Q: What are some important terms to know regarding insurance?
Out-of-Pocket Costs - Costs paid “out of your own pocket”; costs not covered by your insurance that you are in charge of personally paying for.
Premium - An amount of money paid to the insurance company in order to keep your plan active. Payment periods may be monthly, quarterly, semi-annual, or annual. Not paying premiums will result in loss of coverage.
Deductible - The amount of money you must pay out of pocket before your insurance starts paying for covered expenses. It is usually a set amount that resets at the start of each policy period.
Co-Payment - A fixed numerical amount that is paid out of pocket for a health service, such as a doctor’s visit. For example, you may pay $30 every time for a doctor’s visit, and your insurance covers the rest of the total, no matter how much. These are paid even after meeting your deductible. It is a kind of cost-sharing agreement between you and your insurance company.
Co-Insurance - A fixed percentage amount that is paid out of pocket for a health service, such as a doctor’s visit. For example, if you were responsible for 30% of the bill while your insurance covered the other 70%, you would pay $30 if the visit was $100 total, pay $60 if the visit was $200 total, etc. These are paid even after meeting your deductible. It is also a kind of cost-sharing agreement between you and your insurance company.
Claim: The process by which the healthcare provider submits a request for reimbursement from the patient's insurer. This typically includes the cost of the medication, the service provided (administration, monitoring), and other associated fees. Once the insurer processes the claim, they reimburse the provider according to their policy terms.
Q: What are the main differences between BCBS, UHC, Superior HealthPlan, and Cigna in Texas?
BCBS: Large provider network, flexible plans, and nationwide presence. Blue Cross and Blue Shield of Texas is the biggest healthcare provider in Texas.
UHC: The largest healthcare insurance company in the United States and offers nationwide coverage, good for frequent travelers.
Superior HealthPlan: Affordable options for underserved communities, including Medicaid/CHIP. The exclusive provider for STAR, a Medicaid program for individuals under the foster care system.
Cigna: Strong specialist network, good for chronic conditions. Includes plans with no cost for telehealth and prevention care.
Q: How do Employer-sponsored Healthcare Plans compare to Individual Healthcare Plans?
Employer-sponsored Healthcare Plans allows employees to benefit from group rates which are generally lower than individual market rates. Additionally, employers can subsidize a significant portion of the premium, further lowering the cost of the healthcare plan. A downside of employer-sponsored plans is the limitation of options: employees do not have control over the insurer or the in-network provider, and the coverage is not tied to the individual but to the employment.
Q: What is a self-insured business plan, and how does it work?
A self-insured plan is when a business pays for employees' healthcare costs directly instead of using an insurance company. It can reduce costs for employers but requires managing healthcare expenses internally.
Q: What Insurance Plan Would be Right For Me?
There are several different types of insurance plans to choose from. Listed are the 4 most popular insurance plans, including Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Point of Service Plan (POS), and Consolidated Omnibus Reconciliation Act (COBRA). Weigh the general benefits and drawbacks to each plan below:
Preferred Provider Organization (PPO)
Higher premium monthly plans
Don’t Need to Choose a PCP
Flexibility to use providers both in and out of network without a referral
Out-of-pocket medical costs can also run higher
In or Out of Network
May need to file claims
Health Maintenance Organization (HMO)
May choose a PCP
Lower premium monthly pans
Does not cover out of network
Smaller network
Primary Care Physician → Referral → Specialist
No need to file claims
Point of Service Plan (POS)
Provides both in-network and out-of-network benefits but requires that you choose a primary care provider (PCP) and get referrals to see specialists
Uninsured Plans
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Allows individuals and their families to continue their group health insurance coverage for a limited time after a qualifying event, such as job loss, reduction in work hours, or other life events
Q: What is Medicare, and what do I need to know about Medicare?
Medicare is a federal health insurance program for people who are 65 and older and some younger individuals with disabilities or specific conditions. Costs vary by plan. There are multiple parts of Medicare. Parts A and B are run by social security while Parts C and D are run by private companies with government approval. A breakdown of the parts include:
Part A (Hospital Insurance): This covers inpatient care at hospitals, skilled nursing facilities, hospices, and some home health services. Part A is free if you have worked and paid into Medicare tax for 10+ years. You can sign up for Part A alone or in conjunction with Part B.
Part B (Medical Insurance): This covers outpatient care, doctor visits, home health care, medical equipment, and some preventative care. There is typically a monthly premium and deductible based on income level.
Part C (Medicare Advantage Plans): This includes alternative, private insurance plans that combine Parts A, B, and often D. They usually offer additional benefits like dental, vision, and hearing. It is important to note that you cannot have both an Advantage and Medigap policy at the same time; it is either or.
Part D (Prescription Drug Coverage): This covers prescription drugs. You must sign up for Part A or Part B in order to enroll in Part D.
Enrollment Process: There are several ways you can enroll in Medicare, and some are time-sensitive:
Initial Enrollment:
The Initial Enrollment Period (IEP) is for when you first qualify. It starts three months before your 65th birthday and ends three months after.
You will be enrolled automatically in Parts A and B if you are already receiving other Social Security benefits. If not, you need to apply through the Social Security Administration (SSA):
Online: Create an account and enroll online at ssa.gov
Phone: Call 1-800-772-1213 to get real-time assistance with the application process with a live agent.
In-Person: Visit a local Social Security office to complete an application in person.
Special Enrollment:
The Special Enrollment Period is for if you are still working and have employer coverage at age 65. In this case, you may qualify to sign up after the initial enrollment period without penalties.
General Enrollment:
The General Enrollment Period is for those who missed their initial period and runs from January 1 – March 31 each year. Coverage starts July 1, but late penalties may apply.
Medicare Advantage & Part D Enrollment:
You must first be enrolled in Parts A & B before signing up.
You can join a Medicare Advantage or Part D plan during:
Initial Enrollment Period
Annual Open Enrollment / General Enrollment
Special Enrollment (if you qualify)
Renewal and Continuous Coverage: Medicare automatically renews every year. There is only manual work on the patient end if you want to make changes to your plan.
Q: What is Medicaid, and what do I need to know about Medicaid?
Medicaid is a joint federal and state program that provides particular individuals with free or low-cost healthcare based on factors such as income and household size. Eligibility and criteria vary by state. Here are the Medicaid details for Texas:
Eligibility:
Children: Uninsured children who are 18 or younger may qualify for Children's Medicaid or the Children's Health Insurance Program (CHIP) if specific low-income requirements are met.
Pregnant Women: Pregnant women may qualify during pregnancy and up to two months postpartum if specific low-income requirements are met.
Parents and Caretakers: Parents/caretakers of children younger than 19 may qualify if specific income requirements are met.
Seniors and Individuals with Disabilities: People aged 65 or older or those with disabilities may qualify if specific income requirements are met.
Income Guidelines: Eligibility is determined by comparing your income to the Federal Poverty Level (FPL). Income limits vary based on differing situations and are subject to change at any time, so it is important to consult the latest guidelines to avoid future coverage issues.
Covered Services: Medicaid in Texas covers a range of services at little to no out-of-pocket cost, including:
Regular checkups and doctor visits
Hospital care
Laboratory tests and X-rays
Prescription medications
Vision and hearing care
Dental care for children
Mental health services
Long-term services and support for individuals with disabilities
Application Process: There are several ways you can apply for Medicaid in Texas:
Online: Create an account and complete an application at the Your Texas Benefits website.
Phone: Call 2-1-1 or 1-877-541-7905 to get real-time assistance with the application process with a live agent.
In Person: Visit a local HHSC benefits office to complete an application in person.
Renewal and Continuous Coverage: Continuous Medicaid coverage ended on March 31, 2023, due to legal changes. You must renew your benefits on time on the Your Texas Benefits website, over the phone, or in person in order to continue receiving coverage.