There’s a lot to consider when you’re shopping for individual health insurance in Texas. To make things even more complicated, the rules are always evolving. New legislation and court cases will have a major impact on private health plans, while trends in coverage influence who has coverage and who doesn’t. If you live in Texas, there are several recent and ongoing developments that you should know about.
The Battle over Preexisting Conditions and the ACA
Under the Affordable Care Act (ACA), health insurance plans must cover preexisting conditions, and a person cannot be denied coverage or charged a higher premium on the basis of preexisting conditions. A preexisting condition is any condition that has been previously diagnosed or treated, including diabetes, and cancer. This protection is being challenged in court. In Texas v. United States, it’s being argued that the repeal of the individual mandate, which charged a penalty for failing to maintain coverage, also made the ACA unconstitutional. The outcome of the lawsuit could have far-reaching implications, not only for Texas, but for the entire country. If protections for preexisting conditions disappear, many Americans with health problems may have a difficult time finding affordable coverage. According to the Kaiser Family Foundation, approximately 27 percent of American adults under the age of 65 have conditions that could prevent them from getting individual health insurance without protections for preexisting conditions. Women are even more likely to have preexisting conditions, in part because of pregnancy.
The Fight Against Surprise Bills
Nobody likes surprise bills. Unfortunately, when it comes to individual health insurance in Texas, they are very common. Although surprise bills can result from a variety of situations, they often stem from confusion over in-network and out-of-network providers. For example, a patient may go to an in-network hospital where some of the providers are out-of-network. The patient thinks everything is fully covered but is later hit with an unexpected bill for the services of the out-of-network provider. Surprise bills, also called balance bills, can be for tens or even hundreds of thousands of dollars, far more than the average family can afford. Some jaw-dropping surprise bills have made national news. For example, last year, a Texas high school teacher had a heart attack and was rushed to a nearby hospital. Despite being told that the hospital would accept his insurance, he received a bill for more than $100,000. His bill was significantly reduced after the story broke. Surprise bills have become a major health care issue on both the state and national level. Soon, for some Texans at least, there may be relief. Texas Governor Greg Abbott has signed Senate Bill 1264, a law that will protect patients who go to in-network hospitals from surprise bills for out-of-network providers. The law goes into effect on January 1, 2020, and it will apply to state-regulated plans.
Pharmacists and Health Care Practitioners
Another new Texas law, House Bill 1757, adds pharmacists to the lists of health care practitioners. Starting January 1, 2020, insured beneficiaries can select a pharmacist to provide services within the pharmacist’s scope of practice. The law applies to commercial plans. According to the Texas Pharmacy Association, this will prevent payment discrimination against pharmacists.
Faith-Based Health Ministry Blocked
A Texas state district court judge has blocked Aliera Healthcare, a faith-based health ministry headquartered in Georgia, from enrolling new members in Texas. The Texas of Department of Insurance says that Aliera has been operating in Texas without a license. The state has filed a lawsuit against the company, which is estimated to have 17,000 customers in Texas and 100,000 customers in the country. If you are an Aliera customer and you’re having trouble getting claims paid, or if you have other complaints or information, please send an email to EnforcementInfo@tdi.texas.gov.
High Rates of Uninsured Women and Children
A report from the Georgetown University Center for Children and Families looked at the percentage of uninsured women between the ages of 18 and 44, considered to be childbearing age. Nationwide, 12.3 percent of women in this age group lack health insurance. In Texas, 25.5 percent of women in this age group lack health insurance. This means that approximately one in four women of childbearing age in Texas is uninsured, approximately double the national rate. However, it is still an improvement compared to the 2013 figures, when 32.2 percent of women in this age group lacked coverage. The study also looks at Medicaid expansion and how a decision not to expand Medicaid impacts coverage rates. A previous report from the Georgetown University Center for Children and Families found that Texas has a high number of uninsured children, as well. On the national level, about 5 percent of children are uninsured. In Texas, 10.7 percent of children are uninsured.
Average Texas Health Care Ranking
While Texas got a low ranking for coverage rates of young women, the state’s health care appears to be fairly average in other regards. A recent study from MoneyRates.com looked at the best and worst states for health care based on a range of factors. Texas earned a rank of 31 overall, which is considered average. However, when looking at individual health care criteria, Texas received rankings that were both above and below average. Texas earned healthy or robust labels for hospital capacity and nursing home capacity, while the state earned critical or frail labels for health insurance coverage, child vaccination rates and the number of patient care doctors per capita. For both infant survival and longevity, Texas earned an average ranking.
High Hospital Prices
The RAND Corporation has released a report looking at the hospital prices paid by private health insurance plans. While these prices vary considerably, they are significantly higher than the prices paid by Medicare. The study examined the hospital prices paid between 2015 and 2017 in 25 states, including Texas. According to the findings, private health insurance plans in Texas paid 244 percent of Medicare costs.
A Final Note
Before you buy individual health insurance in Texas, be sure to read the policy. Know if preexisting conditions are covered and the copays involved for both in-network and out-of-network providers. Be sure that your favorite doctors are in-network with the plan. You may also want to check the NCQA Health Insurance Plan Ratings for Texas. These will tell you how patients ranked each plan for customer satisfaction, preventative services and treatment. If you need to schedule a surgery soon, compare the out-of-pocket costs for each plan you’re considering. Last but not least, be sure to get multiple quotes. InsuranceLineOne is a great resource – Get an individual health insurance quote now.