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Affordable Texas health insurance  Texas health reform   Essential Health Benefits

Moving to a Mandated Benefits Texas Plan

In years past, healthcare providers have had the freedom to create and offer insurance plans that responded to the needs of the Texas market - plans that included or excluded a variety of options for consumers. But there's a new sheriff in town when it comes to benefits made available to the public. The Affordable Care Act (ACA) requires healthcare providers to include "essential benefits" in every available plan, beginning January 1, 2014.

What Does the Move to Mandated Plans Mean?

First and foremost, the addition of 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:

  1. Maternity care
  2. Mental health services
  3. Substance use services
  4. Preventative care
  5. Pediatric services (including dental and vision)

How will these Essential Benefits be added to existing Texas plans?

For Texas consumers with policies effective BEFORE or on March 23, 2010
For Texas consumers with policies effective AFTER March 23, 2010

Because you secured your policy before the Affordable Care Act was signed into law on 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.)

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.

What Can Texas Consumers Do?

The first thing you should do is take a deep breath. Healthcare reform is finally here, and there is a lot of confusion about the options available. Here are four things to think about, and we hope you'll call us to talk through them:

Do you qualify for a tax credit subsidy? Depending on your income level, you may qualify for a tax credit that can be applied to your monthly premium cost. Contact Stateside to determine if you qualify for one of the subsidies offered by the government.

Consider moving to a policy with a December 1, 2013 effective date. If you secure coverage with a December 1st effective date, you delay the transition to (and expense of) a mandated benefit plan until December 1, 2014. If you don't anticipate needing the newly required benefits such as maternity during 2014, this could afford you and your broker some valuable time to watch the market stabilize in the early months of 2014. When open enrollment reopens on October 15, 2014, you would select a plan in line with the essential benefits requirements, effective in December 1, 2014.

Evaluate which of the four mandated benefit plans is to your advantage - platinum, gold, silver, or bronze. Although all plans will have the essential benefits, the plans will vary by actuarial value, which means the amount of healthcare expenses that will need to be paid by the insured. Texas policyholders will want to understand which plan type is best suited for their health history and current insurance needs.

Do nothing and let the insurance provider move you to a mandated benefit plan. 

We don't yet know how insurance carriers will transition their non-grandfathered plans to one of the mandated plans in Texas (platinum, gold, silver, and bronze). Stateside can assist with whatever documentation is rolled out, maintaining contact with your carrier to implement the transition hassle-free. Health insurance is too important to handle carelessly. Rely on Stateside's experience and strong relationships with carriers to handle your coverage changes with no problems.


At Stateside, we’ve monitored the Affordable Care Act since it was signed into law in 2010.

We have studied and researched the ACA as the rules and regulations were being promulgated. And since the beginning, our Stateside Team has been certified with the Health Insurance Marketplace for every Open Enrollment period.

If you have questions about subsidy eligibility, plan options, carriers, premiums or enrollment, contact us for straightforward advice about the upcoming Open Enrollment.

Contact Stateside by email at  or call us at (866) 444-3332.


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