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Texas Health Reform FAQs

Q: Is my health insurance policy definitely changing, just because the Affordable Care Act is going into effect?

A: It depends on when your current policy began. If your effective-date is BEFORE March 23, 2010, your plan is considered a "grandfathered plan." This means that your plan can remain the same, if your provider continues to offer it as such. The federal government will not require your plan to adopt additional "essential benefits," thereby avoiding the premium increases related to these benefits. (Keep in mind that your healthcare provider may change your premium or offered benefits for other reasons, so always pay attention to any notices they share.) If your effective-date is AFTER March 23, 2010, your plan is considered a "non-grandfathered plan," and you have some important choices to make for 2014. Non-grandfathered plans must meet the essential benefit requirements that go into effect on January 1, 2014. Every non-grandfathered plan will transition on the plan anniversary date in 2014 to a plan that does include the essential benefit requirements. Texas consumers will be offered plans that correspond closely with their current plans or can apply for one of the plans offered in the marketplaces. Learn more about the Affordable Care Act

Q: Is my current healthcare provider going to move me onto an Affordable Care Act-compliant health insurance policy? Will they notify me about it? Do I need to do anything?

A: Because of all of the changes involved in the Affordable Care Act implementation, the details of how providers will convert existing policies over to ACA-compliant policies are not yet clear. Call us and let us help you navigate this transition. Contact Stateside at

Q: What's the single most significant change Texas health insurance consumers will witness with the advent of the Affordable Care Act (ACA)?

A: All plans will now have "essential health benefits" included, as required by law. This includes the addition of comprehensive maternity benefits to plans issued in the health insurance 'exchanges'. Learn more about maternity coverage.

Q: What are the "essential benefits" that everyone now gets across America, with any health insurance plan?

A: These essential benefits will significantly increase healthcare access for Texas consumers. These benefits will now be available on policies written in Texas, whether in the marketplace or outside of the marketplace: Maternity care; Mental health services; Substance use services; Preventative care; Pediatric services (including dental and vision). Learn more about maternity coverage.

Q: Can I get maternity coverage now?

A: Beginning October 1, 2013, Stateside Insurance Services will be able to quote plans - in the marketplace or out of the marketplace - that will include comprehensive maternity benefits with an effective date of coverage beginning January 1, 2014. Learn more about maternity coverage.

Q: I'm young and healthy. Does the Affordable Care Act require that I get health insurance? Do I really have to?

A: Thinking about foregoing health insurance altogether? Or, haven't had it in the past, and don't feel like you need it now? There is a penalty tax to consider. Starting in 2014, individuals who do not enroll in a qualified health insurance plan will pay a tax that is the greater of either: $95 per person, or 1% of household income. The tax will increase to $325 in 2015 and $695 in 2016. After 2016, the tax will be adjusted for cost-of-living. This penalty is intended to motivate you to get health insurance, feeding healthy dollars into the system. But it's glaringly obvious that the amount is not severe enough to encourage a healthy 27-year-old to buy insurance with a premium expected to be anywhere between $3,000 and $4,000 per year! Some subsidies will be in place, but even so, the premium would be far greater than $95 tax charged in 2014. If you can afford the tax, then consider this next topic - your window to get coverage for the year will close with a slammed door on March 31, 2014. In the past, you could apply for coverage almost anytime, and wait 14-30 days for your new plan to go into effect. With the Affordable Care Act, there is a very fixed period of time for enrollment - for every single healthcare provider. When this first ACA open enrollment period closes on March 31, 2014, you will be locked-out of the insurance market until the next open enrollment period begins on October 15th, when you can sign up for coverage starting January 1, 2015. In other words, as of April 1,, 2014, if you've chosen no plan, you cannot GET a plan for the rest of the year. You will be without coverage from that day until December 31st, no matter what. What if you have a water skiing accident at the start of summer, or tear your ACL snowboarding in December? What if you are diagnosed with an unexpected but simple condition in September and need some basic medication with no generic option, costing you hundreds of dollars out of pocket? Learn more about the requirement to purchase health insurance.

Q: Is the Affordable Care Act going to make health insurance more expensive?

A: We anticipate that everyone's premium will go up to offset the insurance carriers' significant additional cost for providing more care to more people. Of all of the benefits now required under ACA, maternity will increase premiums in Texas more than any other. Texas will experience a much higher percentage increase in premiums than other states such as California, which has offered maternity benefits for years. Everyone - those who plan to utilize the new maternity coverage and those who do not - should discuss with their broker smart ways to reduce the impact of premium hikes in 2014. Learn more about ACA expenses.

Q: How can I save money when the Affordable Care Act is rolled out?

A: The Texas marketplace is where consumers will access the federal advanced tax credit that will used to offset anticipated higher premium costs. Beginning on January 1, 2014, depending on an individual or family's household income, a large amount of the monthly premium could be paid by the federal government through the advanced tax credit. Learn more about the ACA tax credit.

Q: Do I quality for the federal advanced tax credit (subsidy)?

A: Depending on your income level, you may qualify for a tax credit that can be applied to your monthly premium cost. Learn more about the subsidy.

Q: I have a pre-existing condition that made health insurance impossible - or too expensive - for me in the past. What about now?

A: Under the Affordable Care Act, healthcare providers cannot deny you coverage because of pre-existing conditions.

Q: I have a rider on my current health insurance policy. Does the Affordable Care Act change that?

A: A rider is a permanent or temporary exclusion of benefits applying to services related to a specific medical condition, or treatment for a specific organ, system, or body part. Riders will no longer apply, or be valid, as of January 1, 2014. The Affordable Care Act requires that policies offered to U.S. citizens be issued with no exclusions or riders. Learn more about the full benefits provided by the Affordable Care Act. Learn more about changes to policies with riders.

Q: I need a health insurance policy for my child only. Is that possible?

A: The Affordable Care Act (ACA) will bring back the option of child-only coverage for Texas families. During the Initial Open Enrollment period from October 1, 2013 to March 31, 2014, parents will be able to select coverage from one of the four metallic plan options offered by the marketplaces - platinum, gold, silver, or bronze. All plans will include the required essential health benefits with preventative care services paid by the carrier at 100% with no deductible. Other essential health benefits that everyone will (and must) receive include prescription benefits and pediatric services, including vision and dental care. Learn more about child-only coverage options.

Q: My child has ADD, or ADHD, and our current health insurance policy considers that a pre-existing condition. We don't have prescription drug coverage for the medication he/she needs. Is this going to change?

A: Prescription benefits will no longer exclude prescriptions related to attention deficit or hyperactivity, which in the past were sometimes excluded. The coverage beginning January 1, 2014 will provide benefits for children with no exclusions for preexisting conditions and no waiting period for benefits. Learn more about essential benefits that the Affordable Care Act provides.

Q: My spouse and I both have full-time jobs with health benefits. In the past, we chose the better of the two plans being offered, and one spouse went onto the other spouse's plan. Should we be thinking about this differently for the future, under the Affordable Care Act? Are our employers going to offer the same plans, essentially, with everything that is being standardized now? How do we figure out if we qualify - together - for the subsidy?

A: Good questions. This is a case-by-case question, but here are some things to consider. If an employer provides coverage for the employee with a premium rate not exceeding 9.5% of that person's full household income, the employee is essentially locked into accepting that employer's offering - and not eligible for tax subsidized coverage from the exchange. Not only is the employee not eligible for the subsidy support, but the employee's spouse is also not eligible for tax subsidized coverage. The employee's premium will typically be subsidized by the employer, but coverage for other members of the family becomes the responsibility of the employee himself, or herself. Imagine paying 10% or more of your household income to health insurance coverage, when better options might be out there. Learn more about spouse coverage.

Q: My employer hasn't sent out any information about benefits changes. I feel like I don't know what's going on. What should I do?

A: Schedule a time to speak with your HR representative. Ask the big questions you're confused about - what's changing? Why? When? Which elements are mandated, and which elements require employees to make decisions about what they want and need? In addition to your HR team, Stateside is here to help you navigate your health insurance coverage needs. Learn more about employer-provided group coverage.

Q: My question isn't here. How can I get an answer?

A: Contact Stateside directly. We'd love to hear from you. You can use the box at the bottom of this page, contact us by email (, or call us at (866) 444-3332.

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