Texas Health Insurance Exchange Open Enrollment (OE) has begun. Affordable TX Marketplace medical Coverage is now available to individuals, families and small businesses. The Affordable Care Act (Obamacare) offers up to a 100% federal subsidy to help Texans purchase healthcare at a heavily discounted (and sometimes) free cost. We make it easy for you to compare all available plans and rates.  Seniors can also review attractive Medigap options for Medicare Supplement and Advantage plans.

Open Enrollment typically begins on November 1st and ends on January 31st. This is the fourth year that Marketplace plans are available, and federal subsidies continue to be offered. You can choose high-Deductible ($7,150) Bronze-tier plans that are very inexpensive, or more comprehensive Silver, Gold, or Platinum-tier plans, that offer lower deductibles and fewer out-of-pocket expenses.

2016 brought four new companies to the Lone Star State, increasing the number of available carriers from 12 to 16. Only Michigan and Ohio offer as many choices to their residents. Also, the number of available plans increases to more than 100, with most applicants qualifying for the federal subsidy.  The average monthly premium should continue to remain under $100.

Harris County will likely once again have the largest number of persons signing up for coverage. In 2015, about 20% of the state’s total enrollment was from Harris County. Several additional counties with high enrollment included Fort Bend, Austin, Walker, Montgomery, Chambers and Matagorda.

Noncompliance Penalty

The tax penalty for not securing coverage that meets the Obamacare requirements is now 2.5% of household income, and will increase in 2017. The penalty is pro-rated, so if you are without coverage only part of the year, a smaller penalty will be imposed. And there are many available exemptions that will waive the tax. For example, if you suffered through financial hardship, or have significant unpaid medical bills, a waiver will be granted.

How To View Texas Obamacare Rates

The easiest way is through the quote box at the top of the page. Once your zip code is provided, and after answering a few basic questions, moments later, you will be able to view prices from the participating companies. Individual and family policies are offered through Open Enrollment. Each year, a new period begins, typically around mid-November. Occasionally (such as 2014) there are extensions to give more time to persons who procrastinated too long, simply forgot, or were having enrollment issues.

The application process is much more streamlined with the average purchase now only taking about 10-25 minutes. There are less invasive questions, despite the increased policy availability. Ancillary  benefits are also offered, including dental and vision. Separately, you can add policies that specialize in critical illness and/or accidental expenses.

How Much Does 2016 TX Medical Coverage Cost? Is It Free?

Actually, it could be free if you qualify for 100% of the subsidy. Otherwise, you may be eligible for a rate reduction based on your household income. For example, in the Dallas area, a family of three (40 year-old parents and one child) that make $50,000 per year will receive a $4,296 federal subsidy to help pay the premium. A $40,000 household income generates a subsidy of $5,820. A family of four with a $50,000 household income (see below for additional examples) earns a $6,720 annual subsidy.

Factoring in the federal aid, we have listed below several of the popular medical plans and their monthly cost. We are assuming a family of four (parents age 45 with two teenagers)  with a household income of $50,000.

Bronze Plans

$131 – Molina Marketplace Choice Bronze – $15 generic drug copay. Most other expenses are subject to the deductible.

$244 – BCBS Blue Advantage 105 – Two pcp office visits (per person) are subject only to a $40 copay (not the major medical deductible). Deductible is $6,750. One free vision exam and pair of glasses each year for children.

$270 – BCBS Blue Advantage 006 – $6,000 deductible before non-preventative benefits begin.

$293 – Aetna Bronze Eligible HSA – $6,450 deductible and HSA-eligible.

$320 – UnitedHealthcare Balanced HSA 5500 – $5,500 deductible and HSA-eligible.

$324 – Oscar Classic Bronze – Low-cost option for customers that like “Oscar.”

Silver Plans

$265 – Molina Marketplace Choice Silver – Low Office Visit Copays of $20 and $55 with $4,000 family deductible. This plan is a very cost-effective option for most individuals and families.

$276 – Molina Marketplace Silver – Office visit copays of $25 for pcp visits and $70 for specialists. Generic and brand-name prescriptions also have copays $35 and $80) and are not subject to the policy deductible.

$452 – UnitedHealthcare Silver Compass Balanced HSA 3000 – $5,000 deductible and  HSA-eligible.

$459 – Oscar Simple Silver – No out-of-pocket cost for preventative or non-preventative pcp office visits.

$494 – UnitedHealthcare Balanced 2000 1 – Low $1,800 deductible with $5,000 maximum out-of-pocket expenses.

$503 – UnitedHealthcare Silver Compass Balanced 2000 – Lower $1,200 deductible, but with $30 and $60 office visit copays.

$504 – BCBS Blue Advantage Silver 103 – $3,125 deductible with 0% coinsurance. No out-of-pocket expenses once deductible is met.

Gold Plans

$433 – Molina Marketplace Choice Gold – Low $500 deductible (per family) with $15 and $35 copays on office visits. $15 and $50 copays on generic and brand drugs.

$440 – Molina Marketplace Gold – NO deductible with higher $20 and $60 copays on office visits.

$644 – UnitedHealthcare Compass Balanced $500 – low $500 deductible with low office visit copays ($20 and $40). Generic drug copay is only $5.

$748 – BCBS Blue Advantage Gold 101 – $20 and $40 office visit copays with no charge for generic drugs. Deductible is $500 with $5,250 maximum out-of-pocket expenses.

$779 – Oscar Market Gold – Very low $600 deductible with $4,000 maximum out-of-pocket expenses.

Important Note: If the income levels shown above are tweaked down to $40,000, prices will reduce. Naturally, higher household incomes (Remember…It’s the Modified Adjusted Gross Income) will result in higher rates.

Household Income Guidelines

Shown below are the specific income range guidelines (courtesy of .gov) that show specific eligibility maximums for individuals and families. For example, a single person could make up to $45,000 and still receive some financial aid. A family of three could have household income up to $78,000 and receive a partial federal subsidy. A family of eight could earn as much as $150,000 and possibly receive a subsidy.  These limits are non-negotiable (at this time) and apply to all states, not just Texas.

What About The High Risk Pool?

The Texas High Risk Pool, which has provided affordable medical coverage for state residents that could not qualify for individual coverage, shut down at the end of 2014.  For 15 years, government grants and insurer funding  financed the program. But past members (about 25,000) were able to apply for guaranteed coverage through the State Marketplace. Of course, medical plans for young adults are available, and typically cost less than adult plans.

The deadline for obtaining a Jan 1 effective date, and thus, avoiding a lapse, is typically December 15th. Each  member was notified in many ways (phone calls and letters) to help expedite the transition of benefits. For many consumers, the savings from changing plans was substantial…easily thousands of dollars per year. Of course, the federal subsidy will be the main reason the new prices are often much lower.

Another advantage of Marketplace coverage is the benefits that are received. Since 10 “Essential Health Benefits” must be included in all  newly-issued plans, perhaps one of the biggest challenges is understanding all of the changes each year, and evaluating which Metal policy is the best choice. Also, it is possible to buy a policy that is not listed on the “Exchange.” One of the advantages of these types of policies is that the  number of participating physicians and specialists may be higher than other options.

Short-Term BCBS Texas Options

If you only need coverage for a few months (and possibly as long as 12 months), a temporary policy may be appropriate. Although a deductible must be met before most expenses are paid, this type of contract provides quick benefits if needed (policy approved within 24 hours) and a 10-minute application. Rates are also extremely cheap.

The monthly cost for a 40 year-old male living in the Dallas area is only $107 for a $2,500 deductible (plan PPO-STM-3-OLC-2) and $126 for a $1,500 deductible. The policy can be kept as long as six months. Extending the maximum coverage period to 11 months  would increase price by about 32%.

Beware Of Scams

The Affordable Care Act is helping many individuals and families in the Lone Star  state cut their medical insurance costs. But when legislation of this magnitude is passed, the scammers always seem to show up, hoping for opportunities to make an illegal buck. Based on our more than 30 years of experience, we listed below a few of our best tips to keep you safe:

Do not talk to someone who  suddenly appears at your front door. Unless you are expecting a broker that you previously set up an appointment with, there is no reason for anyone to visit you unannounced. Also, beware of unexpected phone calls mysteriously requesting to “verify information” for a subsidy. If you receive that type of call, simply hang up.

Do not give out your social security number over the telephone. Typically, if needed, you can provide it, when requested, on an online application. But it generally is not needed until an actual application begins. It is not needed to secure a free quote.

Be wary of any “fees” or “service charges” you are asked to pay. Whether you are getting a quote, getting advice, comparing plans or buying a policy, there is no reason for you to have to pay any money for those services. It doesn’t matter what part of the state you live in (Dallas, San Antonio, etc…) this rule applies to all areas.

If you are told that you “must buy this policy today or the rate will go up,” there’s a good chance that is not true. Although there are specific Exchange Enrollment deadlines, typically, the rates do not change from one day to the next. It is true that prices often tend to increase, but you will usually have 30-90 days to prepare for any increases.

“Navigators” can not sell health insurance. Licensed agents and brokers can. So if a navigator attempts to collect money for a policy, immediately decline the request and report them immediately.

Deadlines

November 15 2014 – Open Enrollment begins for Jan 1 effective dates. However, you can shop and compare policies before that date and it is strongly encouraged.

February 15 2015 – Open Enrollment ends. You will be able to apply for a policy under specific circumstances such as loss of job, divorce, reaching age 26, moving out of your service area, etc…

Texas Health Insurance Exchange rates are published and affordable plans are being offered. Marketplace subsidies can drastically reduce premiums for both individuals and families. Our quotes are free and broker expert guidance is always available, if needed.

UPDATES:

August 15 2014 – The Employee Retirement System of Texas (ERS) has published their health insurance rates for employees not eligible for Medicare, surviving dependents and COBRA. Prices for HealthSelect Medical Advantage and KelseyCare have also been released. Although they are estimates (view all information here), prices will not be higher than the projection.

October 14 2014 – Expansion of Medicaid was rejected for economic reasons. However, almost 3 million children remain covered by Medicaid, which represents an increase of more than 200,000 since late 2014. Many of these children were originally covered by CHIP, but under ACA legislation, changed to Medicaid.

Companies Offering Marketplace Plans

15 Carriers offer policies for individuals and families. Only two other states offer more company choices. It’s also possible that in the future, additional companies will file a request with the Department of Insurance to market their plans. Listed below (in alphabetical order) are the approved carriers.

Aetna – One of the nation’s largest carriers and a big writer in Texas. Their HSA prices are typically very competitive.

Allegian Health Plans – A regional carrier located on NW Loop in San Antonio, Allegian provides benefits to many Teacher Retirement System (TRS) members. The Valley Baptist plans are very popular in selected areas.

Ambetter – From Superior Health Plan, is not one of the biggest companies, but they have been expanding in many states. Dental and vision are available riders, and the provider network is picking up new physicians and facilities each year.

Assurant – A subsidiary of “Time” Insurance Company,  Assurant’s prices are very high throughout most of the state.

Blue Cross And Blue Shield – The biggest insurer in the state, BCBS has been writing policies for more than 80 years. As a customer-owned carrier, plan selection is large and many affordable policies are available in most parts of the state.

Cigna – Another large national company that was formed when Connecticut General and INA merged. Their Bronze Savings 6100 plan is one of their most competitive options.

Community First – As San Antonio’s largest CHIP plan, Community First is locally owned and operated and has been covering Texans for 20 years. Although initially they offered policies in Bexar and nearby areas, they now serve much of South Texas.

Community Health Choice – This local (Houston) non-profit company is located on South Loop West, and redistributes its profits back into the community. CHIP and Children’s Medicaid (STAR) are offered along with Marketplace plans. Almost 10,000 physicians and 70 hospitals are in-network along with an affiliation with the Harris Health System.

FirstCare – Created in 1985 and still locally-owned, FirstCare  provides coverage in more than 100 counties. Ownership of the company is shared by two hospitals – Hendrick Health System and Covenant.

Humana – A national company that offers a wide variety of ancillary products, such s dental and vision, Humana typically offers very competitive HSA rates. Bronze and Silver-tier contracts are typically where you will find these plans.

Molina – Molina is a Fortune 500 company that offers coverage in 15 states. Their provider network is naturally not as large as other national carriers such as Aetn and BCBS.

Scott And White – Since 1982, this non-profit HMO has been helping Longhorn residents. At first, coverage was only available in Bell and Coryell counties. However, they now offer policies in 50 counties in the Central TX region.

Sendero – Sendero is a non-profit  Central Texas entity that was created in 2011. Originally, it served publicly-funded healthcare programs in the state. Low-income households through MAP (Medical Access Program) are frequent clients.

UnitedHealthcare – UHC is one of the nation’s largest carriers and has slowly been expanding their Marketplace offerings. The Compass HSA 4900 is one of their most affordable and popular options.

NOTE: Prices are determined by many factors including your “geographical area.” There are 26 specific areas that are used to set rates. The Center For Medicare and Medicaid Services (CMS) establishes  a Metropolitan Statistical Area (MSA) that serves as a benchmark for the remainder of the state. The Texas Geographic Rating Area is found here.

Essential Health Benefits

All Marketplace individual and small business plans must contain these 10 benefits. Pre-existing clauses will not apply and no waiting period, extra deductible, copay, or coinsurance can be added to the policy. We have listed below each of the 10 required coverages and a brief description of some of the benefits for individual and family plans:

Ambulatory Patient Services – Includes primary care physician and specialist office visits along with other practitioners (nurses and physician assistants). 60 visits to home healthcare facilities and 25 days in a skilled nursing facility are also included. Transplant donor benefits are covered.

Emergency Services – Transportation by ambulance and the routine expenses associated with an ER visit are covered.

Hospitalization – Typical inpatient hospital services including room and board, physician/surgical expenses, and related costs are typically covered. Additionally, a mastectomy with reconstructive surgery (assuming a minimum stay) are included.

Maternity And Newborn Care – Prenatal, postnatal, delivery and inpatient expenses are included. A minimum maternity stay and coverage for complications must also be included. However, In Vitro Fertilization is not included.

Mental Health And Substance Abuse – Outpatient services up to 25 visits and inpatient services (up to 10 days) are covered. Substance abuse (inpatient and outpatient) are included subject to three incidents in lifetime.

Prescriptions – Four types of drugs are covered. They are: Generic, Preferred Brand, Non-Preferred Brand, and Specialty. Copays, coinsurance and possible deductibles to meet will vary, depending upon the plan. Also included are certain contraceptives, Amino-acid formulas, and  drugs considered “off-label.”

Rehabilitative Devices And Services – Durable medical equipment, outpatient rehab and habilitative services, and prosthetic/orthotic devices included. Additional coverage for brain injuries.

Laboratory Testing – Diagnostic testing including  x-rays and lab work. Also MRIs, PET and CT scans. NOTE: Network-negotiated pricing can substantially reduce the out-of-pocket costs of these tests.

Wellness and Preventative – Accepted preventative screenings, annual physicals, mammograms, and immunizations are covered at 100%. Common screenings include cardiovascular, prostate, and colon or cervical  cancer along with various diabetes tests.

Pediatric Treatment And Services – Annual eye exam with glasses. Dental visit also included. Screening for hearing and  surgery (reconstructive) for specific abnormalities.

Latest News

May 2015 – Rice University’s Baker Institute and the Episcopal Health Foundation reported that the number of Texas residents without medical coverage declined by more than 30%. The study was based on findings from 2013-2015 and focused on persons between the ages of  18 and 64. The decrease is largely attributed to the ACA Legislation and federal subsidies that substantially reduce rates for many households.

Despite the encouraging trend, Texas still has the most uninsured persons in the US and also the highest percentage of citizens without coverage. As expected, upper-income households have a much higher coverage rate.

June 2015 – 2016 TX  Marketplace rates are increasing. Some carriers and specific plans are seeing price hikes of more than 30%. Of course, other plans will see their cost remain fairly stable. Below, we have posted various company/policy requests. NOTE: These increases must be approved by the Department of Insurance before implemented.

64.7% – Time Individual QHP, LBP

34.1% – Scott And White Catastrophic

32.4% – Scott And White Silver

29.7% – Humana EPOx

22.7% – UnitedHealthcare Off Exchange

19.9% – Blue Cross  Blue Shield Blue Advantage HMO

17.2% – Allegian Choice PPO

15.9% – Cigna TX-IND-Local Plus

October 2015 – Humana, one of the nation’s biggest insurers (currently in the process of merging with Aetna), will be working closely with UT Medicine, from the UT Health Science Center School of Medicine. Through the new collaboration, Humana group policyholders will be able to access more than 50 additional primary care physicians in the area.

The concept of “Accountable Care” will be used, which features  cost-cutting and quality patient experiences. Treatment is more personalized, with preventative and chronic care treatment emphasized.

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