FREQUENTLY ASKED QUESTIONS

These acronyms describe how your plan manages your access to doctors and specialists. Choosing the right one is based on your budget and preference for flexibility:

• HMO (Health Maintenance Organization): Generally has the lowest premiums. You must use in-network providers and usually need a referral from your Primary Care Physician (PCP) to see a specialist. Out-of-network care is typically not covered, except in emergencies.
• PPO (Preferred Provider Organization): Offers the most flexibility. You can see specialists without a referral and can go out-of-network, but you will pay significantly more for out-of-network care. Premiums are generally the highest. PPOs in Texas are rarely offered in the Marketplace.
• EPO (Exclusive Provider Organization): A hybrid plan. Like an HMO, it generally only covers in-network care, but like a PPO, it usually does not require referrals to see a specialist.
• POS (Point-of-Service): Balances flexibility and cost. You may need a PCP referral, but you have the option to seek out-of-network care (at a higher cost).

PPOs are less common and typically more expensive on the individual Marketplace compared to HMOs or EPOs. We can filter your options to see if PPOs are available in your area, but it is rare.

Coverage outside of Texas depends heavily on the plan’s network type:

• HMO / EPO: These plans generally offer no coverage for non-emergency care outside their local Texas network.
• PPO / POS: These plans are more likely to offer some coverage out of state, but it will be limited.

If you travel frequently, you must check the plan’s documentation for the “service area” and “travel coverage.”

You can keep your child on your family plan until they turn 26. However, if your Marketplace plan is an HMO or EPO, the plan’s local network (which is in Texas) may not cover your child’s doctors or hospitals in the other state. You would need to choose a plan (often a PPO or a plan with a national network option) that offers adequate coverage in the college town.

The primary way to lower your monthly premium is by applying for a Premium Tax Credit (PTC) through the Marketplace. Eligibility is based on your household size and estimated income. If you qualify, the government pays a portion of your premium directly to the insurance company.

Additionally, choosing a Bronze metal-tier plan or a plan with a higher deductible will lower your premium but will raise your out-of-pocket costs when you need care.

Your main costs include:

1. Premium: The fixed monthly amount you pay just to keep your coverage active.
2. Deductible: The amount you must pay out-of-pocket each year before your insurance company starts paying its share (excluding preventive care).
3. Copayments (Copays): A fixed amount (e.g., $30) you pay for a specific service, like a doctor visit or prescription.
4. Coinsurance: Your share of the costs for a covered health service, calculated as a percentage (e.g., 20%) after you have met your deductible.

They work in sequential order:

• Deductible: Must be paid first (annually) before major coverage begins.
• Copay: A small, fixed fee paid at the time of service for certain services (often applies before or after the deductible).
• Coinsurance: Your percentage share of costs after the deductible is met (e.g., if the bill is $1,000, and your coinsurance is 20%, you pay $200).

This is a tricky area and depends on your plan! Generally:

• Coinsurance payments typically do not count toward your annual deductible because you are usually required to pay full price until your deductible is met. Coinsurance does count toward your maximum out-of-pocket limit.
• Copayments often do not count toward your deductible, but they always count toward your annual Out-of-Pocket Maximum.

Always review your specific Summary of Benefits, as plan rules can vary significantly.

An HSA (Health Savings Account) is a tax-advantaged savings account that can be used for qualified medical expenses. To qualify for an HSA, you must be enrolled in a High Deductible Health Plan (HDHP). HDHPs typically have lower premiums and higher deductibles than standard plans.

HSAs offer triple tax advantages: contributions are tax-deductible, funds grow tax-free, and withdrawals for qualified medical expenses are tax-free.

Yes, these are called supplemental plans or fixed indemnity plans.

These plans pay benefits directly to you (not the doctor) when specific events occur (e.g., a hospital stay, critical illness, or accident). You can use this cash to cover your deductible, rent, or other living expenses. We often recommend these to clients who want peace of mind against high out-of-pocket costs.

The primary time to enroll is during the Open Enrollment Period (OEP). This period typically runs from November 1st to January 15th each year (though dates can vary slightly). If you enroll by December 15th, your coverage usually starts on January 1st.

If you miss the OEP, you can generally only enroll if you qualify for a Special Enrollment Period (SEP). This is triggered by a Qualifying Life Event (QLE), such as losing other coverage, getting married, moving, or having a baby. If you do not qualify for an SEP, you must wait until the next OEP.

QLEs are major changes in life that allow you to enroll in a Marketplace plan outside of Open Enrollment. Common QLEs include:

• Losing minimum essential health coverage (due to a job loss, divorce, etc.).
• Gaining or becoming a dependent (marriage, birth, adoption).
• Permanently moving to a new area that offers different health plans.

To be eligible to enroll through the Marketplace, you must:

1. Live in the United States.
2. Be a U.S. citizen, U.S. National, or be lawfully present.
3. Not be currently incarcerated.

Yes. Under the Affordable Care Act (ACA), children can remain on a parent’s health plan (including Marketplace plans) until they turn 26 years old, even if they are married, not living at home, financially independent, or eligible for employer coverage.

You can always buy a plan on the Marketplace, but you can only qualify for the Premium Tax Credit (subsidy) if the plan offered by your employer is deemed either:

1. Unaffordable: The premium for the employee-only coverage exceeds a certain percentage of your household income (check current affordability rates).
2. Lacking Minimum Value: The plan doesn’t cover at least 60% of total average medical costs or doesn’t cover inpatient and physician services.

If your job’s plan is considered affordable and offers minimum value, you can enroll in a Marketplace plan, but you will not receive any financial assistance.

Marketplace plans are categorized into four “metal tiers” based on how the premium and out-of-pocket costs are divided between you and the insurer. The key is the Actuarial Value (AV), which is the average percentage of costs the plan pays:

• Bronze (60% AV): Lowest premiums, highest deductibles. Best for healthy people who only need coverage for catastrophic events.
• Silver (70% AV): Moderate premiums and deductibles. This is the only tier eligible for Cost-Sharing Reductions (CSRs).
• Gold (80% AV): High premiums, low deductibles. Best for those who use healthcare frequently.
• Platinum (90% AV): Highest premiums, very low deductibles. Insurer pays the majority of costs immediately.

Catastrophic plans are available only to people under age 30 or those with a hardship exemption. They have extremely low premiums but come with a very high deductible, which is usually the maximum annual out-of-pocket limit. They cover three primary care visits before the deductible is met.

Should you get one? They are only recommended as a last resort for very healthy, low-income individuals who want protection against medical bankruptcy, as they are not eligible for premium tax credits (subsides).

This is a serious concern, which is why we discuss options like Cost-Sharing Reductions (CSRs) and supplemental insurance:

• Cost-Sharing Reductions (CSRs): If your income qualifies and you enroll in a Silver Plan, CSRs dramatically lower your deductible and copay amounts.
• Supplemental Insurance: These plans pay you cash directly when certain events occur (like an accident or illness), giving you funds to immediately cover high out-of-pocket expenses without relying on savings.

Yes. Under the ACA, all Marketplace plans are required to cover 100% of the cost for preventive health services (including annual physicals, routine cancer screenings, and many vaccines) before you meet your deductible.