Understanding Texas Health Plans – What You Need to Know

If you’re a new or prospective health insurance customer, you might be wondering what you need to know about Texas health plans. Understanding your options is the first step to deciding which plan is best for you.

Each year, nearly 1 in 5 Texans don’t have health insurance. That’s the highest percentage of uninsured residents in the country.

What is a Health Plan?

A health plan is a type of insurance that offers coverage for your medical needs. It may be private or government-funded.

There are many different types of health plans, from group health plans to Medicare and Medicaid. Understanding them can help you make the best choice for your needs.

The type of plan you choose depends on your budget, how much care you use and how much you want to pay out-of-pocket when you receive health services. Some plans also offer tax credits (subsidies) to help you pay for your premium and out-of-pocket costs.

What is Coverage?

Coverage is the total amount of health care services that are covered by your policy. It varies depending on what type of plan you choose.

In Texas, private insurers can go as far back in your medical history as 24-months before your coverage begins to determine if you have a pre-existing condition that can be excluded from your insurance.

In addition, if you’ve had continuous creditable coverage, which means you’ve had coverage for at least 18 months before applying for an individual or group health plan, you’re eligible for a waiver of the pre-existing condition exclusion period.

What is a Deductible?

A deductible is the amount of money you must pay before your health insurance plan starts to cover medical expenses. This deductible is usually a fixed amount, such as $2,000 for a single person.

Once you have met your deductible, the costs of your services will be divided between you and your health insurance company. You and your insurance company will then share the cost of your covered services in a way that works for you.

What is a Coinsurance Rate?

A coinsurance rate is a percentage of the cost of a covered health service that you and your insurance plan will pay after you meet your deductible.

In many cases, your coinsurance rate will be different if you receive services from in-network providers than if you go to an out-of-network provider. In-network providers are preferred providers who have a business relationship with your health insurance or plan and usually charge you less than out-of-network ones.

You can usually find your coinsurance rate on the Summary of Benefits or in your member handbook. If you see a high coinsurance rate, it could mean that you need to use in-network doctors and hospitals more often to keep costs low.

What is a Copay?

A copay is a fixed amount you pay for certain health services, like visiting the doctor or filling your prescriptions. It varies based on the type of service, but usually is less than $25.

Copays typically appear on your insurance card, and can vary among insurers. For instance, there may be one set of copay rates for primary care doctors and another for specialists.

Most plans also have separate copay amounts for visits to the emergency room or urgent care, and for certain types of specialty medicine. These fees can add up, so it’s important to review the summary of benefits for your plan.

What is a Premium?

A premium is the amount you pay for health insurance coverage. This includes the cost of the plan, deductibles, copayments, and coinsurance.

The cost of health insurance depends on your age, income and family size. You may be eligible for subsidies to help pay for your premiums.

A premium is the money you, your employer or both pay to the health insurance provider each month. You’ll need to fax or mail in proof of payment every month.

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