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Health Insurance Marketplace in Texas

The Health Insurance Marketplace is a shopping and enrollment service that provides affordable health insurance to interested persons. It was established in 2010 by the Affordable Care Act (ACA), commonly referred to as Obamacare. Through the Marketplace, Texas residents can get low-cost health insurance that fits their income. Every Marketplace healthcare plan has the same list of essential health benefits, which provide prevention services and protection against emergencies. Insurers in the Marketplace do not use medical underwriting or deny health insurance because of a pre-existing condition.

The federal government administers the Texas health insurance Marketplace for individuals and families. Some other states, like California, Maryland, New York, and Washington, run their own Marketplace websites.

By using Marketplace health insurance, you can save on premiums and get lower out-of-pocket costs, like deductibles and copayments, based on your income. You can also preview Marketplace plans and prices based on your location. Furthermore, you may qualify for premium tax credits (also referred to as subsidies) in the following circumstances:

  • If your yearly earnings are around 100% and 400% of the federal poverty level (FPL), you may be eligible for other saving benefits on Marketplace insurance, in addition to premium tax credits.
  • If your yearly household income is more than 400% of the FPL, you may still be eligible for premium tax credits that reduce your monthly premium cost.
  • Suppose your yearly household income is less than 100% of the FPL, and you are not qualified for Medicaid. In that case, you may be eligible for premium tax credits and other discounts on Marketplace insurance if you fulfill all other eligibility requirements.

The health insurance Marketplace in Texas is for persons without health insurance. That is, if you do not have health insurance through a job, Medicare, Medicaid, CHIP, or another source that provides qualifying health insurance, the Marketplace can assist you in obtaining coverage. You can choose to purchase health insurance through the Marketplace even if your employer offers coverage, but you will pay full price, unless the employer's plan does not meet certain standards. The majority of job-based plans meet the required standards.

You may not move to Marketplace insurance if you have Medicare. You can only use a Marketplace plan to supplement your coverage or buy a dental plan.

Enrollment into the marketplace plan is usually done during the open enrollment period, which usually happens at the end of the calendar year, for the new plan to take effect the following year. During this time of the year marketplace shoppers can:

  • Select a health plan for the first time
  • Sign up or enroll for a new health plan to replace an old one
  • Re-enroll for present health plan (if offered)
  • Make changes to your present health plan

Over 1.2 million Texas residents enrolled for private individual market plans sold on the Texas health insurance Marketplace during the open enrollment period in 2021. Furthermore, about 300,000 Texans signed up for coverage in the first few months of the COVID-related special enrollment period in 2021. This was three times more than the normal enrollment number at the time (when a qualifying event would normally be necessary to enroll).

If you do not purchase a plan during the open enrollment period, you can qualify for the special enrollment period if you have experienced certain life events. This includes losing health coverage, moving to a new state to live in, getting married, having a baby, or adopting a child.

Persons interested in affordable health insurance in Texas can shop and enroll through the following means:

  • Online
  • Over the phone by calling (800) 318-2596
  • Completing an application form and submitting it via mail
  • Through in-person application with the assistance of an agent or broker
  • Through the assistance of someone in your neighborhood
  • By using certified enrollment partner websites
  • By submitting a written request

Your insurer can only answer questions or concerns about your health coverage - Not the questions regarding doctors, medications, treatments, and medical equipment.

If you do not have the contact or know how to reach your ACA-compliant insurance company, contact the Marketplace Call Center on (800) 318-2596. You can also call the Texas Marketplace Call Center when you want to appeal a dispute with your insurance company.

What are Health Insurance Marketplaces and Who are They Meant for?

The Health Insurance Marketplace is a platform created to provide individuals and their households access to affordable healthcare coverage. It is also called the Health Exchange. You can compare different health coverage plans on the health insurance Marketplace. Your search for health plans can be based on your income, family size, and health needs.

Any interested and eligible Texan can enroll for Marketplace. The eligibility requirements are:

  • You must reside in any of the states in the U.S.
  • You must be a U.S. citizen or national (or be lawfully present)
  • You must not be incarcerated
  • You must not have Medicare coverage

The requirement of being "lawfully present" makes immigrants eligible for healthcare coverage through the federal health insurance Marketplace. To be "lawfully present" means an immigrant who has:

  • "Qualified non-citizen" immigrant status with no waiting period.
  • Humanitarian statuses or situations (including asylum seekers, temporary protection, special juvenile status, Convention against Torture, victims of human trafficking, etc.).
  • Valid non-immigrant visas.
  • Legal status conferred by other laws, such as temporary resident status, LIFE Act, and Family Unity Individuals.

What Does Health Insurance Through the Marketplace Mean?

Health insurance through the Marketplace in Texas means that the health insurance you obtain is:

  • Purchased from the health marketplace,
  • Coverage is guaranteed to meet the requirements of the Affordable Care Act (ACA)
  • If the applicant's income falls in the range of 100%-400% of the Federal Poverty Level (FPL), they may qualify for cost-saving credits and subsidies, making coverage more affordable.

The Marketplace offers interested persons affordable health plans, with subsidized costs based on their income and family size.

What are the Types of Insurance Marketplaces?

There are three types of insurance marketplaces:

  1. State-based Marketplace administered by the state platform: These are marketplaces that are administered and run by state. The states are in charge of carrying out all marketplace functions for the individual market. Residents of these states can apply and sign up for coverage through their marketplace websites. As of 2022, there were 17 states and the District of Columbia that fell within this category of administration. These states wereCalifornia, Colorado, Connecticut, Idaho, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, Vermont, and Washington.
  2. State-based Marketplace administered on the federal platform: These are marketplaces that are administered and run by the state but on the HealthCare.Gov website owned by the federal government. The states have a state-based marketplace for which they carry out all the marketplace functions. However, the states use the federal HealthCare.Gov website for activities relating to enrollment and eligibility. There are three states that fall into this category. They include Arkansas, Oregon, and Virginia.
  3. Federally-facilitated Marketplace: The federally-facilitated Marketplace is where the United States Department of Health and Human Services (HHS) carries out all health coverage functions including enrollment and eligibility through the HealthCare.Gov website. HHS administers it for states without state-based marketplaces. Texas operates under the federally-facilitated marketplace. Some states in this category help carry out plan management activities to support certification of qualified health plans. There are 13 states that help with plan management activities: Delaware, Hawaii, Illinois, Iowa, Kansas, Michigan, Montana, Nebraska, New Hampshire, Ohio, South Dakota, Utah, and West Virginia. The other 17 states that leave it entirely to the HHS are: Alabama, Alaska, Arizona, Florida, Georgia, Indiana, Louisiana, Mississippi, Missouri, North Carolina, North Dakota, Oklahoma, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

There are certain features that distinguish these different marketplaces:

  • Individual mandates: Before 2019, persons who were uninsured or did not have minimum health coverage were subject to a federal penalty when they filed their taxes. This penalty was eliminated in 2019. However, some states that run their marketplace have their own individual mandates and require their residents to have a minimum health coverage, which if they do not have will attract penalties. These states include California, District of Columbia, Massachusetts, New Jersey, Rhode Island, and Vermont.
  • Open enrollment periods: States that have their own marketplace website have flexibility to choose their open enrollment periods. For example California, Colorado and the District of Columbia have permanently extended open enrollment. However, states that use the HealthCare.gov platform cannot change their open enrollment periods. It is fixed by the federal government.
  • Allowing non-ACA-compliant plans to be sold on the marketplace: Some states that operate their health marketplace expanded plans available on their websites to non-ACA-compliant plans. These states provide a cheaper alternative for healthy residents who cannot afford ACA-compliant coverage. These states include Idaho, Indiana, Kansas, Tennessee, and South Dakota. (In Texas, non-ACA compliant health plans (Short-term and Supplemental) are available off-marketplace - through state-licensed health insurance agents).
  • Essential health benefits: Although all marketplace policies provide a minimum set of essential health benefits, the specific coverage offered usually varies from state to state. It depends on the benchmark plan that the state uses.

These marketplaces are also similar in that they all provide health coverage through four plan types: HMO, PPO, POS, and EPO. They also have four metal categories prescribing limits on cost-sharing between you and your insurer. It is a form of protection for you because your health provider must cover their part. There are also catastrophic plans for persons under 30 years or people who fall under the hardship exemption.

What Makes Insurance Marketplaces Different?

Through its establishment by the ACA in 2010, the Marketplace has created a platform to shop and enroll for health insurance, different from what existed before. Before the existence of Marketplace, persons that wanted health insurance had to contact health insurance companies directly or through their agents to get quotes. There were no standard cost-reduction and coverage benefits. These plans were usually medically underwritten, which means that a person could be excluded from receiving coverage because of a pre-existing condition.

The Marketplace was established to provide a one-stop platform for several ACA-compliant plans. Individuals can do comparison-shopping easily. The exchange platform allows you to search plans and their costs based on your location. Individuals, families, and small businesses can compare various health plans side by side on the Marketplace.

The Marketplace also provides lower monthly charges or coverage that is free or low-cost for some people. It is the only place where you can get premium subsidies and cost-sharing reductions that will lower your coverage costs. Furthermore, in getting health coverage, the insurer will not determine your premium by using medical underwriting. Thus, you cannot be denied coverage based on your health. Even if you have a pre-existing condition, you cannot be denied coverage or be given higher premiums to pay.

Marketplace insurance plans guarantee basic coverage through essential health benefits. These benefits include emergency care, pediatric care, maternity care, preventive services, and other services. There are four major types of insurance plans on the Marketplace. Under some plans, you can see practically any doctor or go to almost any health care facility. Other plans restrict your options or charge you more if you go outside their network of providers. The four types of plans are:

  1. Exclusive Provider Organization (EPO) Plans: As the name goes, an EPO requires you to exclusively use the provider's medical professionals and facilities, such as their doctors, specialists, and hospitals. In essence, you have to use only the medical services within the plan network for you to be covered. You cannot go outside the network and receive coverage. It is usually best to negotiate a lower monthly premium under an EPO. Because when you have to use medical services outside the network, it will be an out-of-pocket payment that the insurance will not cover. For example, where the provider does not have a specialist on a recent illness you developed, you will have to pay if you end up getting treated by a specialist that is not part of the provider's network. Hence, it will be reasonable for you to spend less on premiums in preparation for unexpected out-of-network medical expenses.
  2. Health Maintenance Organization (HMO) Plans: They provide access to a broad range of medical services through a network of providers. You may have to select a primary care physician who will handle the majority of your medical needs. You will need a referral from your Primary Care Provider (PCP) to see a specialist within the network. Referrals will also be needed for out-of-network care; if not, you will not have coverage. Because of the broad range of services provided, HMOs usually have low out-of-pocket expenses. However, you may have to pay a deductible before coverage begins. Your copays will mostly be cheap.
  3. Preferred Provider Organization (PPO) Plans: They provide coverage for any visit you make to a healthcare provider within the network. You do not need a referral from your PCP to be covered. There are more benefits to using in-network services than out-of-network services. PPO plans typically require you to pay a yearly deductible before coverage begins. You also may be required to pay a copay or coinsurance for some medical services.
  4. Point-of-Service (POS) Plans: It is a hybrid of HMO and PPO plans, as it has both plans' characteristics. However, benefits depend on whether you are getting in-network or out-of-network care. Like an HMO plan, a POS plan makes you choose a PCP in charge of your medical needs. The services you get from your PCP are not subject to a deductible. If there is the need to see a specialist within the network, your PCP has to make a referral. Also, like a PPO plan, you can receive care out-of-network but with higher out-of-pocket fees. Furthermore, you may be responsible for copays, coinsurance, or a yearly deductible.

Four metal categories prescribe how you and your plan share medical costs for coverage. They are bronze, silver, gold, and platinum plans. They range from the lowest premium rate (bronze) to the highest (platinum).

  1. Bronze plans: They have the lowest monthly premiums but the highest costs for medical care. The insurer will cover 60% of your medical expenses while you pay the remaining 40%. You may consider bronze plans if you want a cheaper solution to protect yourself from worst-case medical eventualities, such as major illness or injury.
  2. Silver plans: They have moderate monthly premiums and medical expenses. You pay around 30% of your medical costs, while the insurer covers about 70%. Silver plan deductibles are typically lower than bronze plans. To obtain the extra savings, you must choose a Silver plan if you qualify for cost-sharing reductions. You can save a lot annually with this plan.
  3. Gold plans: They have high monthly premiums and high coverage of medical costs. You also pay low deductibles. The insurance company covers about 80% of medical expenses, while you the remaining 20%. Gold plans are good if you are ready to pay more monthly to receive more coverage for healthcare.
  4. Platinum plans: They have the most expensive monthly premiums but the cheapest medical costs. They also have the lowest deductibles. Your insurer covers 90% of your medical care costs, and you pay the remaining 10%. It is best for people who use a lot of care or expect to use a lot of benefits, so paying the high monthly premium makes financial sense.

In picking a plan, consult a licensed health insurance agent. An agent can guide you on what plan is best to fit your needs.

Apart from the plans above, there is something called a catastrophic plan. They are used for worst-case scenario coverage. It is available only to people who are either under 30 years old or have a hardship exemption. You are eligible for a hardship exemption if your circumstances make it hard to purchase health insurance. For example, a homeless or recently homeless person will be eligible for a hardship exemption. Catastrophic plans, on average, cover less than 60% of your medical costs. Premiums are typically lower than conventional health plans, but you may be required to pay a large deductible before the plan pays for your treatment. They provide the same essential health benefits required by the Marketplace. The preventive services of catastrophic plans come at no cost. Furthermore, it covers a minimum of 3 primary care visits annually before you have met your deductible.

Does Texas Have Marketplace Insurance?

No. Texas uses the federal health insurance Marketplace to provide Marketplace insurance to its residents. As of January, 2022, there are 17 states and the District of Columbia that have their own Marketplace exchanges.

What Type of Health Insurance Marketplace is Used in Texas?

The Texas health insurance Marketplace is administered through the federal health marketplace at HealthCare.gov.What Is the Purpose of Marketplace Health Insurance in Texas?

Marketplace health insurance was created by the Affordable Care Act (ACA) to extend health coverage to uninsured people. It seeks to broaden access to health coverage and make health insurance affordable. Texans who have been unable to access health coverage due to the unaffordability or pre-existing condition can now apply for and obtain health insurance, using government assistance (subsidies), according to their income level.

The Marketplace offers health plan shopping and enrollment via the internet, phone centers, and in-person assistance. The Health Marketplace fosters competition among insurance companies in a particular location for uninsured persons to get suitable plans. You can compare and enroll for plans on the Marketplace during the open enrollment period.

Do You Have to Use the Marketplace for Insurance in Texas?

No. In Texas, getting health insurance through the Marketplace is optional. If you do not have an existing health insurance coverage, you can buy insurance coverage through a state-licensed health insurance agent or directly from an insurance company. However, the Marketplace is a major way for Texans to qualify for subsidies for health insurance based on their income. This help comes in the way of premium credits (which reduce the monthly fee for coverage) and cost-sharing reductions on out-of-pocket costs like deductibles, copayments, and coinsurance. Make sure to use the help of a qualified and licensed Texas insurance professional to assist you in making an informed buying decision, based on your needs.

Do I Have to Go Through the Marketplace for Health Insurance?

No, you do not have to buy insurance through the marketplace. You can also get insurance directly from an insurance company, a health insurance agent, an online health insurance agency, through a government program, or an employer. If you get health coverage directly from an insurance company, the insurer determines your premium based on your health history, age, tobacco use, and location. Premiums are medically underwritten, and you may be denied coverage if you have a pre-existing condition. These plans are called non-ACA compliant plans. Some examples of them include short-term health insurance, indemnity insurance plans, and medical discount plans. Many insurance companies have websites that allow you to compare the products they sell.

Getting insurance through an independent agent or broker in Texas allows you to compare plans of the different insurance companies they represent. Using an agent does not mean you pay more because agents are paid by the insurance company whose product they sell. Search for agents using the Marketplace's Find Local Help tool or the TDI's list of licensed agents in Texas.

You can also obtain health insurance from an online seller. They are usually websites that sell the health plans of various health insurance companies. They enable you to compare prices and sign up for coverages. Note that it is possible they do not have all the plans accessible in your location.

Furthermore, there are many government health programs, particularly Medicare, Medicaid, and Children's Health Insurance Program (CHIP). Taxes fund these programs. They have their eligibility criteria. For example, Medicare is typically for people above 65 years, and CHIP, as the name goes, is for children not older than 18 years in Texas. If you qualify, you will be covered by them to the extent specified. You can check out the various government programs to see if you qualify.

Not everyone is interested in getting health insurance from the Marketplace. The Marketplace is the best for applying for government subsidies. In some cases, you will find out that you are not eligible for subsidies or that a plan sold outside the Marketplace is better for you. This is why you should talk to a licensed agent in Texas, so you can consider what option fits you best.

How Do I Know if My Insurance is a Marketplace Plan?

You can check if your health coverage is a Marketplace plan by checking online through HealthCare.gov. Log into your account. Select "My applications & Coverage" from the dropdown menu by clicking on your name in the top right corner. Under "Your existing applications," find your completed application and select it. You will find an overview of your coverage there. The start date of your coverage is determined by when you enrolled or switched plans. Call your insurance company if you do not see your summary or are not sure you have completed enrollment. They can check to see if you have signed up and paid your first premium.

Make sure you examine the enrollment paperwork for your health insurance. Your insurer sends you a membership package that includes enrollment documents and proof of insurance in the form of a health insurance card. Examine these carefully, then check your plan's provider directory to know where you might receive healthcare. Keep the card safe because you will be using it to access healthcare services. If you have not received a card, contact your insurance company to verify if you should have received one and confirm that your coverage is still valid. The phone number for your insurer can be found on their website. If you have any questions, contact your health insurance agent or the Marketplace health insurance number at (800) 318-2596.

Do I Qualify to Purchase Health Insurance on the Marketplace in Texas?

You qualify to purchase health insurance on the marketplace in Texas if you meet the basic set of qualifications and income requirements:

Who Qualifies for the Health Insurance Marketplace?

To qualify for Texas Marketplace health insurance, you must:

  • reside in the U.S.
  • be a U.S. citizen or national. If you are not, then you must be a lawful resident
  • not be in jail
  • not be qualified for Medicare.

Is Marketplace Insurance in Texas Based on Income?

You have to consider your income when getting Marketplace insurance. It is an important factor when negotiating premiums and seeing if you qualify for premium subsidies. Your income, the extent of coverage, and the cost of premium are three main factors to consider. Under the Marketplace, "income" is your household income for that year. Hence, your income, your spouse, and any other person you claim to be a tax dependent on in your federal tax return is calculated.

You can check if you qualify for lower costs in Texas based on your household income. If you are eligible for premium subsidies, the income you report on the Marketplace application must be the same as what you reported as your modified adjusted gross income (MAGI) on your taxes at the end of the year.

Do You Have to Have Income to Qualify for Marketplace Insurance?

No. Because of the premium subsidies and cost-sharing reductions provided by the Marketplace, an unemployed person with no income may be able to buy a health plan. However, while you can buy from the health Marketplace, you may not get any subsidies. That is, you will likely pay the full price. To get subsidies, there must be income. You qualify for health coverage subsidies on the Marketplace based on your income and household size.

Otherwise, if you are below the 100% FPL, you should consider getting coverage through Texas assistance programs like Medicaid.

What is the Minimum Income for Marketplace Insurance in Texas?

The minimum income to qualify you for premium tax credit on Marketplace insurance depends on your household income. Below is the table for the minimum income based on household size in 2021.

Household size Minimum income (100% of FPL)
1 $12,880
2 $17,420
3 $21,960
4 $26,500
5 $31,040
6 $35,580
7 $40,120
8 $44,660

What is the Maximum Income to Qualify for Marketplace Insurance in Texas?

The maximum income you can earn to qualify for a premium tax credit on Marketplace insurance is determined by your household income. Below is the table for the maximum income based on household size in 2021.

Household size Maximum income (400% of FPL)
1 $51,520
2 $69,680
3 $87,840
4 $106,000
5 $124,160
6 $142,320
7 $160,480
8 $178,640

According to the American Rescue Plan Act (ARP), you may still qualify for tax credit if you earn above the maximum income limit.

What are the Income Limits for Premium Tax Credit?

Before 2021, to qualify for premium tax credit, your household income had to be between 100% to 400% of the federal poverty line (FPL) for your family size. The federal poverty line is a yearly income amount depending on family size that is considered poverty level for the year. The Department of Health and Human Services (HHS) sets the FPL each year. With regards to premium tax credit, the FPL for the open enrollment period of a year is based on the FPL published in the previous year. That is, 2022 tax credit is based on the 2021 FPL.

Below is the FPL for 2021:

Household size Minimum income (100% of FPL) Maximum income (400% of FPL)
1 $12,880 $51,520
2 $17,420 $69,680
3 $21,960 $87,840
4 $26,500 $106,000
5 $31,040 $124,160
6 $35,580 $142,320
7 $40,120 $160,480
8 $44,660 $178,640

Through the American Rescue Plan Act (ARP) in 2021, you can still be eligible for premium tax credits to reduce monthly premium cost for a Marketplace plan. This Act sought to make Marketplace coverage even more affordable. It repealed the FPL income cap that denied people that earned more than 400% of the FPL any subsidies. Regardless of how high your income is, you may still qualify for premium subsidies in the form of tax credits.

The ARP also increases the amount of subsidies available to persons earning less than 400% of the FPL. Furthermore, after the increased government subsidies, anyone who obtained or was accepted for unemployment benefits as of July 1, 2021, can enroll in a free (or low-cost), low-deductible health plan.

The following are the requirements needed to qualify for premium tax credit in Texas:

  • You must not be someone's dependent in their tax return
  • You must have an income between 100% to 400% of the FPL. If you do not, you may still qualify for premium tax credit according to the ARP.
  • If you are married, you must file a joint return with your spouse. The exception to this is when you are unmarried for head of household filing status, or a victim of domestic abuse or spousal abandonment.
  • You must have signed up or purchased a health plan on the Marketplace
  • You must pay your premiums
  • You must not be eligible for other minimum essential coverage, like Medicaid.

Is My Income too High for Health Coverage Tax Credits?

No. Before 2021, if your income was not between 100% to 400% of that year's FPL, you do not qualify for premium tax credit. This has changed under the ARP. According to the ARP, you may still qualify for premium tax credit if your income is above 400% of the FPL. Therefore, your income may not be too high for health coverage tax credits.

Upon qualifying for premium tax credit, you can get government assistance with paying your monthly premium, in the form of an advanced premium tax credit. Alternatively, you may decide to get the tax credit when filing the annual tax return.

What Insurance Plans are in the Marketplace in Texas?

There are four plans in the Marketplace in Texas. They are:

  • Exclusive Provider Organization (EPO)
  • Health Maintenance Organization (HMO)
  • Point of Service (POS)
  • Preferred Provider Organization (PPO)

There are also four metal levels that specify how you and your insurer share the cost of your coverage. They are: Bronze, Silver, Gold, and Platinum.

Can you get HMO through the Marketplace?

Yes, you can get a Health Maintenance Organization (HMO) coverage through the Marketplace in Texas.

Does the Marketplace have HMO insurance?

Yes. HMO insurance is part of the various plans available on the Marketplace.

Can you get a PPO through the Marketplace?

Yes. Preferred Provider Organization (PPO) coverage can be obtained through the Marketplace in Texas. It is one of the types of plan networks offered to persons that sign up for health coverage through the Marketplace.

Does the Marketplace have PPO insurance?

Yes. The Marketplace has PPO insurance.

Is Obamacare and Marketplace the Same Thing?

The federal health insurance Marketplace, often known as the "Marketplace" or "Exchange", is an online resource that helps people explore, compare, and buy health insurance under the Affordable Care Act (ACA), also called Obamacare. ACA or Obamacare establishes a set of guiding regulations, which the plans sold by insurers that abide by it are called ACA-compliant. They can be group or individual coverage. The Marketplace is just a convenient one-stop place for an individual to obtain ACA-compliant coverage. Alternatively, there are non-ACA plans - which are neither on Marketplace, nor do they belong to Obamacare

Because Texas does not have or operate its own Marketplace, it uses the federal health insurance Marketplace. Private companies in Texas provide health plans through the Marketplace, but they must include all essential health benefits required by the ACA.

Discuss all you health insurance needs with state-licensed, knowledgeable, and experienced insurance professionals, who can advise you on all options of coverages available in the state of Texas.