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Resources & Guides to Help Texans Gain Access to Easy and Affordable Health Insurance.
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General Information
Individual and Family
Medicare
Terminology
General Information
Explanation of Benefits and How to Understand
An Explanation of Benefits, commonly referred to as an EOB, is a statement from your health insurance company providing payment details for medical service(s) you recently received. The EOB explains what portion of services were paid by your insurance plan and what...
HIPAA
Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) is legislation that provides data privacy and security provisions in order to safeguard medical information. It was created primarily to...
Dental Insurance
There are pros and cons to purchasing a dental policy, either from your employer or as an individual from a private insurance carrier. In some cases, dental coverage will not save you money at all, even if you are needing dental care.Dental plans emphasize preventive...
Why do health insurance policies rely on drug formularies?
Drug formularies are probably the least understood component of a health insurance policy. Texas consumers rarely discuss the prescription formulary and how a formulary functions before securing coverage. All Texas health insurance carriers rely on drug formularies...
What are the major differences between HSA plans and Non-HSA plans?
Health savings account (HSA) plans have become very popular because consumers are able to combine the tax deductibility traits of an Individual Retirement Account (IRA) with a high deductible health insurance plan. However, Texas consumers should identify the...
You got the C.O.B.R.A letter. Now what?
When an employee leaves employment, regardless if the separation is voluntary or involuntary, one of the first items to address is the letter outlining your benefits under C.O.B.RA. Although carrying the same name as the world’s largest venomous snake, there is...
Silver vs Bronze: Who takes the medal?
Key Topics: Metallic tiers were simplifiedCost-sharing was discontinued which resulted in “Silver Loading”Four major plan differences: deductible, out-of-pocket maximum, office copay and prescription benefitsPurchase decision justification When the Affordable Care Act...
Why Are Insurance Agents Regulated by the State?
When it comes to health insurance, the application and subsequent policy documents establishes the contractual requirements of the responsible parties, the insurance carrier and the policy owner. The insurance agent (or...
Bridge the Coverage Gap with Short-Term Insurance
If you didn’t enroll in health insurance during Open Enrollment or you are trying to reduce your premium expenses, short-term insurance can fill the gap before the next Open Enrollment, from November 1 thru December 15 for a January 1 effective date. There are many...
How To Survive Another Affordable Care Act (ACA) Open Enrollment
Key Topics: Get organized and start earlyCalculate household incomeLook at the past to help with plan selectionDon’t drag your feet and try to beat the deadline. Each year as Open Enrollment for the Affordable Care Act (ACA) approaches you vow to do a better job in...
Medical Air Transport
Most consumers believe their health insurance coverage will provide benefits when requiring air transport in response to a medical event. Their expectation is when they are injured while traveling for either pleasure or business or if medical care is need in an...
Evaluating Health Insurance in Texas
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...
Why a Consumer Should Rely on a Health Insurance Broker
The Internet has provided today’s consumer with a wealth of health insurance information. With a few keystrokes the consumer has access to multiple insurance carriers, plan details, benefits, premiums and the online application process. With all of this information...
Why Should You Pay Attention to a Health Insurance Formulary?
After determining a premium, most people focus their choice of insurance carrier on plan benefits such as deductibles, copayments, provider networks, and maximum out-of-pocket reimbursements. All these factors are important to understand, but people often overlook a...
What Is the Difference Between A Navigator and An Insurance Agent?
The Affordable Care Act (ACA) created a new entity that is involved in the distribution of health insurance products to the health insurance exchange or the health insurance marketplace as they are now known by. Navigators were created under ACA to assist with an...
Why Health Insurance Agents Must Maintain Continuing Education Credits
In the health insurance industry, contractual agreements are required between the insurance carrier and the policy owner; and the insurance agent, also known as a broker or producer, stands in the middle of both. The broker, through an appointment contract is...
Affordable Texas Health Insurance
Price is always foremost on the minds of Texas consumers when shopping for health insurance. At the same time, consumers typically want the most coverage for the least amount of premium. You can immediately see that there exists a significant conflict when the need is...
What Happens after Open Enrollment ends January 15, 2022?
A common misunderstanding is that an individual can enroll in an Affordable Care Act (ACA) plan at any time during 2022. This is not the case at all. Open Enrollment is scheduled to end on January 15th and ACA compliant plans will not be available again until the...
What Happens When Deductible Is Met?
Health insurance policies are divided into levels of financial responsibility for the policyholder: deductible and co-insurance. Although the probability of meeting deductible in any given year is somewhat unlikely, it is important to understand the insured’s...
Short-Term Coverage vs. Affordable Care Act Coverage
Key Topics: Executive order breathes life into short-term coveragePreexisting conditions limitations return with short-term coverageBenefits can be limited under short-term coverageLoss of short-term coverage does not qualify for a Special Enrollment Period...
How Does the Affordable Care Act Deal With Tobacco Use?
Health insurance carriers have, in the past, established higher premiums for policyholders who used tobacco products as compared to policyholders who abstained. It was generally accepted that users of tobacco products would generate higher claims expense because they...
The History of Healthcare Reform
The History of Healthcare Reform Healthcare reform was passed and signed into law by President Obama on March 23, 2010. Promulgation of rules and regulations began immediately with the first wave of rules taking effect October 1, 2010. Affordable Care Act History...
The Value of the Office Visit Co-Pay Benefit
When Texas consumers research health insurance options, the office visit co-pay is one benefit that is typically a priority when determining a plan selection. An office visit co-pay benefit has been considered a requirement for employer sponsored group coverage, which...
Health Insurance Exchange Overview
Health Insurance Exchange Overview Effective as of January 1, 2014 health insurance exchanges will begin to provide health insurance coverage options for consumers. A health insurance exchange is not a health insurance carrier but an inventory of standardized...
Blue Cross Blue Shield Silver Plus 202 vs. Oscar Classic Silver
Key Topics in Article: On-Marketplace & Off-Marketplace PlansAvailable Carriers in TexasBlue Cross Blue Shield Silver Plus 202 vs. Oscar Classic Silver Benefit ComparisonNetwork size within Texas The Affordable Care Act (ACA) was signed into law March 23, 2010...
Open Enrollment Tip – Don’t Call the Carrier
As Open Enrollment for 2021 approaches, Stateside Insurance Services is recommending that our clients not contact either their health insurance carrier or the Health Insurance Marketplace. I am sure that this sounds counterintuitive, but there are several reasons why...
Medical Insurance for the Overseas Traveler
Texas consumers believe that the health insurance coverage they maintain in the U.S. will be more than adequate when they travel to a foreign country. Nothing could be further from the truth. In fact, the plans issued under the Affordable Care Act (ACA) are...
Moving to a Mandated Benefits 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. With passage of the Affordable Care Act (ACA) healthcare...
Loss of Health Insurance Coverage
Loss of Health Insurance Coverage in Texas Texas consumers can lose coverage either from actions they have taken or by actions taken by the insurance carrier. In either instance, there are protections for the policyholder. It is first important to understand that...
Deductible: High or Low?
A health insurance plan deductible is a predetermined amount of money that an insured member must pay before the health insurance carrier is required to make any benefit payments. The purpose of a deductible is to keep costs reasonable by shifting the initial claims...
Healthcare Reform Alters Premium Payment Grace Period
Texas health insurance policyholders know that in order to maintain their coverage they must make premium payments according to the terms of the policy. For years Texas health insurance carriers have operated with this simple, straightforward approach that was fair,...
Evaluating Health Insurance in Texas
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...
Cheap Health Insurance
Everyone Is Looking for Cheap Health Insurance By far the most frequent request by Texas consumers for health insurance is that the coverage be cheap. When asking for cheap health insurance, the consumer is not considering the outcome of “cheap” insurance results in...
Blue Cross Blue Shield Gold 203 vs. Oscar Classic Gold
Key Topics in Article: On-Marketplace & Off-Marketplace PlansAvailable Carriers in TexasBlue Cross Blue Shield Gold 203 vs. Oscar Classic Gold Benefit ComparisonNetwork size within Texas The Affordable Care Act (ACA) was signed into law March 23, 2010 marking a...
Blue Cross Blue Shield Silver 205 vs. Oscar Classic Silver
Blue Cross Blue Shield Silver 205 vs. Oscar Classic Silver Key Topics in Article: On-Marketplace & Off-Marketplace PlansAvailable Carriers in TexasBlue Cross Blue Shield Silver 205 vs. Oscar Classic Silver Benefit ComparisonNetwork size within Texas The Affordable...
Individual & Family
Dental Insurance
There are pros and cons to purchasing a dental policy, either from your employer or as an individual from a private insurance carrier. In some cases, dental coverage will not save you money at all, even if you are needing dental care.Dental plans emphasize preventive...
Turning 26? Health Insurance Options
Typically, before the Affordable Care Act (ACA), carriers could remove adult children from the policyowner’s coverage based on their age, regardless of their student status. Upon the implementation of the ACA, singed into law March 23, 2010, which requires plans and...
The Status of Children Health Insurance in Texas
Coverage for children in Texas has been dramatically altered since passage of the Affordable Care Act (ACA) on March 23, 2010. Availability of coverage, benefits, and premiums have been dramatically altered by the ACA. Until the passage of the ACA, long-term...
What Do You Do About Covering Your Spouse Through Your Plan?
Decades of Employer-Sponsored Coverage Since World War II, employer-sponsored group coverage has been the holy grail for individuals seeking health insurance coverage for themselves, their spouse, and any dependents. Typically, group plans in this country have been...
If You are Under 30, Why Bother with Health Insurance?
What is “Guaranteed Issue”? “Guaranteed issue” means that regardless of your health history or current conditions, you are guaranteed to receive health insurance with no restrictions or waiting periods related to preexisting conditions. How can insurance companies...
How Subsidies Can Reduce Your Health Insurance Premiums
What’s Happening with Premiums. Now that there is more complete claims history from previous Open Enrollments, insurance companies are better able to determine their premiums. In addition to more complete claims data, carriers are requesting higher premiums to shore...
So, How Can Subsidies Help You?
Open Enrollment begins November 1 for a January 1 effective date. Chances are, you are wondering what will happen to premiums. Here is the not-so-good news: Because the industry can now base premiums on two years of real claims history, premiums will likely go up. The...
The Advantages of Private Insurance Compared to Group Health Insurance
With the implementation of the Affordable Care Act (ACA) on January 1, 2014, Texas consumers now have a viable alternative to employer-sponsored group coverage. Prior to ACA, group coverage had an advantage over private insurance in Texas because: Group coverage...
Personal Health Insurance Overview
The Affordable Care Act (ACA) has created an environment where personal coverage for an individual or an entire family is much more accessible than it was prior to the legislation. Personal coverage is now a viable alternative as compared to coverage secured through...
Why Doesn’t Every Member of a Family Have an Individual Identification Card?
Families often question why the policyholder is the only one listed on a health insurance identification card. Parents, to avoid delays in receiving medical services question whether they should request individual identification cards in the name of each child. ...
What Are the Differences Between HMO and PPO?
We recently shared Blue Cross Blue Shield’s announcement that they will no longer offer their individual Blue Choice PPO plans – Off Marketplace (nonsubsidized) and On Marketplace (subsidized) – for 2016 and going forward. Further, they will automatically transfer...
What Are the Differences Between HMO and EPO?
Health insurance in Texas was turned on its head during the 2016 Open Enrollment when the state’s insurance companies dropped their Preferred Provider Network (PPO) , limiting people’s choices to Health Maintenance Organization (HMO) or Exclusive Provider Organization...
What is a Federally Run Health Insurance Exchange?
The Affordable Care Act (ACA), which was signed into law on March 23, 2010, established health insurance exchanges to provide a single marketplace for consumers to evaluate and purchase health insurance coverage. A health insurance exchange does not function as a...
Family Group Coverage Available for Family-Owned Businesses
Good News for Family-Owned Businesses. Family-owned businesses benefited from a big change during 2017’s Open Enrollment – and it’s likely to remain for the upcoming Open Enrollment for 2021. Before the 2017 Open Enrollment, group coverage was only available for...
Short-Term Coverage vs. Affordable Care Act Coverage
Key Topics: Executive order breathes life into short-term coveragePreexisting conditions limitations return with short-term coverageBenefits can be limited under short-term coverageLoss of short-term coverage does not qualify for a Special Enrollment Period...
Medicare
Medicare Part B Premiums
Medicare is divided into three parts: Part A (hospitalization), Part B (medical services) and Part D (prescription benefits). Individuals who have worked 40 quarters during their lifetime will not have to pay a premium for Medicare Part A. The Medicare Part D premium...
Easy as ‘ABD’ – Here’s Medicare Part B
Along with Part A, Medicare Part B is one of the original parts that President Lyndon Johnson signed into law in July 1965. Medicare Part B services are pretty basic and easy to understand. So what’s covered? Medicare Part B: What it covers In general,...
Medicare Part D: Easy as ABC? Maybe Not!
Medicare Part D, the Medicare Prescription Drug Benefit, is a federal government program offering prescription drug coverage to people eligible for Medicare. Unlike Parts A & B, Medicare Part D was not part of the original Medicare law that became effective in...
Medicare Information: Coverage for Oxygen Therapy
What is covered in Medicare Part B for Oxygen Therapy? Medicare covers rental of oxygen equipment (considered durable medical equipment – or DME), or you can purchase your equipment and Medicare will cover content and supplies. The following conditions must first be...
Turning 65? Want to Save Money? You’ve Got Choices!
If you are turning 65 within the next 12 months, it is time to think about Medicare – and your next move. Still working and have insurance through your employer? Or have an individual plan? Either way, you have choices to make before Medicare kicks in. Those decisions...
Your Road Map to Senior Medigap Health Insurance
Texas Medigap Insurance Market Summarized In Texas senior health insurance concentrates on Medicare for those individuals 65 and older or individuals under 65 who qualify for Medicare due to a disability. Medicare is divided into four components: Part A for hospital,...
Medicare Enrollment – What, Why, When, and How
Medicare Enrollment – What, Why, When, and How Individuals contact Stateside Insurance Services prior to turning 65 and ahead of qualifying for Medicare with a high degree of anguish created by the awareness that they are about to transition from adulthood to becoming...
Terminology
Explanation of Benefits and How to Understand
An Explanation of Benefits, commonly referred to as an EOB, is a statement from your health insurance company providing payment details for medical service(s) you recently received. The EOB explains what portion of services were paid by your insurance plan and what...
HIPAA
Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) is legislation that provides data privacy and security provisions in order to safeguard medical information. It was created primarily to...
Community Rating
What does the term community rating mean as it applies to health insurance?Health insurance carriers have different methods for determining the cost of a health insurance policy. The amount paid for health insurance coverage is referred to as a “premium.” If a...
Essential Health Benefits
The U.S. Department of Health and Human Services (HHS) issued a list of frequently asked questions (FAQ) in order to clarify the rules pertaining to the essential health benefits. The requirements for essential health benefits were included in the Patient Protection...
Health Protector Guard
The Affordable Care Act (ACA) has created instability in the individual market, which has resulted in a dramatic escalation of premiums and an exodus of carriers providing coverage. The lack of carrier competition has reduced plan options and limited provider network...
The Benefit of Negotiated Rates
Texas health insurance policy holders receive a benefit every time they file a claim but are probably not aware that they are receiving the benefit. The most common type of health insurance for individuals and families is classified as a HMO or Health Maintenance...
Cost-Sharing Reduction
The Health Insurance Marketplace (www.healthcare.gov), also called exchanges, is the source for people to buy health coverage with a subsidy that can be used to reduce monthly premium. In addition to the subsidy, known as the Advance Premium Tax Credit (APTC), In...
Essential Benefit & Actuarial Value Rules Released by Health and Humana Services (HHS)
U.S. Department of Health and Humana Services (HHS) issued proposed rules addressing essential health benefits (EHB) and the determination of actuarial value (AV) in order to clarify key provisions of the Affordable Care Act. The rules issued by HHS will cover the...
What Does Family Deductible Mean?
Health Insurance policies assign a plan deductible for each person insured up to a maximum number of insured members. An individual plan deductible is easy to understand – the plan deductible is assigned to the one individual covered by the health insurance policy. A...
What are Formulary Tiers?
The term “formulary” is defined as a list of drugs identified by the carrier that provides the highest degree of efficacy, or the capacity to produce a desired effect, for the treated condition in relationship to the most favorable cost. The list of drugs included on...
How to Make a Health Savings Account Work for You
A Health Savings Account (HSA) plan that works in conjunction with the compatible High Deductible Health Plan (HDHP) are the best example of the how health insurance coverage has adapted to the needs of the Texas consumer. HSA plans have provided consumers with a more...
Are You Confused by Deductibles?
A health insurance plan deductible is an established amount of money that an insured member must pay before the health insurance carrier is required to make benefit payments not associated with an office visit or prescription co-pay. The purpose of a deductible...
What Does the Office Visit Co-pay Benefit Cover?
What services an office visit co-pay covers is a very common point of confusion for Texas consumers. An office visit co-pay establishes a fixed, predetermined price for the consultation with a physician. Many consumers believe that whatever services are received...
Open Enrollment: What to Know!
What’s Open Enrollment? And why do we have it? Open Enrollment is the annual period when you can evaluate your health insurance options and change your plan accordingly. The most important thing to understand about Open Enrollment is the time frame for applying...
How Does a Health Insurance Policy Prescription Deductible Work?
Traditional health insurance policies typically have two deductibles: one deductible is assigned to medical benefits such as hospital, physician or lab services, and the second deductible is assigned to the prescription benefits. Prescription drug cost growth...
What Does it Mean When an Insurance Claim is Subrogated?
The requirement to have an insurance claim subrogated is rare but can happen in the case of an accident involving two or more people where one of the individuals involved is at fault. The definition of subrogate is to substitute one for another. The legal definition...
What happened to the Medical Savings Account?
Medical Savings Accounts (MSAs) were introduced to consumers in 1996 as an amendment to the Health Insurance Portability and Accountability Act. The amendment was sponsored by Texas Congressman Bill Archer, and the MSA became known as the Archer MSA. MSAs were...
Guidelines Issued to Clarify Preventative Care Benefits
Since passage of the Affordable Care Act (ACA) in March 2010, the addition of preventative care benefits has been one of the principal selling points. However, the expectations of consumers did not match the benefits provided by health insurance carriers. The...
Sales Tax on Health Insurance Plans Added
Like many other products Texas consumers purchase like soft drinks, clothes, restaurant meals, computers, and furniture, health insurance will have a sales tax levied on it beginning January 1, 2014. The Affordable Care Act (ACA) imposed the “fee,” known as the...
Definition of Modified Adjusted Gross Income
With passage of the Affordable Care Act (ACA), a new term was created to determine eligibility for Medicaid or premium subsidies offered for plans within the exchange. The new term Modified Adjusted Gross Income or MAGI has been adopted in order to standardize the...