Compare Texas Health Insurance Exchange Rates – Affordable TX Plans

Texas Health Insurance Open Enrollment (OE) provides affordable TX Marketplace medical coverage 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. Regardless if you live in Dallas, Houston, Austin, San Antonio, or any other city in the state, low-cost options are offered. After this period, additional policies are available.

Seniors can also review attractive Medigap options for Medicare Supplement and Advantage plans. Part D prescription drug coverage can also be purchased separately, or packaged with many Advantage contracts. Supplement plans are standardized, but there will be differences in cost and network coverage area. Persons that have reached age 65, and have enrolled in Medicare Parts A and B, may be eligible for several options. Prescription drug plans can be purchased separately, and are also included in many Advantage contracts.

 

TX Open Enrollment

Open Enrollment typically begins on November 1st and ends on December 15th.  However, “special enrollment periods” allow you to qualify for coverage throughout the year. This is the fourth year that Marketplace plans are available, and federal subsidies continue to be offered. You can choose high-deductible ($7,900) 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.

In previous years, as many as 16 companies offered Exchange contracts in the state. Only Michigan and Ohio offered as many choices to their residents. However, Scott And White, Aetna, Humana, Prominence, and UnitedHealthcare  have exited the state. Current carriers offering plans include Ambetter, BCBS Of Texas, CHRISTUS, Community Health Choice, FirstCare, Sendero, Molina, and Oscar.  The number of available policies remains at more than 100, with most applicants qualifying for the federal subsidy.  The average monthly premium should continue to remain under $100.

More than 1.1 million person signed up last year for coverage, about 8% less than the previous year. The shorter enrollment period was a major factor, although and extension period was provided for applicants that were impacted by recent hurricanes.  More than 1.3 million persons enrolled in the prior year.

Harris County had the largest number of persons signing up for coverage. Previously, 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 Has Been Removed

The tax penalty for not securing coverage that meets the Obamacare requirements was 2.5% of household income. This individual mandate penalty was pro-rated, so if you were without coverage only part of the year, a smaller penalty was imposed.  The maximum tax was $2,085 ($695 per adult, and $347.50 per child).  For example, if you suffered through financial hardship, or had significant unpaid medical bills, a waiver was granted.  This penalty terminated on January 1, 2019.

 

How To View Texas Health Insurance 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.

TX Marketplace Health Insurance Rates

Harris County Features Some Of The Lowest Health Insurance Rates In Texas

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 2019 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 $8,592 ($716 per month)  federal subsidy to help pay the premium. A $60,000 household income generates a subsidy of $6,888 ($574 per month). A family of four with a $70,000 household income earns a $9,624 annual subsidy. Higher household incomes may force the elimination of subsidy-eligibility. Lower household incomes may allow adults or children to become eligible for Medicaid or CHIP.

We have listed below many of the most popular and affordable medical plans, and a basic outline of their coverage. Since several carriers are regional, not all plans are offered in each county. Network providers also vary, depending on the specific company, and county of residence.

 

Catastrophic Plans

Oscar Simple Secure – $7,900 deductible with maximum out-of-pocket expenses of $7,900 and 0% coinsurance. First three pcp office visits (including mental health) are not subject to deductible.

BCBS Of Texas Blue Advantage Security HMO 200 – $7,900 deductible with maximum out-of-pocket expenses of $7,900 and 0% coinsurance. First three pcp office visits (including mental health) are subject to a $20 copay.

CHRISTUS  CHP TX Catastrophic – $7,900 deductible with maximum out-of-pocket expenses of $7,900 and 0% coinsurance.

 

Bronze Plans

Oscar Simple Bronze – $7,900 deductible with maximum out-of-pocket expenses of $7,90o and 0% coinsurance.  $75 copay for Urgent Care visits.

Oscar Classic Bronze – $4,500 deductible with maximum out-of-pocket expenses of $7,90o and 50% coinsurance.  $75 copay for Urgent Care visits.

Oscar Saver Bronze – $5,500 deductible with maximum out-of-pocket expenses of $6,650 and 50% coinsurance.

BCBS Blue Advantage Bronze HMO 204 – Two $40 PCP Visits – $6,000 deductible with $7,900 maximum out-of-pocket expenses and 50% coinsurance. $40 pcp office visit copay for first two visits with $60 copay for Urgent Care visits. Preferred generic and non-preferred generic drug copays are $15 and $25 ($45 and $75 for mail order).

BCBS Blue Advantage Plus Bronze HMO 301 – $7,900 deductible with $7,900 maximum out-of-pocket expenses and 0% coinsurance.

BCBS Blue Advantage Plus Bronze HMO 305 – $5,000 deductible with $7,900 maximum out-of-pocket expenses and 50% coinsurance.

Ambetter Essential Care 1 – $7,900 deductible with maximum out-of-pocket expenses of $7,900 and 0% coinsurance. Generic drug copay is $20 ($60 for mail-order).

FirstCare Bronze HSA – HSA-eligible plan with $6,650 deductible and maximum out-of-pocket expenses of $6,650 and 0% coinsurance.

Molina Bronze No Deductible For PCP Visits – $6,400 deductible with maximum out-of-pocket expenses of $7,900 and 40% coinsurance. Pcp office visit copay is $35 with a $75 Urgent Care copay.  The generic drug copay is $20.

Community Health Choice HMO Bronze HDHD HSA – HSA-eligible plan with $6,750 deductible and maximum out-of-pocket expenses of $6,750 and 0% coinsurance.

Community Health Choice HMO Bronze – with $6,500 deductible and maximum out-of-pocket expenses of $7,900 and 30% coinsurance. Office visit copays are $40 and $65 with a $65 Urgent Care copay.  Generic, preferred brand and non-preferred brand drug copays are $10, $60, and $110. Mail-order copays are $25, $150, and $275.

CHRISTUS Texas Individual Expanded Bronze – $40 and $60 office visit copays with $60 Urgent Care copay. $5,500 deductible with maximum out-of-pocket expenses of $7,900 and 50% coinsurance.  Generic drug copay is $10.

IdealCare Bronze High Deductible – $7,900 deductible with maximum out-of-pocket expenses of $7,900 and 0% coinsurance.

 

Silver Plans

BCBS Blue Advantage Silver HMO 205 – $1,900 deductible with $7,900 maximum out-of-pocket expenses and 50% coinsurance. $25 pcp office visit copay for first two visits with $50 copay for Urgent Care visits. Preferred generic and non-preferred generic drugs receive $5 and $15 copays ($15 and $45 copays for mail-order).

BCBS Blue Advantage Plus Silver 202 – $1,110 deductible with $7,900 maximum out-of-pocket expenses and 50% coinsurance. $10 pcp office visit copay with $15 copay for Urgent Care visits. Preferred generic and non-preferred generic drugs receive $5 and $15 copays ($15 and $45 copays for mail-order).

Ambetter Balanced Care 5 – $40 and $80 office visit copays with $100 Urgent Care copay. $7,350 deductible with maximum out-of-pocket expenses of $7,350 and 0% coinsurance. Generic and preferred brand drugs receive $20 and $60 copays ($60 and $180 copays for mail-order).

Ambetter Balanced Care 11 – $30 and $60 office visit copays with $100 Urgent Care copay. $6,000 deductible with maximum out-of-pocket expenses of $7,900 and 40% coinsurance. Generic and preferred brand drugs receive $20 and $60 copays ($50 and $150 copays for mail-order).

Ambetter Balanced Care 4 – $30 and $60 office visit copays with $100 Urgent Care copay. $7,050 deductible with maximum out-of-pocket expenses of $7,050 and 0% coinsurance. Generic and preferred brand drugs receive $15 and $50 copays ($45 and $150 copays for mail-order).

Ambetter Balanced Care 2 – $30 and $60 office visit copays with $100 Urgent Care copay. $6,500 deductible with maximum out-of-pocket expenses of $6,500 and 0% coinsurance. Generic and preferred brand drugs receive $15 and $50 copays ($45 and $150 copays for mail-order).

Ambetter Balanced Care 1 – $30 and $60 office visit copays with $100 Urgent Care copay. $5,500 deductible with maximum out-of-pocket expenses of $6,500 and 20% coinsurance. Generic and preferred brand drugs receive $10 and $50 copays ($30 and $150 copays for mail-order).

Ambetter Balanced Care 3 – $30 and $60 office visit copays with $100 Urgent Care copay. $3,000 deductible with maximum out-of-pocket expenses of $6,750 and 30% coinsurance. Generic and preferred brand drugs receive $25 and $50 copays ($75 and $150 copays for mail-order).

Oscar Saver Silver – $5,000 deductible with maximum out-of-pocket expenses of $5,000 and 0% coinsurance.  $100 copay for Urgent Care visits.

Oscar Classic Silver – $50 and $75 office visit copays with $100 Urgent Care copay. $4,500 deductible with maximum out-of-pocket expenses of $7,350 and 50% coinsurance.  Generic and preferred brand drugs receive $15 and $100 copays ($37.50 and $250 copays for mail-order).

Oscar Simple Silver – $25 and $50 office visit copays with $100 Urgent Care copay. $7,000 deductible with maximum out-of-pocket expenses of $7,000 and 0% coinsurance.  Generic and preferred brand drugs receive $20 and $100 copays ($50 and $250 copays for mail-order).

IdealCare Complete Standard Silver – $3,850 deductible with maximum out-of-pocket expenses of $7,350 and 20% coinsurance. $20 and $60 office visit copays with $60 Urgent Care copay. Diagnostic tests are subject to a $30 copay, and the imaging copay is $300. The generic drug copay is $10.

Community Health Choice HMO Silver 009 – $30 and $60 office visit copays  with $60 Urgent Care copay. $5,000 deductible with $7,000 maximum out-of-pocket expenses. Generic and preferred brand drugs receive $15 and $70 copays ($37.50 and $175 copays for mail-order). Non-preferred brand drug copays are $120 and $300.

Community Health Choice HMO Silver 004 – $30 and $60 office visit copays  with $60 Urgent Care copay. $3,000 deductible with $7,900 maximum out-of-pocket expenses. Generic and preferred brand drugs receive $10 and $60 copays ($25 and $150 copays for mail-order). Non-preferred brand drug copays are $100 and $250.

Community Health Choice HMO Silver 002 – $40 and $75 office visit copays  with $75 Urgent Care copay. $0 deductible with $7,900 maximum out-of-pocket expenses. Generic and preferred brand drugs receive $35 and $110 copays ($87.50 and $275 copays for mail-order). Non-preferred brand drug copays are $120 and $300.

Molina Choice Silver 250 – $30 and $75 office visit copays with $50 Urgent Care copay. $5,350 deductible with $7,900 maximum out-of-pocket expenses and 30% coinsurance. Generic and preferred brand drugs receive $20 and $60 copays. 40% coinsurance applies to other drugs.

Molina Silver 250 – $40 and $85 office visit copays with $75 Urgent Care copay. $0 deductible with $7,900 maximum out-of-pocket expenses and 50% coinsurance. Generic and preferred brand drugs receive $35 and $85 copays. 50% coinsurance applies to other drugs.

CHRISTUS Texas Silver High-Deductible – $10 and $35 office visit copays with $35 Urgent Care copay. $5,000 deductible with maximum out-of-pocket expenses of $6,000 and 20% coinsurance.  Generic and preferred brand drugs receive $12 and $60 copays ($24 and $120 copays for mail-order). The non-preferred brand drug copays are $95 and $190.

CHRISTUS Texas Silver Low-Deductible – $10 and $35 office visit copays with $35 Urgent Care copay. $3,000 deductible with maximum out-of-pocket expenses of $5,000 and 35% coinsurance.  Generic and preferred brand drugs receive $12 and $60 copays ($24 and $120 copays for mail-order). The non-preferred brand drug copays are $95 and $190.

 

Gold Plans

Molina Marketplace Choice Gold – $10 and $35 office visit copays with $60 Urgent Care copay. $3,800 deductible with $7,350 maximum out-of-pocket expenses and 20% coinsurance. Generic and preferred brand drugs receive $15 and $50 copays. 30% coinsurance applies to other drugs.

Molina Marketplace  Gold – $30 and $70 office visit copays with $60 Urgent Care copay. No deductible with $7,350 maximum out-of-pocket expenses and 20% coinsurance. Generic and preferred brand drugs receive $10 and $50 copays. 30% coinsurance applies to other drugs.

Ambetter Secure Care 1 – First three pcp office visits are covered at 100%. $1,000 deductible with maximum out-of-pocket expenses of $6,350 and 20% coinsurance. Generic drugs receive $10 copay while other drugs must meet deductible.

BCBS Of Texas Blue Advantage Gold HMO – $30 pcp office visit copay for the first three office visits. Specialist office visits are subject to coinsurance and deductible. Urgent Care copay is $45. $350 deductible with maximum out-of-pocket expenses of $7,350 and 40% coinsurance. Preferred generic and non- preferred generic drugs receive $0-$10 and $10-$20 copays. Preferred brand and non-preferred brand drugs are subject to coinsurance.

BCBS Of Texas Blue Advantage Plus Gold HMO – $15 and $50 office visit copays  with $50 Urgent Care copay. $750 deductible with maximum out-of-pocket expenses of $7,350 and 30% coinsurance. Preferred generic and non- preferred generic drugs receive $0-$10 and $10-$20 copays. Preferred brand and non-preferred brand drugs are subject to coinsurance.

Community Health Choice HMO Gold 005 – $20 and $45 office visit copays  with $45 Urgent Care copay. $5000 deductible with $5,000 maximum out-of-pocket expenses. Generic, preferred brand, and non-preferred brand drugs subject to coinsurance.

Community Health Choice HMO Gold 001 – $30 and $65 office visit copays  with $65 Urgent Care copay. $0 deductible with $7,350 maximum out-of-pocket expenses. Generic and preferred brand drugs receive $15 and $40 copays ($37.50 and $100 copays for mail-order). Non-preferred brand drug copays are $80 and $200.

IdealCare Total Standard Gold – $1,000 deductible with maximum out-of-pocket expenses of $5,000 and 20% coinsurance. $20 and $45 office visit copays with $60 Urgent Care copay. Diagnostic tests are subject to a $20 copay, and the imaging copay is $300. The generic, preferred brand, and non-preferred brand drug copays are $5, $40, and $80.

Oscar Classic Gold – $25 and $50 office visit copays with $100 Urgent Care copay. $1,500 deductible with maximum out-of-pocket expenses of $7,350 and 20% coinsurance.  Generic and preferred brand drugs receive $10 and $50 copays ($25 and $125 copays for mail-order).

CHRISTUS Texas Gold – $5 and $20 office visit copays with $20 Urgent Care copay. $2,600 deductible with maximum out-of-pocket expenses of $4,150 and 15% coinsurance.  Generic and preferred brand drugs receive $4 and $35 copays ($8 and $70 copays for mail-order). The non-preferred brand drug copays are $75 and $150.

 

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.

Get Cheap Healthcare In Texas

Get Lower Texas Health Exchange Prices

 

 

 

 

 

 

 

 

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 four years ago.  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. However, it is possible that President Trump will propose a return of the High Risk Pools, each managed by their home state. By the beginning of 2019, specific guidelines, if approved by Congress, will be published.

 

Enrollment Deadlines

The deadline for obtaining a Jan 1 effective date, and thus, avoiding a lapse, is typically December 15th. Each  member is notified in many ways (phone calls and letters) to help expedite the transition of benefits. For many consumers, the savings from changing plans is substantial…easily thousands of dollars per year. Occasionally, a carrier will cease offering private coverage, and termination letters are sent. Typically, correspondence is  sent about three months before the current policy expires, which provides ample time to shop for a new plan. Often, the new plan will feature a larger network of doctors, specialists, and hospitals.

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.

 

Texas Senior Health Insurance (Medicare Supplement, Advantage, And Part D Prescription Drug)

 

Medicare Supplement coverage is offered by many TX carriers. All companies must offer Plan A. However, if they also market additional options, Plan C or F must also be made available. Additional contracts, including a high-deductible Plan F, can also be considered. A summary of your rights  (Consumer Bill Of Rights) must be provided when you purchase any policy. Plans are standardized, which makes the comparison process much easier than comparing under-65 contracts. The Texas DOI must approve all companies that conduct business in the state.Listed below are the companies approved to sell Medicare Supplement plans in Texas:

Aetna, American National Life American Republic, American Retirement Life,  Americo, Assured Life, Bankers Fidelity, BCBS Of Texas, Central States, Christian Fidelity, Colonial Penn, Combined Insurance, Continental Life, Coventry, CSI Life, Equitable, First Health, Gerber, Globe, Government Personnel, Guarantee Trust, Heartland National, Humana, Individual Assurance, Liberty National, Loyal American, Manhattan Life, Marquette National, Medico, Old Surety Life, Omaha Insurance, Oxford Life, Physicians Mutual, Reserve National, Sentinel Security, Standard Life And Accident, Standard Life And Casualty, State Farm, Thrivent, Transamerica, Unified Life, United American, United Commercial, Travelers, United National Life, UnitedHealthcare, Universal Fidelity Life, and USAA.

 

Medicare Supplement

 

Shown below are estimated current monthly rates for selected plans in the state’s largest counties for a 65 year-old male. Female rates are usually lower. Companies typically do not offer all available plans in each county.

 

Harris County Plan A

$117 – Philadelphia American Life

$126 – Amerigroup

$128 – Lumico

$128 – Western United Life

$130 – Aetna

$134 – Guarantee Trust Life

$136 – Transamerica Premier Life

$141 – Loyal Christian Benefit

$143 – Greek Catholic Union

$147 – Cigna

$155 – United World Life

$156 – Medico

$177 – Oxford Life

$183 – AARP-UnitedHealthcare

$183 – Americo

$192 – Humana

$197 – Gerber

 

Harris County Plan C

$168 – Western United Life

$168 – AARP-UnitedHealthcare

$208 – Thrivent

$210 – Christian Fidelity Life

$216 – Humana

$258 – United American

 

Harris County Plan F

$161 – Philadelphia American

$169 – AARP-UnitedHealthcare

$169 – Transamerica

$170 – Western United Life

$170 – Guarantee Trust Life

$175 – Equitable National Life

$178 – Liberty Bankers Life

$181 – Shenandoah Life

$183 – Cigna

$186 – Greek Catholic Union

$195 – Pekin Life

$199 – Aetna

$201 – Thrivent

$204 – Medico

$205 – Companion Life

$205 – Combined Insurance

$214 – United American

$214 – CSI Life

$216 – Oxford Life

$220 – Humana

$298 – Gerber

 

Harris County Plan F (HD)

$40 – United American

$45 – Philadelphia American

$47 – Thrivent

$54 – Cigna

$57 – United World life

$70 – Humana

$80 – Aetna

 

Dallas County Plan C

$168 – Western United Life

$168 – AARP-UnitedHealthcare

$208 – Thrivent

$210 – Christian Fidelity Life

$216 – Humana

$258 – United American

 

Dallas County Plan F (HD)

$33 – United American

$37 – Philadelphia American

$43 – Thrivent

$44 – Cigna

$63 – Humana

$69 – Aetna

 

Dallas County Plan N

$96 – Shenandoah Life

$99 – Transamerica

$99 – Guarantee Trust Life

$100 – Cigna

$101 – Greek Catholic Union

$101 – Western United Life

$013 – Equitable National Life

$107 – CSI Life

$108 – Liberty Bankers Life

$110 – Aetna

$110 – Pekin Life

$120 – AARP-UnitedHealthcare

$122 – Humana

$124 – Individual Assurance

$129 – American Retirement Life

$131 – Oxford Life

$138 – Christian Fidelity Life

$139 – Combined Insurance

$139 – Medico

$160 – United American

 

Tarrant County Plan F

$147 – Philadelphia American

$151 – Cigna

$151 – Guarantee Trust Life

$154 – Western United Life

$156 – Equitable National Life

$158 – Shenandoah Life

$162 – Liberty Bankers Life

$164 – AARP-UnitedHealthcare

$166 – Greek Catholic Union

$171 – Pekin Life

$172 – Aetna

$174 – Transamerica Premier

$177 – United American

$178 – Combined Insurance

 

$180 – Humana

$185 – Thrivent

$185 – Companion Life

$188 – CSI Life

$190 – Medico

$191 – Oxford Life

$202 – Individual Assurance

$206 – American Retirement Life

$268 – Gerber

 

Tarrant County Plan F (HD)

$33 – United American

$41 – Philadelphia American Life

$43 – Cigna

$50 – United World Life

$57 – Humana

$66 – Aetna

 

Tarrant County Plan G

$114 – Philadelphia American

$117 – Cigna

$118 – Manhattan Life

$120 – Transamerica

$121 – Greek Catholic Union

$128 – CSI Life

$129 – United World Life

$129 – Oxford Life

$130 – Aetna

$134 – AARP-UnitedHealthcare

$134 – Pekin Life

$151 – Central States

$157 – American Retirement Life

$159 – Equitable

$188 – Gerber

$206 – United American

 

Bexar County Plan Plan F

$138 – Transamerica

$144 – Cigna

$146 – AARP-UnitedHealthcare

$147 – Philadelphia American

$155 – Greek Catholic Union

$158 – Shenandoah Life

$159 – Pekin Life

$160 – Manhattan Life

$164 – Aetna

$168 – United American

$171 – CSI Life

$177 – Medico

$178 – United World Life

$179 – Oxford Life

$180 – Humana

$181 – Combined Insurance

$186 – Individual Assurance

$188 – American Retirement Life

$192 – Companion Life

$263 – Equitable

$273 – Gerber

 

Bexar County Plan F (HD)

$31 – United American

$41 – Philadelphia American

$43 – Cigna

$50 – United World LIfe

$57 – Humana

$66 – Aetna

 

Bexar County Plan N

$83 – Transamerica

$94 – Manhattan Life

$96 – Shenandoah Life

$100 – Cigna

$101 – Greek Catholic Union

$104 – AARP-UnitedHealthcare

$105 – United World Life

$107 – CSI Life

$110 – Aetna

$110 – Pekin Life

$111 – Humana

$117 – Individual Assurance

$119 – Oxford Life

$121 – American Retirement Life

$123 – Medico

$146 – Combined Insurance

$151 – United American

$176 – Equitable

 

Medicare Advantage (Part C or MA)

 

Shown below are many available Advantage contracts that are issued by private carriers approved by Medicare. Parts A and B are provided by the insurer, instead of original Medicare. Additional benefits are often provided, including dental, vision, and hearing. All plans shown below include prescription drug benefits, unless otherwise specified. Prices, copays, deductibles, plan availability, and some benefits will vary throughout the state.

AARP MedicareComplete Plan 1 – $125 deductible with maximum out-of-pocket expenses of $3,400.  3,779 formulary drugs are available. Inpatient hospital copay is $350 per stay. Outpatient hospital copay is $200 per visit. Office visit copays are $0 and $40, while the Urgent Care and ER copays are $30-$40 and $90. Diagnostic tests, procedures, and radiology services are subject to 20% coinsurance,  outpatient x-rays have a $14 copay, and lab tests have a $7 copay. Outpatient mental health therapy visits are subject to $40 copay (group and individual). Foot, preventative dental, hearing, and vision exams are covered, subject to policy limits.  A comprehensive dental option is offered for an additional $34 per month. 30-day prescription drug cost-sharing copays are $3 (Tier 1), $14 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 30% (Tier 5).

AARP MedicareComplete Plan 2 – $195 deductible with maximum out-of-pocket expenses of $5,900.  3,779 formulary drugs are available. Inpatient hospital copay is $335 for 5 days. Outpatient hospital copay is 20%. Office visit copays are $5 and $45, while the Urgent Care and ER copays are $30-$40 and $90. Diagnostic tests, procedures, and radiology services are subject to 20% coinsurance,  outpatient x-rays have a $14 copay, and lab tests have a $7 copay. Outpatient mental health therapy visits are subject to $30 and $40 copays (group and individual). Foot,  hearing, and vision exams are covered, subject to policy limits.  A comprehensive dental option is offered for an additional $39 per month. 30-day prescription drug cost-sharing copays are $3 (Tier 1), $14 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 29% (Tier 5).

Aetna Medicare Premier Plan 1 – $150 deductible with maximum out-of-pocket expenses of $5,000.  5,223 formulary drugs are available. Inpatient hospital copay is $300 for the first 5 days. Outpatient hospital copay is $50-$275 per visit. Office visit copays are $15 and $50, while the Urgent Care and ER copays are $15-$50 and $80. Diagnostic tests and procedures have a $50 copay,  radiology services are subject to 20% coinsurance, and outpatient x-rays and lab tests have a $0 copay. Outpatient mental health therapy visits are subject to $40 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $167.50 for days 21-100. Foot, dental, hearing, and vision exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $2 (Tier 1), $5 (Tier 2), $42 (Tier 3), $100 (Tier 4), and 30% (Tier 5).

Aetna Medicare Prime Plan – $400 deductible with maximum out-of-pocket expenses of $3,400.  5,282 formulary drugs are available. Inpatient hospital copay is $285 for the first 5 days. Outpatient hospital copay is $20-$275 per visit. Office visit copays are $0 and $20, while the Urgent Care and ER copays are $0-$20 and $80. Diagnostic tests and procedures have a $40 copay,  radiology services are subject to 20% coinsurance, and outpatient x-rays and lab tests have a $0 copay. Outpatient mental health therapy visits are subject to $40 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $167.50 for days 21-100. Foot, dental, hearing, and vision exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $0 (Tier 1), $5 (Tier 2), $42 (Tier 3), $100 (Tier 4), and 25% (Tier 5).

Allwell Medicare – $0 deductible with maximum out-of-pocket expenses of $4,300.  4,096 formulary drugs are available. Inpatient hospital copay is $250 for the first 7 days. Outpatient hospital copay is $225 per visit. Office visit copays are $0 and $35, while the Urgent Care and ER copays are $35 and $80. Diagnostic tests and procedures have a $50 copay,  radiology services are subject to 20% coinsurance, and outpatient x-rays and lab tests have a $0 copay. Outpatient mental health therapy visits are subject to $40 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $165 for days 21-100. Hearing exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $0 (Tier 1), $14 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5).

Blue Cross Medicare Advantage Basic – $0 deductible with maximum out-of-pocket expenses of $2,600.  3,261 formulary drugs are available. Inpatient hospital copay is $250 per stay. Outpatient hospital copay is $0-$175 per visit. Office visit copays are $0 and $30, while the Urgent Care and ER copays are $30 and $80. Diagnostic tests and procedures have a $0-$100 copay,  radiology services are subject to a $250-$300 copay, and outpatient x-rays and lab tests have a $0-$50 copay. Outpatient mental health therapy visits are subject to $35 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $167.20 for days 21-100. Hearing and vision exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $0 (Tier 1), $8 (Tier 2), $39 (Tier 3), $95 (Tier 4), and 33% (Tier 5).

Care N’ Care Choice – $0 deductible with maximum out-of-pocket expenses of $4,500.  3,797 formulary drugs are available. Inpatient hospital copay is $250 for day 1, and $125 for days 2-6. Outpatient hospital copay is $250 per visit. Office visit copays are $15 and $50, while the Urgent Care and ER copays are $30 and $75. Diagnostic tests and procedures have a $10 copay,  radiology services are subject to a $50-$200 copay, and outpatient x-rays and lab tests have a $10 copay. Outpatient mental health therapy visits are subject to $40 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $167.20 for days 21-100. Hearing exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $5 (Tier 1), $15 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5).

Humana Gold Plus – $200 deductible with maximum out-of-pocket expenses of $2,600.  4,400 formulary drugs are available. Inpatient hospital copay is $200 for days 1-7. Outpatient hospital copay is $200 per visit. Office visit copays are $0 and $25, while the Urgent Care and ER copays are $0-$35 and $80. Diagnostic tests and procedures have a $0-$200 copay,  radiology services are subject to a $250-$300 copay, and outpatient x-rays and lab tests have a $0-$95 copay. Outpatient mental health therapy visits are subject to $25 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $167.20 for days 21-100. Hearing exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $3 (Tier 1), $47 (Tier 2), $39 (Tier 3), $99 (Tier 4), and 29% (Tier 5).

Lasso Healthcare (MSA) – $0 deductible with maximum out-of-pocket expenses of $6,700.  $0 copay on all covered medical expenses until $6,700 has been reached. Then, 100% coverage. This plan does not include drug benefits.

SeniorCare Select – Value Rx – $285 deductible with maximum out-of-pocket expenses of $6,700.  3,413 formulary drugs are available. Inpatient hospital copay is $375 for days 1-5. Outpatient hospital copay is 20%. Office visit copays are $20 and $50, while the Urgent Care and ER copays are $40 and $200. Diagnostic tests and procedures, radiology services, and outpatient x-rays and lab tests are subject to 20% coinsurance. Outpatient mental health therapy visits are subject to $15 copays (group and individual).  The skilled nursing facility copay is  $0 for days 1-20, and $125 for days 21-100. Hearing  and vision exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $6 (Tier 1), $20 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 27% (Tier 5).

Vital Traditions – $200 deductible with maximum out-of-pocket expenses of $4,300.  3,413 formulary drugs are available. Inpatient hospital copay is $275 for days 1-5. Outpatient hospital copay is $275 or 20% per visit. Office visit copays are $0 and $45, while the Urgent Care and ER copays are $50 and $80. Diagnostic tests, procedures, and radiology services are subject to $0-$250 copays. Outpatient mental health therapy visits are subject to $40 copay (group and individual). Foot,  hearing, and vision exams are covered, subject to policy limits. 30-day prescription drug cost-sharing copays are $2 (Tier 1), $12 (Tier 2), $47 (Tier 3), $99 (Tier 4), and 29% (Tier 5).

 

Medicare  Prescription Drug (Part D)

 

Blue Cross MedicareRx Basic – $30.70 per month with $415 deductible and 3,056 available formulary drugs. 3-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $4 (Tier 2), 14% (Tier 3), and 30% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), 14% (Tier 3), and 30% (Tier 4).

Blue Cross MedicareRx Value – $82.10 per month with $415 deductible and 3,511 available formulary drugs. 3-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $8 (Tier 2), $42 (Tier 3), and 40% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $24 (Tier 2), $126 (Tier 3), and 40% (Tier 4).

Blue Cross MedicareRx Plus – $140.10 per month with $0 deductible and 3,511 available formulary drugs. 3-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $2 (Tier 2), $30 (Tier 3), and 35% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $6 (Tier 2), $90 (Tier 3), and 35% (Tier 4).

Aetna Medicare Rx Select – $16.10 per month with $380 deductible and 3,737 available formulary drugs. 3-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $2 (Tier 2), $47 (Tier 3), and 40% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $6 (Tier 2), $141 (Tier 3), and 40% (Tier 4).

Aetna Medicare Rx Saver – $21.30 per month with $355 deductible and 3,283 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $2 (Tier 2), $30 (Tier 3), and 37% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $6 (Tier 2), $90 (Tier 3), and 37% (Tier 4).

Humana Walmart Rx – $20.40 per month with $405 deductible and 3,274 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $4 (Tier 2), 21% (Tier 3), and 35% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), 21% (Tier 3), and 35% (Tier 4).

Humana Preferred Rx – $24.70 per month with $405 deductible and 3,191 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $1 (Tier 2), 20% (Tier 3), and 35% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $3 (Tier 2), 20% (Tier 3), and 35% (Tier 4).

Humana Enhanced – $75.50 per month with $0 deductible and 3,540 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $3 (Tier 1), $7 (Tier 2), $42 (Tier 3), and 44% (Tier 4). 90-day preferred pharmacy copays are $9 (Tier 1), $21 (Tier 2), $126 (Tier 3), and 44% (Tier 4).

Express Scripts Medicare Saver – $24.00 per month with $415 deductible and 2,806 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $4 (Tier 2), 18% (Tier 3), and 33% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), 18% (Tier 3), and n/a (Tier 4).

Express Scripts Medicare Value – $46 per month with $405 deductible and 3,187 available formulary drugs. 4-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $3 (Tier 2), $26 (Tier 3), and 48% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $9 (Tier 2), $78 (Tier 3), and n/a (Tier 4).

Express Scripts Medicare Choice – $105.70 per month with $350 deductible and 3,681 available formulary drugs. 4-Star Rating by CMS. 30-day preferred pharmacy copays are $2 (Tier 1), $7 (Tier 2), $42 (Tier 3), and 48% (Tier 4). 90-day preferred pharmacy copays are $6 (Tier 1), $21 (Tier 2), 100% (Tier 3), and 100% (Tier 4).

Symphonix Value Rx – $23.30 per month with $405 deductible and 3,233 available formulary drugs. 3-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $3 (Tier 2), $35 (Tier 3), and 25% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $9 (Tier 2), $105 (Tier 3), and 25% (Tier 4).

SilverScript Choice – $23.50 per month with $0 deductible and 3,157 available formulary drugs. 4-Star Rating by CMS. 30-day preferred pharmacy copays are $9 (Tier 1), $19 (Tier 2), $46 (Tier 3), and 49% (Tier 4). 90-day preferred pharmacy copays are $22.50 (Tier 1), $47.50 (Tier 2), $115 (Tier 3), and 49% (Tier 4).

SilverScript Plus – $46.40 per month with $0 deductible and 3,193 available formulary drugs. 4-Star Rating by CMS. 30-day preferred pharmacy copays are $2 (Tier 1), $8 (Tier 2), $40 (Tier 3), and 46% (Tier 4). 90-day preferred pharmacy copays are $5 (Tier 1), $20 (Tier 2), $100 (Tier 3), and 46% (Tier 4).

Cigna-HealthSpring Rx Secure – $22.70 per month with $415 deductible and 3,191 available formulary drugs. 2-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $3 (Tier 2), $30 (Tier 3), and 37% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $9 (Tier 2), $90 (Tier 3), and 37% (Tier 4).

Cigna-HealthSpring Rx Secure Extra – $54.60 per month with $0 deductible and 3,621 available formulary drugs. 2-Star Rating by CMS. 30-day preferred pharmacy copays are $4 (Tier 1), $10(Tier 2), $42 (Tier 3), and 50% (Tier 4). 90-day preferred pharmacy copays are $12 (Tier 1), $30 (Tier 2), $126 (Tier 3), and 50% (Tier 4).

Cigna-HealthSpring Rx Secure-Essential – $21.80 per month with $415 deductible and 3,154 available formulary drugs. 2-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $3(Tier 2), 20% (Tier 3), and 50% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $9 (Tier 2), 20%6 (Tier 3), and 50% (Tier 4).

WellCare Classic – $24.30 per month with $415 deductible and 2,989 available formulary drugs. 3.0-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $1 (Tier 2), $29 (Tier 3), and 40% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $3 (Tier 2), $87 (Tier 3), and 40% (Tier 4).

WellCare Extra – $65.50 per month with $0 deductible and 3,059 available formulary drugs. 2.5-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $0 (Tier 2), $32 (Tier 3), and 42% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $0 (Tier 2), $96 (Tier 3), and 42% (Tier 4).

WellCare Value Script – $10.40 per month with $415 deductible and 3,327 available formulary drugs. 3.0-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $5 (Tier 2), $40 (Tier 3), and 48% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $15 (Tier 2), $120 (Tier 3), and 48% (Tier 4).

AARP MedicareRx Walgreens– $26.70 per month with $405 deductible and 3,130 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $0 (Tier 1), $6 (Tier 2), $31 (Tier 3), and 32% (Tier 4). 90-day preferred pharmacy copays are $0 (Tier 1), $18 (Tier 2), $93 (Tier 3), and 32% (Tier 4).

AARP MedicareRx Saver Plus– $46.50 per month with $405 deductible and 3,233 available formulary drugs. 3.5-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $11 (Tier 2), $33 (Tier 3), and 33% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $33 (Tier 2), $99 (Tier 3), and 33% (Tier 4).

AARP MedicareRx Preferred– $84.30 per month with $0 deductible and 3,682 available formulary drugs. 4.0-Star Rating by CMS. 30-day preferred pharmacy copays are $5 (Tier 1), $14 (Tier 2), $34 (Tier 3), and 40% (Tier 4). 90-day preferred pharmacy copays are $15 (Tier 1), $42 (Tier 2), $102 (Tier 3), and 40% (Tier 4).

EnvisionRxPlus– $46.80 per month with $405 deductible and 3,198 available formulary drugs. 3.0-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $3 (Tier 2), 15% (Tier 3), and 35% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $9 (Tier 2), 15% (Tier 3), and 35% (Tier 4).

First Health Part D Value Plus– $52.60 per month with $0 deductible and 5,366 available formulary drugs. 3.0-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $2 (Tier 2), $47 (Tier 3), and 50% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $6 (Tier 2), $141 (Tier 3), and 50% (Tier 4).

Magellan Rx Medicare Basic – $75.60 per month with $405 deductible and 3,650 available formulary drugs. 2.0-Star Rating by CMS. 30-day preferred pharmacy copays are $1 (Tier 1), $4 (Tier 2), 13% (Tier 3), and 50% (Tier 4). 90-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), 13% (Tier 3), and 50% (Tier 4).

 

Short-Term Texas Options (Under Age 65)

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, and several carriers offer coverage. Shown below are monthly rates for different scenarios.

Male Age 30 Harris County

$41 – LifeShield $7,500 deductible

$45 – LifeShield $5,000 deductible

$56 – LifeShield $2,500 deductible

$89 – IHC Group $2,500 deductible

 

Female Age 40 Harris County

$65 – LifeShield $7,500 deductible

$71 – LifeShield $5,000 deductible

$90 – LifeShield $2,500 deductible

$121 – IHC Group $2,500 deductible

 

Married Couple (2 Persons) Age 30 Tarrant County

$77 – LifeShield $7,500 deductible

$83 – LifeShield $5,000 deductible

$101 – LifeShield $2,500 deductible

$162 – IHC Group $2,500 deductible

 

Married Couple (2 Persons) Age 50 Tarrant County

$176 – LifeShield $7,500 deductible

$191 – LifeShield $5,000 deductible

$237 – LifeShield $2,500 deductible

$309 – LifeShield $1,000 deductible

 

Beware Of Scams

The Affordable Care Act helps many individuals and families in the Lone Star  state cut their medical insurance costs. Although the ACA Legislation is more than five years old, the scammers always seem to show up, hoping for opportunities to make an illegal buck. Based on our more than 35 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.

TX Health Marketplace Plans Online

Get The Best Texas Health Exchange Rates Here

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 (Under Age 65)

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

December 15 – 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.

 

Companies Offering Marketplace Plans

Many 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.

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. Prices are typically very competitive.

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 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.

Texas Healthcare Plans And How To Apply

The Texas Department Of Insurance Helps Regulate Companies

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. A wide array of policy options are offered.

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 Aetna and BCBS. Rates are very attractive in many parts of the state, including Dallas.

IdealCare and Oscar also offer qualified plans.

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.

 

PAST UPDATES:

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.

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.

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.

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

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.

Open Enrollment for 2018 has begun with fewer available companies. We have updated the changes.