you provide your information, the easier Open Enrollment will be for you! Stateside Insurance Services has helped Texans understand the complexities of health insurance since 2003. Feel free to contact our Stateside Team by email at or call us at (866) 444.3332 to discuss your coverage situation and to determine how healthcare reform will affect your coverage options.
You can contact Stateside Insurance Services in whichever way is most convenient for you:
Toll Free: (866) 444-3332
Austin Local: (512) 542-9760
Toll Free Fax: (800) 349-2730


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You can get the enrollment process started using any of the following:

Click on the Instant Quote link and provide census information.  Stateside will respond with a proposal that outlines your various plan options with premium cost.

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