TEXAS HEALTH INSURANCE BASICS

Texas Health Insurance Health Plan Basics:

Texas Health Insurance Health care plans pay for most, and sometimes all, of the treatment costs for illnesses and injuries. They can generally be classified as either “fee for service” or “managed care.” Many people obtain Texas Health Insurance health coverage as part of a group – such as an employer, professional association, or other organization – that offers health coverage to its employees or members. Others may buy individual Texas Health Insurance health coverage directly from an agent or insurer. The type of Texas Health Insurance plan you have and how you obtained it usually determines the benefits included, how you access and receive medical care, and what you’ll have to pay out of pocket.

Texas Health Insurance Fee for Service vs. Managed Care

Texas Health Insurance Fee-for-service plans, often called “indemnity plans,” are sold by traditional insurance companies. With a Texas Health Insurance fee-for-service plan, you can go to any doctor or provider you want, and you don’t 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.

Often your provider will bill your insurance company directly for its share of your health care costs. In some cases, however, you may have to pay the bill up front and then file a claim with your insurance company for reimbursement. Texas Health Insurance law requires companies to pay claims promptly, but it could take several weeks for you to receive your reimbursement.

With a fee-for-service plan, you will pay:

Premiums. A premium is a fee to participate in the plan. You’ll have to pay premiums for as long as you have Texas Health Insurance coverage. If you have a plan through your work, your premium will likely be deducted from your paycheck. Employers who offer health plans usually contribute toward some or all of your premium costs, but they aren’t required to do so.

Deductibles. A deductible is an amount that you must pay out of your own pocket before your plan will begin to pay. If you have a Texas Health Insurance family plan, the deductible may apply to your entire family, or each individual may have a separate deductible. You’ll usually have to meet your deductible each year. Many insurance companies offer high-deductible options for plans. In general, the higher your deductible, the lower your premium will be.

Coinsurance. Once you’ve met your deductible, most fee-for-service plans will pay a percentage of the remaining cost for covered health services and require you to pay the rest. This cost-sharing is called coinsurance. The coinsurance will vary by plan. For instance, some Texas Health Insurance plans may pay 80 percent of the cost, leaving you to pay 20 percent, while others may pay 70 percent, leaving you to pay 30 percent. In Texas, health plans must pay at least 50 percent of the cost of covered services after the deductible has been met. As with deductibles, the higher the amount you pay in coinsurance, the lower your premium will be.

Texas Health Insurance 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.

There are three types of managed care plans, each with a different level of provider choice:

Texas Health Insurance Health maintenance organizations (HMOs) generally require you to receive health care only from providers within the HMO’s network. There are exceptions for medical emergencies and when medically necessary services are not available within the network. With an HMO, you’ll choose a “primary care physician” from a list of doctors in the HMO’s network. Your primary care physician oversees all of your medical care and provides referrals to specialists and other providers. HMOs usually pay primary care physicians a set monthly fee – called a capitation fee – for each member, regardless of the amount of covered services performed.

Texas Health Insurance HMOs with a point-of-service (POS) option allow members to use providers outside the HMO’s network without first having to receive a referral. However, if you use providers outside the network, you’ll 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 a “rider,” or an add-on to the contract, for an additional fee.

Texas Health Insurance Preferred provider organization (PPO) plans allow you to go to any provider you choose. However, you’ll pay less if you use providers in the PPO’s network. You don’t have to select a primary care physician to oversee your care in a PPO plan.