Texas General Health Insurance FAQ

Do I need health insurance?

Health insurance provides you and your family affordable access to high-quality health care. Accidents and illness can happen without warning, and medical treatments can be expensive. Having health insurance means knowing many of your health expenses will be covered.

Is health insurance expensive?

Health insurance isn't cheap, but it's a bargain compared to the cost of a trip to the hospital. With our quoting tool located on ILHealthAgents.com, you can instantly get quotes to over 150 insurance plans, so it's easy to find a plan that works for your budget.

Can my health insurance application be denied?

Yes. Whether your application is approved or denied primarily depends on your health history.

If you're concerned about how a health insurance company will view your medical record, get a professional assessment from a knowledgeable health insurance agent.

Is there an extra fee to use an insurance agent or broker?

No, health insurance agents and brokers are paid a commission by the health insurance company. Your insurance rates will always be the same whether you use an agent or buy directly from an insurance company. For no additional charge, an insurance agent can provide advice and assistance during the insurance application process.

 

What is a health plan network?

A health plan network consists of all the doctors, physicians, hospitals, clinics, and specialists that agree with an insurance company to charge discounted prices for their services in exchange for patient referrals.

What is a PPO?

PPO stands for Preferred Provider Organization and is the most common type of health plan network. It consists of a managed care arrangement consisting of a group of hospitals, physicians, and other providers who have contracts with an insurer to provide health care services to enrollees at a predetermined rate.

PPOs also allow members to see physicians and hospitals out of the insurance company's network, however, these visits will require higher out-of-pocket costs for the member. One should seek care at a PPO provider whenever possible to maximize their plan benefits.

What is a health savings account?

A health savings account is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA account in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. To qualify for a health savings account in 2009, one must be enrolled in a High Deductible Health Plan with a minimum deductible of $1150 for single coverage and $2300 deductible for family coverage.

What is a drug formulary?

This is a list of all the prescription drugs that are covered under an insurance plan.

What is a pre-existing condition?

Any health condition or illness that you had before your insurance coverage begins can be considered a pre-existing condition.

Will my pre-existing condition be covered?

In the state of Texas people that are applying for an individual health insurance plan can be turned down at the insurance company's discretion due to pre-existing conditions unless that person is eligible for an Texas HIPAA health insurance plan.

In the state of Texas they follow HIPAA laws very strict. The Health Insurance Portability and Accountability Act created in 1996 and effective in 1997 provides protection for people that have medical pre-existing illnesses. The law protects people by limiting their exclusion period when purchasing health insurance, lowering the chances for a member with a pre-existing condition to lose coverage, providing protections when they change jobs and guaranteeing that your health insurance policy gets renewed at the end of your coverage year.

The law however, has not eliminated the ability of individual carriers of denying health insurance to pre-existing condition people or exclude medical conditions. The only guarantee issue provisions lie in State sponsored plans and insurance company funded plans. What HIPAA does provide is for guaranteed acceptance health insurance coverage for people that meet 6 HIPAA requirements. When someone meets these 6 requirements they are considered "HIPAA eligible" and can qualify for a guaranteed issue HIPAA health insurance plan. The 6 requirements for HIPAA eligibility can often be the only avenue of health insurance coverage available to some high risk individuals with major pre-existing health conditions.

Some of the most important insurance companies in the state of Texas handle pre-existing conditions a little bit differently, because of this it is important to do some research and actually shop around for a policy before deciding to apply. Individual plans have more exclusion that group plans and that is why they are quite a bit less expensive, because they are more restrictive.

Aetna Health Insurance who is one of the "big dogs" in the health insurance business across the United States is a primary example of exclusion period. They offer a 365 day period starting from the day of enrollment, in which a person with a pre-existing condition is not covered. It is important to note however, that if the person that has a pre-existing condition has had prior creditable coverage within 63 days immediately before the signature of the application; then the exclusion period will be waived.

Another example of this can be seen with Blue Cross and Blue Shield of Texas, who is one of the 39 independent, community-based insurance companies that make up the national Blue Cross Blue Shield network. Since they are independent that means they might not have the same provisions as Blue Cross Blue Shield companies in other states. In Texas, BCBS requires a member with a pre-existing condition to wait a 365 day exclusion period from the day that they sign the policy before receiving coverage for their illness.

Compared to individual coverage, group plans are a little better. They cannot turn you down due to a pre-existing condition, which makes group plans more expensive. Under HIPAA law an employer can only deny pre-existing condition coverage if the person is diagnosed, receives treatment or has care and treatment 6 months before the enrollment date. A good thing to note is that pregnancy cannot be accounted as a pre-existing condition by an employer insurer.

The total time a person can be excluded from a group health plan if they have a pre-existing condition is 12 months after enrollment (18 months if they enroll late), for this reason it is important for a person to sign up for health insurance as soon as they are offered it (if not you can be subject to 18 months instead of 12). Fortunately for some, the time can be less in case that they were covered by an insurance company for the 63 days before enrollment. Also, an insurer cannot deny coverage to a small employer (2-50) under HIPAA law.

Finding Texas health insurance coverage when one has a pre-existing condition can be very tough. Not to mention that pre-existing conditions cover everything from cancer, HIV, Hepatitis C and even high cholesterol. It is key however, for a person that has a pre-existing condition to know all the exclusions and their rights that are provided under the HIPAA law. This is important because once you know your rights, you will be able to be more knowledgeable about the subject and avoid long exclusion periods.

Can I get individual health insurance if I smoke? 

You can find health insurance if you smoke, but your plan will most likely be more expensive than non-smokers. Obviously, you should consider kicking the habit for your health, but also to save money. Many plans require you to be smoke-free for a year to get non-smoker rates.

What is the difference between individual and group health insurance?

An individual health plan provides coverage for one person, and can include children and your spouse. Group health insurance is coverage for a group of employees at a company, or members of an organization. In the state of Texas, a group is guaranteed health insurance, regardless of their medical conditions. However, a group's health insurance rates are based on a combination of their demographics, type of industry the company works in, and medical history are usually more expensive but often have higher levels of coverage than Individual plans.

Unlike group health plans, individual plans are able to deny applicants coverage based on their medical history and are limited to individuals who are generally in good health. If you have any pre-existing conditions, most individual plans will either rider them out or exclude the condition. Some conditions are even cause for decline. These conditions vary based on each carriers (companies) underwriting requirements. Another major difference is that  maternity coverage in individual plans is an optional benefit while maternity coverage is included small group health plans by Texas law.

Will my health insurance rates increase because I get older?

Yes. As people get older they tend to use more medical services, so health insurance companies accordingly adjust their premium requirements. For example, the health insurance rate charged to a 60-year-old is typically more than three times the health insurance rate charged to a 20-year-old.

Can I add dependents to my existing individual health insurance policy?

Yes. You can automatically add newborns, but adding other dependent family members is subject to underwriting evaluation.

Can a health insurance company terminate my individual health insurance policy?

An insurance company can only terminate your policy if you fail to pay your premium within the allowed grace period, you misrepresent your health history on your insurance application, or if an insurance company withdraws from the individual insurance business in your state.

How do I know if I'm eligible for coverage?

Your health history determines if you're eligibile for individual medical insurance. If you're not sure how an insurance company will view your medical history, consult a knowledgeable health insurance agent or broker. If you've been turned down for major medical coverage due to a pre-existing condition, you may want to consider a guaranteed-issue health plan.