Beginning in 2014, the Affordable Care Act no longer covers those with pre-existing conditions. Insurance companies can no longer discriminate against people with pre-existing illnesses by not covering them, charging them more, making them wait longer for care, or otherwise limiting their access to care. Cosmetic surgeries and other elective operations are the only exceptions to this rule. The only health-related factor considered by insurance companies for setting prices is whether or not you smoke.
An insurance provider can charge you up to 50% more than a nonsmoker if you’ve smoked tobacco at least 4 times a week over the prior six months. Pre-existing condition provisions are still applicable to grandfathered or group/company policies from before 2014, as well as short-term insurance plans, which is why this page is provided as a reference.
Health Insurance Laws and Rules for Individuals in Texas
You may wish to consider purchasing individual insurance from a commercial health insurer if you are not covered by this employer-sponsored group health plan. However, in Texas, like in most other states, there is no legal right to purchase private health insurance for yourself. COBRA, state continuation, and the Texas Health Insurance Risk Pool are all alternatives to private individual health insurance. You will find a concise summary of your rights under various forms of health insurance below.
How do health insurance companies decide if I am eligible for coverage?
In Texas, private health insurance providers are free to set their own criteria for accepting policyholders into their plans. An insurance company is not obligated to accept any application. Only infants (during the first 30 days of life) and handicapped, dependent children (if their parents have a policy that covers dependents) are exempt from this rule.
For those who are HIPAA-eligible but have been unable to secure coverage through a private insurer, the state guarantees acceptance into the Texas Health Insurance Risk Pool (the state’s high-risk insurance pool) to meet the requirements of the HIPAA Group-to-Individual Portability Coverage regulations. Most persons are subject to a tax penalty if they do not have health insurance that fulfils federal requirements. In most cases, this is met by employer-provided health insurance or by one of many federal or state health insurance programmes (such as Medicare, Medicaid, CHIP, TRICARE, and some programmes for veterans).
Some persons are exempt from the federal mandate to have insurance or face a tax penalty. The following situations may qualify you for this exemption from the fine:
if your household income is below the tax filing level ($10,300 for an individual), you qualify for a hardship exemption from the marketplace, the cost of your sole available coverage exceeds 8% of your household income, or you were uninsured for fewer than three months of the year.
Which Medical Services Must Texas Health Insurance Policies Include for Individuals?
While health insurance companies in Texas are not obligated to offer uniform plans to their clients, they are required to provide certain services, such as diabetes management and breast cancer screenings.