HealthCare.gov is a web portal that allows consumers to enter information about their health, age, and location in order to obtain individualized information on health coverage in their area. This site brings together all pertinent information regarding health insurance plans. Consumers can compare health plans in their area, learn about their rights, and find out more information about the Patient Protection and Affordable Care Act.

As of October 1, 2010 – HealthCare.gov includes information on cost estimates of private health insurance plans offered to individuals and families, policy comparison charts, and other important facts about various health plans offered in Texas. The following link shows a sample comparison chart of 3 private insurance plans for a 35 year old male, non-smoker, residing in Austin, Texas: Sample Comparison

CLICK HERE to access HeathCare.gov.

PCIP.gov provides information on the Pre-Existing Condition Insurance Plan, formally known as the Federal High Risk Pool. Consumers can access information on enrollment through this website. The Pre-Existing Condition Insurance Plan was created to make health insurance available to consumers who have had a problem getting insurance due to a pre-existing condition. The site includes information on eligibility, application, and FAQs.

CLICK HERE to access PCIP.gov.

The Office of Public Insurance Counsel has prepared a very concise summary of this important federal legislation. If you would like to review it, please click here.

If you need more detailed information, click here to read a new report titled "PPACA: Consumer Recommendations for Regulators and Lawmakers." This report was drafted by 21 leading advocacy organizations. Please note that OPIC has not endorsed the specific recommendations within this report.

TDI Federal Health Care Reform Resource Page

For frequently asked questions, and links to Federal Websites please click here.

Healthy Texas

Healthy Texas is a private/public statewide health insurance product designed for small employers and their employees. Requirements for small business owners to participate in Healthy Texas include:

• The employer must qualify as a small business with 2-50 employees;
• An employer must not have provided group insurance 12 months prior to Healthy Texas application;
• At least 30 percent of employees must receive annual wages at or below 300 % of the federal poverty level; The employer must pay at least 50 percent of the premium costs for employees;
• At least 60% of eligible employees must elect to participate in the program.

Implementation plans are in progress and updates will be available on the Texas Department of Insurance's Healthy Texas website.

If you would like additional information about any subject referenced above, please contact us.

The two basic types of health coverage available to Texans are:

Managed care plans

Managed care plans use networks of doctors, hospitals, clinics, and other health care providers that have contracted with the plan to provide health services to the plan's members. Some managed care plans require you to use providers within the plan's network for all routine care. Others pay for care from any provider, but offer financial incentives for you to use providers within the network.

In some instances, you may be "balanced-billed" if you use a non-network provider. Balance billing occurs when a physician who is not contracted with the managed care plan bills you the difference between the amount the health plan pays and the amount the physician believes to be adequate reimbursement. Texas has enacted new protections for consumers who have been "balanced-billed". For more information, click here.

The different types of managed care plans include:

• Health maintenance organization (HMO) plans typically require that you use network physicians, hospitals and other health care providers. Your personal gatekeeper physician must provide a referral if you want to go to a specialist or outside the HMO's network for treatment. Two reports can help you decide on which HMO to choose: Comparing Texas HMOs and Guide to Texas HMO Quality.
• Preferred provider organization (PPO) has a provider network like an HMO, but differs from an HMO because it provides some coverage for services by providers outside the network. You choose your personal doctor and do not need a referral to see a specialist. PPO members can see providers outside the network, but must pay more out of their own pocket when they do.
• Point-of-service (POS) plans are a combination of HMOs and PPOs. You will be required to choose a primary care physician, but you may visit an out-of-network doctor without a referral. However, if you use providers outside the network, you will have to pay more for your health care. A POS plan may exclude the option for out-of-network care for certain medical conditions. POS coverage is usually offered as an add-on to the plan, called a rider, for an additional fee.

Traditional Plans allow you to go to any doctor or provider you want, and you do not need a referral to see specialists. A fee-for-service plan will generally pay for most, but not all, of the costs to treat medical conditions covered by the policy. Your provider will usually bill your insurance company directly for its share of your health care costs. In some cases, you may have to pay the bill up front and then file a claim with your insurance company for reimbursement.
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HEALTH INSURANCE NEWS

OPIC SEEKS BAN OF DISCRETIONARY CLAUSES IN INSURANCE CONTRACTS

OPIC has filed a petition for the adoption of a rule banning discretionary clauses with the Texas Department of Insurance (TDI). A discretionary clause gives the insurer broad discretion to interpret policy terms and evaluate an insured's claim for benefits. These provisions also instruct reviewing courts to presume the insurer's decision is correct making it nearly impossible to overturn. The following is an example of a discretionary clause:

The company has full, exclusive, and discretionary authority to determine all questions arising in connection with the policy, including its interpretation, and when making a benefit determination under the policy, the company has the discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy.

OPIC believes these clauses are harmful to consumers. They effectively nullify a carrier's promise to pay benefits owed. These clauses may also deny Texans the protections of the insurance and other laws of this state. Further, these clauses create an inherent conflict of interest as the insurer responsible for providing benefits also has discretionary authority to decide what benefits are due. To see a video news story reflecting how these clauses can harm consumers, please click HERE.

Twenty-two states have enacted legislation, adopted rules, or issued bulletins prohibiting the use of discretionary clauses. In 2004, the National Association of Insurance Commissioners (NAIC) adopted the Discretionary Clause Prohibition Act, which several states have also adopted.

Click here to return to the OPIC homepage