Texas Health Insurance Plans Buyer’s Guide

Health Insurance Plans

America’s health care system has changed dramatically since 2012. The Affordable Care Act (ACA) has turned the industry on its head, and with it created a slew of laws that many health insurance recipients aren’t aware of.

Buying health insurance, or receiving coverage from your group health insurance plan, can be complicated. For many, not understanding coverage options can lead to costly surprise out-of-pocket expenses. It is therefore imperative that you understand your options and what to look for in both individual and group health insurance plans.

Unfortunately, keeping up to date with the complicated structure of the ACA isn’t something the average person or company has time to do. That’s where we can help. At HCI America, we have over 30 years of industry experience, and are well versed in the new laws surrounding the ACA. In an effort to give you a general overview of what to expect from your health insurance plans, we have put together a Buyer’s Guide for your convenience.

Guide Covers Aspects Such as:

  • ACA insurance guidelines
  • In and Out of Network Medications
  • What type of plan are you looking at and why that matters
  • How to figure out if your current doctor is in your new network
  • What do office visits include under the new plan?
  • What kind of support does your carrier offer?

Let’s dive right into these questions so you can get the answers and support you need to make an informed decision. Remember, the more you learn about your insurance plans, the better decisions you’ll make for your budget and family.
Does my new plan meet ACA guidelines? What is the penalty if it doesn’t?
ACA has set forth an individual mandate for each person in the country. The individual mandate includes what is known as Minimum Essential Coverage (MEC). In many cases, employers provide health insurance plans based on this mandate.

Requirements under law demand each plan to include:

These benefits are also know as the minimum essential benefits (MEC).

  • Ambulatory patient services (out-patient services)
  • Emergency services (emergency room trips)
  • Hospitalization (treatment for inpatient care)
  • Maternity and newborn care (prenatal care all the way through to post-delivery care)
  • Mental health services and addiction treatment
  • Prescription drugs (limitations apply)
  • Rehabilitative services and equipment
  • Laboratory service
  • Preventative care services, wellness, and chronic disease treatment
  • Pediatric services

When opting through the exchange, all plans of Bronze level and higher meet the MEC guidelines. However, it is important to verify that these standards are being met by your employer. If they are not, you will be required to make up for the difference on the marketplace.

The penalty for failing to meet the MEC guidelines for employers is equal to the number of full-time employees employed for a month multiplied by 1/12 of $2,000, and only full-time employees are counted for the penalty.
Individuals who fail to meet these standards in 2016, and have a high enough income to warrant it, will be penalized according to the Individual Shared Responsibility payment. This fee is calculated either by a percentage of your income (2.5% of household income, or the total yearly premium of a Bronze plan), or a one-time fee of $695 per adult and $347.50 per child under 18. The total maximum penalty is $2,085.

Are my drugs covered by the network offered?

Have I viewed the formulary to verify what tier drug they are and the costs associated under the new plan?
Another important question to ask is are the prescription medications you are taking covered by your network? Your insurance plan’s formulary will list the drugs covered by your plan, but it is important you look at this list before you look for coverage. The formulary will provide a full list of the drugs that are covered, so be sure to give that a thorough look through.

Additionally, you’ll want to investigate if your prescription medications require prior authorization. Some carriers provide easier authorization than others, which can save you time and hassle.
Understanding the tier group your medication falls under will also help you understand the co-pay costs (if applicable) you will have to pay as well. Clearly, the lower the co-pay the better your plan is.

What type of plan is being offered?

There are several types of plans available for insurance. These include:

  • Exclusive Provider Organization Plan (EPO)
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Reference Based Pricing (RBP)


As a member of an EPO plan, you have access to hospitals and doctors that are within your network, but you are prohibited from going out of network for care. This plan offers no out of network benefits with the exception of a true emergency. Referrals generally not needed for care.


HMO’s give you access to a limited number of hospitals and doctors. Its network consists of providers that are agreeing to lower their rates for certain patients with an HMO plan without sacrificing on the quality and benefits of the service. However, you are only covered in network. Referrals are required for care.


PPO plans are the most popular plans available. They allow you to visit in-network physicians and healthcare providers without obtaining a referral from your primary care physician. This is one of the greatest benefits offered by PPOs over the other types of plans.


Also known as reference based pricing. This is typically only found in partially self-funded or fully self-funded plans. An example of this might work is the plan will not have network instead they will agree to pay the provider 130% of Medicare.

Are your doctors in network?

One very important question to ask is if your doctor is in network. As we can see from the various insurance plans offered, in most plans your doctor must be in your network in order for your services to be covered. Any doctor out of your network can cost you a high out-of-pocket fee. Don’t rely strictly on what you see on your carrier’s website. Instead, contact your provider for a direct answer.

How is your office visit covered?

  • Does your insurance plan include comprehensive coverage? Some plans have expensive copays, and it is important to understand what those fees are and what you can expect your office visit to run you with laboratory tests and more. A copay test is a great way to avoid balanced billing later on.

Get to know your carrier

As a patient it is important to recognize what your carrier offers in way of extra services:

  • Will your carrier fight every claim or are they willing to pay out to patients quickly and easily? The process of understanding these carriers and their track record isn’t always easy.
  • Does your health insurance plans carrier offer a wellness program to not only benefit your health but decrease your premiums? Some carriers offer a 15% discount for participating in their wellness program.
    How We Can Help

At HCI we take the headache out of finding carriers and understanding complicated health insurance plans and laws. We can do all of this for you at no charge to you. Contact us today to learn more about our service.

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