Affordable Care Act (ACA) health insurance in Texas is a way for Texans to acquire quality and comprehensive health insurance coverage.
The Affordable Care Act (ACA) (also called Obamacare) was established in 2010 to provide people with access to quality and comprehensive healthcare. It created rules and standards for health insurance and every plan that follows them are considered ACA-compliant plans. These ACA-compliant plans are the various ACA health insurance policies that exist. Common examples of ACA plans in Texas are health insurance marketplace plans, individual health plans sold outside the marketplace, and job or group-affiliation based plans.
Generally, ACA plans may be individual or group policies. They cover the ten essential health benefits, with no annual or lifetime coverage limits. The key feature of an ACA-compliant health insurance is that pre-existing conditions are not a factor in determining eligibility during open enrollment. ACA-compliant insurance is guaranteed to be issued to any eligible applicant.
Prior to the establishment of ACA compliance standards, individual-market health plans in Texas were underwritten based on your health, and quite frequently denied coverage to individuals with pre-existing conditions.
Additionally, ACA-compliant insurance must adhere to medical loss ratio (MLR) requirements, which mandate them to spend at least 80% of premiums on medical expenses (85% for big group plans).
The factors used to determine premium rates for ACA insurance are:
Note: As there are ACA-compliant plans, there are also non-ACA-compliant plans. These are plans that do not follow the standards of the ACA. A common example in Texas is short-term health insurance. Also, it is not a requirement for insurance companies to sell their products on the Texas Health Marketplace. Hence, some insurers may sell both on and off the Marketplace; others choose to stay out of the Marketplace completely.
In 2022, ACA expanded coverage benefits to new demographic groups and the Texas senate introduced the new insurance rate review process, with a goal of increasing the benefits for those Texans who are truly in need of affordable coverage. This resulted in an influx of insurers that previously offered ACA plans off-marketplace, to join the Texas health marketplace and offer even more selection for the ACA plan shopper.
All health insurance that meets the definition of an ACA-compliant plan is considered ACA Insurance. In order to be considered Affordable Care Act compliant, health insurance plans must follow minimum requirements:
Here are the recent historical ACA max out-of-pocket numbers (before applying any government discounts (aka Subsidies). With the subsidies, the max out-of-pocket may be significantly lowered:
2022 - $8,700 for individual plan and $17,400 for a family
2021 - $8,550 / $17,100
2020 - $8,150 / $16,300
2019 - $7,900 / $15,800
2018 - $7,350 / $14,700
The purpose of the ACA insurance in Texas is to provide Texans with health insurance coverage that meets and/or exceeds the stringent rules of the federal Affordable Care Act (ACA). The most important feature of ACA-compliant insurance is that it guarantees acceptance regardless of pre-existing conditions.
Additionally, ACA provides a way for the lower income Texans to obtain health insurance with extensive preventive features, at a fraction of the full cost. The amount of government subsidies (discounts) is based on the income level.
In 2021, significant savings were realized by 92% of the insurance plans purchased on the Texas health marketplace, through the use of advanced premium tax credits (APTC), and 57% of Texans received cost-sharing reductions (CSR).
ACA insurance is for individuals to have access to quality and comprehensive healthcare in every state, including Texas. It does this by ensuring that your pre-existing condition or medical history is not considered when you apply for coverage. It also makes plans affordable to low income earners by providing premium subsidies and cost-sharing reductions.
There are two types of ACA health insurance in Texas:
Both of these types may be further subdivided into four additional sub-types:
Yes, you need health insurance that is compliant with Affordable Care Act rules, especially if you have been unable to obtain coverage for your medical needs through other means. ACA-compliant insurance provides the most comprehensive health coverage on the market and does not discriminate against pre-existing conditions or medical history. So, if you have any pre-existing conditions that you would like to be treated for, then ACA insurance is your best option. If you are among the Texans who qualify for subsidies, you may also be able to get ACA coverage at a significant discount.
Contact a licensed agent in Texas to consider your options with ACA health insurance. Alternatively, you can visit the health insurance Marketplace to check out the various plans yourself, and then reach out to a health insurance agent with questions. Agent's assistance with determining your needs and finding an appropriate plan does not cost you anything extra.
There are several benefits to having ACA insurance:
As with most insurance products, how much ACA insurance you need depends on your actual and anticipated medical needs. A thought process during the determination of your ACA insurance needs should be along the following lines:
The ACA Marketplace provides subsidies and cost-sharing reduction benefits for low-income Texans, which makes plans affordable. You can check if you are eligible for subsidies based on your income. You can also use the income calculator to figure out your best estimate.
Whenever making an insurance decision, it is best to talk this over with a Texas-licensed health insurance agent, who can assess your needs and give a recommendation based on your particular life scenario.
Deciding what ACA insurance coverage you need or should get largely depends on what you can afford and your projected needs. For instance, if you have surgeries planned for the year, you might want the lowest deductible. Generally, four metal levels prescribe how much cost will be shared between you and the insurance company. Expect to pay more for the plans that provide more coverage. The metal tiers are:
In determining what ACA coverage you need, talk to a licensed insurance agent in Texas. An agent will provide you with all the necessary information and factors to consider and guide you to make the best decision. Make sure to ask your agent a lot of questions. The health insurance agent's professional help in Texas does not cost the insured (you) anything extra.
Having ACA insurance or any type of health coverage is not required by federal or Texas state law. When the Affordable Care Act was initially introduced, it required everyone to have minimum health coverage for themselves and their families. The punishment for not having minimum health coverage was a tax penalty. However, in 2019, this tax penalty was removed, which made ACA insurance no longer a requirement in Texas.
The Affordable Care Act created a set of standards that an insurance plan must meet, to qualify to be called ACA-compliant. ACA-compliant insurance in Texas may be purchased on the Texas Health Marketplace, through an employer, or through the insurers who meet the requirements, but choose to not sell their plans on the Marketplace.
Generally, to get ACA insurance on the marketplace, you have to sign up during the open enrollment period on the Texas health insurance marketplace. Open enrollment is a period of the year when you make health coverage decisions that will take effect in the following year's insurance plan. It is usually around two months long and starts at the end of the year (normally 1 November - 15 January).
In order to qualify for coverage outside of the Open Enrollment, there is a special enrollment period. This is when you encounter a significant life event, such as getting married, having or adopting a baby, or losing your health plan.
There are companies that sell ACA health plans outside the marketplace. You can usually get these plans from the insurance company itself or agents allowed to sell those plans, through a portal linked to the marketplace.
When you get an ACA plan, your plan will inform you about the various terms of coverage. This includes your premiums and out-of-pocket costs, how the coverage works, and information of health providers within their network.
When you receive health services, the medical provider bills your insurer. If the provider is within your plan's network, your insurer ensures that you are charged the pre-negotiated (lower) rate (and not the rate that you get if you walk in without insurance). Then, your insurer handles the claim according to the terms of your policy. If there is a deductible left to pay, it may get applied. At the end of the year the deductible and benefits get reset, unless you use a carry-over provision, which allows you to carry over medical expenses from the last three months of the year into the following year.
ACA insurance in Texas covers health by providing preventive and treatment services for physical and mental health issues. These services are called essential health services. They are available in all ACA plans. They include:
ACA insurance is good for getting quality and comprehensive healthcare at affordable prices, especially if government discounts (subsidies) are applied. ACA insurance provides a good alternative for health coverage for persons without insurance from their employer or other government health programs. ACA insurance is good for practically everyone. Here are a few examples of persons that should consider ACA insurance:
ACA insurance is good for everyone, if you can afford it. Contact a health insurance agent licensed in Texas to find out how ACA insurance can be good for you.
Every ACA insurance plan in Texas typically includes what is called essential health benefits. These health benefits cut across various mental and physical health, pregnancy and neonatal, prescription medication, doctor visits or consultations, and general hospital services. The central theme around the essential health benefits is to provide every enrollee with treatment and preventive services. These benefits are:
Consider speaking to a licensed insurance agent in Texas to find out more about what ACA insurance normally covers and how it can fit your health insurance needs.
An individual ACA insurance in Texas covers the policyowner, who is also the insured. A family plan covers every member of the household. Group employment insurance plan covers all employees of the business listed in the policy. Also, ACA plans offer dependent child coverage that allows the health coverage of a parent to extend to their child, as long as the child is under 26 years. Married and unmarried children are eligible for coverage. It applies to all individual market and employer plans.
ACA insurance in Texas covers several essential health benefits (EHB), including preventive care for adults, women, and children. EHBs are created as a set of requirements, generally seen to provide comprehensive health coverage. For example, if you are involved in an accident and rushed into the emergency room, your insurance plan will cover it. It does not matter that the hospital that you get emergency care from is an out-of-network hospital. Your insurer will not require you to pay more in coinsurance or copayment.
Where the emergency treatment extends to you needing hospitalization, either through surgery or overnight hospital stay, your plan will cover it.
Also, in treating an illness, ACA insurance covers the costs of prescription drugs, including vaccines, injections, immunizations, and supplements.
Furthermore, ACA plans cover mental health and substance abuse disorders. For example, patients with opioid use disorder (OUD) will receive full treatment services through their ACA plan. This includes outpatient treatment, residential treatment, detoxification, recovery support services, and prescription drugs.
In addition, the ACA provides several preventive coverages for women, including pregnant and lactating women. Before the ACA, it was quite hard to get access to insurance plans with low premiums that provide preventive care for pregnant women. This made it hard for women in the lower income bracket to get health coverage. With the invention of ACA, women can have their plans cover different screenings and counseling. For example, you can get breast cancer screening every two years through your ACA plan.
There is no particular list of things that are not covered by ACA in Texas. Apart from the list of essential health benefits, plans may have different restrictions on coverage. That is, while some cover some medical expenses, others may not. Therefore, it is important to know your plan and what it covers. You can get this information by reading the exclusion section of the policy, contacting your insurance company or your insurance agent.
It is usually the insurance company that determines what it will exclude from coverage. Some examples of medical expenses typically not covered by ACA insurance in Texas include:
An example of ACA insurance in Texas is:
Employer-sponsored group health insurance, where every member of the group is able to get coverage at the same rate as everyone else, represents the largest part of the ACA-compliant insurance market.
Taking a broader view of ACA, including the state health marketplace, the most common use of ACA insurance is to provide health insurance coverage with a guarantee of acceptance. So, no matter what you might have in your medical history - you are guaranteed to get the coverage. If everyone has turned you down, ACA will take you. Plus, you might even qualify for a lower cost, based on your income.
Another way to look at ACA insurance is as a strategic financial instrument that can cover your future potentially high medical expenses. For example, if you find out that you need an expensive medical procedure, let's say costing hundreds of thousands of dollars, a switch from an alternative Texas health plan to an ACA plan with the lowest maximum out-of-pocket costs might be a good strategy for you. The fact that you need the surgeries is a pre-existing condition, and will bar you from full coverage from most alternative insurers, but it does not matter to ACA. It will accept you regardless.
The premium for ACA coverage will be based on your income and can vary drastically, but you will be paying for the coverage that you will be actively using - to save you a lot more money that you would have paid without it. With bills in the hundreds of thousands, if not in millions, all of them could be taken care of under the ACA-compliant plans. Lower deductible usually means a higher monthly cost, so you must compare the math of your future medical procedures and their related costs vs the math of insurance coverage that is affordable to you. After all, everyone wants to get the most amount of coverage for the least amount of money.
Talk to a Texas-licensed health insurance agent who deals with multiple types of insurance, including ACA, to go over your medical needs, to see what kind of Texas health insurance may be a better fit for your specific needs.
ACA and Short-Term health insurance are two of the most popular individual health coverages in Texas. However, they are very different:
Short-term plans do not need to meet the standards of the Affordable Care Act and therefore are not required to provide comprehensive health coverage. The essential health benefits provided by ACA plans are usually not covered in short-term plans.
Common coverages that are excluded by short-term plans include maternity, mental health, and preventive care, although some short term plans (longer than 2 years) recently started offering partial preventive care and allowing pre-existing conditions after a year or more of coverage. In 2021, some short-term insurers in Texas surprised their insureds by covering the cost of Flu vaccinations and Covid testing/vaccines, while not listing it as a benefit of the plans.
Unlike the ACA health insurance plans, short-term plans are medically underwritten. This means that the short term insurer uses your health condition to determine eligibility and your level of risk. Consequently, the short-term insurance company determines if it is willing to take your level of risk as a client and bases your premium rate on your medical history. Meanwhile, ACA insurance is underwritten as a guaranteed issue.
Unlike the ACA, in Texas you can be denied short-term coverage because of a pre-existing condition. This is because short-term plans only cover your medical conditions that have not yet happened and no medical conditions you already have. Extended short-term policies (2 years or more), may cover some pre-existing conditions after one year of continuous coverage.
In the end, ACA and Short-term health insurance both offer specialized types of coverage, which can be used to cover your health insurance needs. Short-term plans are perfect for you in various situations. For example, if you just lost coverage from your former job, have outgrown coverage of your parent's plan, or if you are using short-term insurance with additional supplemental policies, to fill the coverage gaps and save on monthly premiums - compared to a non-subsidized ACA plan.
On the other hand, ACA insurance is best for an all-in-one comprehensive health coverage. ACA is straightforward and all-encompassing, every time.
Always discuss your health insurance needs with a licensed insurance professional who is knowledgeable about all current health insurance options available on the Texas market. Texas health insurance agents help you tailor the insurance solution based on your health specifics and your affordability needs, and this doesn't cost you anything extra.
Both ACA insurance and short-term insurance provide major health coverage. Hence, if you have one, you do not need the other. However, whether you choose an ACA or short-term health insurance plan, it is vital to understand the policy terms. Before you buy, speak with a competent insurance agent who can help you choose the health plan that suits you based on your medical and financial needs.
Yes. Adult dental and vision coverage are not part of the essential health benefits. Hence, getting dental and vision coverage as supplemental plans for preventive and treatment services for your teeth and eyes is advisable. They are both stand-alone plans.
If you already have ACA coverage in Texas, reach out to the licensed agent that sold you the plan to recommend the best dental and vision insurance for you. If you do not have an agent, find a trusted Texas-licensed agent to help evaluate the benefits of these plans. They can also provide guidance on which insurance company to purchase their insurance products.
In Texas, every citizen, national, or legal resident can get ACA insurance. If you have pre-existing medical conditions and do not have active insurance coverage, you should consider getting ACA insurance.
Speak to a licensed agent in Texas to know more about getting ACA health coverage.
Almost all legal residents of Texas are qualified for ACA insurance. To get ACA insurance, you:
People who are "lawfully present" include immigrants, who have:
If you have questions about qualifying for ACA insurance in Texas, contact a licensed health insurance agent and/or keep reading.
You need ACA insurance if you have pre-existing medical conditions and do not have active insurance coverage. Non-ACA-compliant insurers may deny you coverage, while ACA is guaranteed to extend your coverage.
You should get ACA insurance if:
You can get more information on who should get ACA health coverage from a licensed agent in Texas. They can help with clarifying any questions about ACA insurance.
First, let's cover the PROs of ACA insurance:
Now, to the CONs.
There are also a few downsides to ACA insurance. They are:
Generally, it is best to discuss your health insurance needs with a Texas-licensed agent, who can answer all your questions based on the current insurance market offerings.
Yes, ACA insurance is worth it.
A licensed insurance agent is your best source of answers about how ACA insurance can be particularly beneficial to you.
On the one hand, there are no legal consequences for not having ACA insurance in Texas. In 2019, the government removed the tax penalty for not having minimum health coverage.
On the other, if you do not have ACA insurance, you should definitely consider getting health coverage through any of the other available ways. If you do not have access to health coverage through an employer or some group, you should speak to an insurance agent about your options.
Thankfully, Texas offers several different options that the agent can cover based on your specific medical needs. If you do not have pre-existing conditions, you have multiple paths in front of you.
If you have pre-existing conditions and you want them covered by your insurance, you need to get ACA-compliant insurance. Your chosen agent can help you get ACA coverage too.
ACA insurance is important because it makes health coverage accessible and affordable to practically everyone in Texas. It does not discriminate based on medical history or financial status. Through the essential health benefits provided, everyone has access to various preventive and emergency services.
When a policy is said to lapse, it means the policy is terminated because of non-payment of premium. Thus, your insurer can terminate your plan if you do not pay your monthly premiums. However, before the plan is terminated, you have a grace period. This is a short time you have to pay your monthly premiums.
In Texas you have a 90-day grace period if:
If you do not qualify for premium tax credit on the Marketplace, you usually have a grace period of 30 days. Check your policy or with your insurer for details.
When you cannot pay your premiums after the grace period, the insurance company will cancel your plan. If this happens, you can take any one of these two actions:
Appeal the cancellation: You should only appeal when you believe that the cancellation is unwarranted. You can appeal the cancellation by contacting your insurance company. If your appeal is denied, you may contact the Texas Department of Insurance by calling (800) 252-3439 or submitting an online complaint. You may also contact the Health Insurance Marketplace by calling (800) 318-2596.
Buy another plan: You can buy other health coverage. You should discuss your options with a licensed health insurance agent in Texas. For example, if the cancellation occurred shortly before the open enrollment period, you can just buy another ACA-compliant plan during the next open enrollment period. You may also qualify to buy another ACA plan during the special enrollment period. Note that while you may be eligible for special enrollment because you lost health coverage, you will not qualify for a Special Enrollment Period if the reason is only because of non-payment. Another option is purchasing a short-term plan until the next open enrollment period.