As a Texas consumer, you should always examine completely the proposed health insurance coverage and understand the benefits as outlined in the coverage Summary of Benefits document. The goal in securing health insurance coverage should be to provide the most important benefits for the most affordable premium.
Before you make a decision regarding a particular health insurance plan, Stateside Insurance Services suggests you examine the health insurance carrier in detail. Important aspects related to the carrier’s financial rating should be identified. Financial rating organizations such as A.M. Best, Moody’s or Standard & Poor’s can provide information to compare different health insurance carriers’ financial strengths. Also, verify that the carrier you are considering is licensed to issue health insurance policies within Texas. All insurance business conducted in Texas is regulated by Texas Department of Insurance (TDI). TDI can be contacted as follows:
Texas Department of Insurance
333 Guadalupe
Austin, TX 78701
P.O. Box 149104
Austin, TX 78714
Telephone: (512) 563-6169
Consumer Help Line: (800) 252-3439
Website: www.tdi.texas.gov
The TDI website provides background information on all health insurance carriers licensed to issue coverage and complaint history. Other sources of information regarding health insurance carriers are your friends, family members or healthcare providers.
Information that you should identify before making a decision regarding a health insurance plan include:
- How is the deductible applied for a family with three or more family members?
- Do the healthcare providers, like doctors and specialists, you use participate in the carrier’s network?
- Does the plan limit benefits such as office visit co-pays?
- How extensive is the plan’s prescription formulary?
- How long has the plan been available in Texas?
- Do I qualify for a subsidy?
Once a policy has been identified as suitable coverage, it is important to complete the application as accurately as possible. An application for health insurance is actually a contract between the applicant and the health insurance carrier and is the basis for how the carrier and policyholder administer the policy. If information is inaccurately provided, the carrier can rescind the coverage within the first two years of a policy. A carrier’s ability to void a health insurance policy based on a misrepresentation or omission made when the policy was issued is known as the contestability clause.
When completing an application, in print or an online application, be sure you verify the accuracy of the information and provide the required signature attesting to the application’s accuracy. If payment is submitted with the application, be sure payment is made payable to the health insurance carrier. If an agent is involved with helping you submit an application, be sure to get complete contact information for the agent.
Stateside and our website www.texasplans.com maintains direct links that provide access to each carrier’s online application for Off-Marketplace coverage. Stateside can establish the online application account on behalf of our clients and complete 80% of the application. Once the online account has been established by Stateside, login information is forwarded to the client so the application can be reviewed, authorized and premium payment submitted.
Subsidy determination and enrollment for On-Marketplace plans can be just as easy. Stateside uses subsidy application software that provides direct Enhanced Direct Enrollment (EDE) as approved by the Health Insurance Marketplace. Stateside’s EDE software reduces the subsidy enrollment time from 1 hour to under 15 minutes. Once the software confirms the subsidy awarded by the Health Insurance Marketplace enrollment in the selected plan can be accomplished with one click.
Once enrollment is complete for either an Off-Marketplace or On-Marketplace plan Stateside continues to monitor the application to confirm that enrollment has been completed, the requested effective date assigned, premium payment posted and enrollment material received by the client.
In order to make health insurance more affordable and to increase enrollment by providing a financial incentive to secure coverage, the federal government introduced premium subsidies as a key component of the Affordable Care Act (ACA.) The goal of the subsidies is to help consumers who cannot access affordable coverage from employers or the private insurance market.
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. 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.
Health insurance plans offered within the exchange consist of three levels of coverage designated as metallic plans because they are titled Gold, Silver and Bronze. Each plan has a different actuarial value, which is the percentage of costs each plan will cover. For example, Gold plans will have an actuarial value of 80%, which means the plan will cover 80% of healthcare costs, and the remaining 20% will be the responsibility of the insured. Silver plans will provide an actuarial value of 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 150% of the FPL will be required to pay no more than 4.7% 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 |
| 100% to 150% FPL | 2.1 to 4.7% of Modified Adjusted Gross |
| 150% to 200% FPL | 4.7 to 6.5% of Modified Adjusted Gross |
| 200 to 250% FPL | 6.5% to 8.4% of Modified Adjusted Gross |
| 250 to 400% of FPL | 8.4% to 10.2% of Modified Adjusted Gross |
Texas insurance regulations provide consumers with a 10-day “free look” provision, which means you can review the coverage as offered by the health insurance carrier for 10 days, and if you elect not to accept the coverage, the carrier must refund in full the initial premium. The 10-day free look period starts when you receive the policy enrollment documents, not as of the effective date of the policy.
Texas is classified as a “file and use state” which means carriers must file plans with TDI, but the state has limited authority to regulate or approve rates. However, if rates filed with TDI exceed 10%, the plans are subject to review by State or Federal independent experts to determine if the rates are justifiable. The rate review procedure applies to all plans with effective dates after March 23, 2010.
Any decision regarding a change in coverage should be made without experiencing a gap in coverage. A gap in coverage means you have no access to coverage during that period. It is important that you consult and coordinate any change of coverage with your insurance broker before making a change.
Open Enrollment is a period each year when changes can be made to Affordable Care Act (ACA) plans. During Open Enrollment, Texas consumers can evaluate their plan options for the coming year and change coverage with a January 1 effective date. Open Enrollment is also the time if individuals have qualified for subsidies, which are paid by the federal government, that their subsidy application is updated, and the subsidy amount is adjusted and applied to next year’s premium. All changes to coverage must be completed during Open Enrollment or an individual must qualify for a Special Enrollment Period to be insured by an ACA plan after the close of Open Enrollment.
An individual also has a Special Enrollment Period (SEP) if the individual experiences a significant life event outside of the annual Open Enrollment period. The SEP duration is 60 days following the triggering of one of the following nine life events.
- Loss of Essential Health Coverage – includes loss of employer coverage or loss of Medicaid or CHIP as a result of a reported change in household income or other circumstances.
- Change in Family Size – marriage, divorce, death of a family member, birth, or adoption.
- Change in Citizenship – gaining status as a citizen or a lawfully present individual in the U.S.
- Enrollment Error – experienced an error in your original enrollment.
- Violation of Plan Benefits – an individual who enrolled in a qualified health plan and is able to demonstrate that the plan substantially violated a material provision of the plan.
- Change in Premium Subsidy Eligibility – becoming newly eligible or newly ineligible for the premium subsidy or cost sharing reductions.
- Relocation – new plans become available based on moving to a new area.
- Indian – the individual is an Indian, as defined by the Indian Health Care Improvement Act.
- Exceptional Circumstances – a qualified enrollee is subject to other exceptional circumstances as determined by the Exchange.
Typically, if an individual is applying during a SEP, they will be required to provide documentation that a life event has occurred. Either the Health Insurance Marketplace or the insurance carrier will review the documentation to verify that the individual qualifies for the SEP.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
Stateside can be contacted either by phone (866) 444-3332 (toll free) or by email at info@texasplans.com. Our Telephone Appointment System can be accessed through:
Phone Appointment Reservation.
By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.