Health Insurance

Getting Individual Health Insurance

If you buy health insurance for yourself and/or your family then you are in the “individual” market. You can buy this kind of plan from an insurance company, agent, broker, or through the federal health insurance marketplace (marketplace). In Texas, this kind of plan is regulated by the Texas Department of Insurance (TDI).

Marketplace. You must buy marketplace coverage during the annual open enrollment period, unless you qualify for a special enrollment period due to a life event like losing other coverage, getting married, moving, or having a baby.

To learn more about marketplace coverage, visit healthcare.gov or call 1-800-318-2596.

*️⃣ Depending on your income, you may be able to get marketplace coverage at a lower cost with subsidies outlined in the Affordable Care Act (ACA). To see if you qualify for these subsidies, use healthcare.gov’s Income Levels and Savings Calculator.

Non-Marketplace. If you buy health care coverage from an insurance company, broker, or agent, you aren’t limited to enrollment periods.

Other. You may also consider other types of health care coverage, such as group insurance. To learn more about these types of coverage, read Other Types of Health Care Coverage.

What kinds of plans are available?

Health Maintenance Organization (HMO)

HMOs provide health care services through networks of doctors, hospitals, and other health care providers.

  • You must choose a primary care physician (PCP). You will need a referral from them to make an appointment with other doctors or specialists in the network.
  • You usually pay copays for in-network doctor visits, medicine, emergency visits, and hospital stays. You will not pay a deductible or coinsurance.
  • HMOs usually don’t pay if you go to a doctor or hospital that is not in their network. They will pay for out-of-network providers in some situations, like emergencies or when care is not reasonably available in-network.
  • A doctor or hospital in your network cannot bill you for any balance after the copay is met.

 

Preferred Provider Organization (PPO)

PPOs let you get health care services through both in-network and out-of-network health care providers.

  • You usually do not need a referral from a primary care physician (PCP) to see other doctors or specialists.

  • You usually will pay a deductible.

  • When you use the PPO network, you usually pay a copay for services covered by your plan.

  • You may also have to pay for part of the total cost (coinsurance).

  • Unlike HMOs, PPOs will usually pay for out-of-network care. But you usually will pay more in coinsurance.

  • In emergencies or when care is not reasonably available in-network, your cost for out-of-network providers should be the same as in-network.

 

Exclusive Provider Organization (EPO)

EPOs have features of HMOs and PPOs, but generally have fewer providers in their network.

  • You usually do not need a referral from a primary care physician (PCP) to see other doctors or specialists.

  • You may pay copays or coinsurance for services covered by the EPO.

  • Many EPO plans require you to meet a deductible before paying for services.

  • In emergencies or when care is not reasonably available in-network, your cost for out-of-network providers should be the same as in-network.

  • Otherwise, EPOs don’t pay if you go to a doctor or hospital that is not in-network. That means you’ll have to pay the full cost of your bill.

 

Point-of-Service (POS)

A POS plan is a combination of an HMO and a PPO. A POS plan is rarely sold as a standalone product. They are usually sold as a part of an HMO or PPO.

  • You must choose a primary care physician (PCP). You will need a referral from them to make an appointment with other doctors or specialists in the network.

  • A POS plan usually pays for more of the bill if you use in-network doctors and hospitals.

  • You may also have to pay for part of the total cost (coinsurance).

  • When you use the network, you must pay copays.

  • Unlike an HMO, a POS plan usually pays for out-of-network care. They will pay more of the bill if you use in-network doctors and hospitals.

  • In emergencies or when care is not reasonably available in-network, your cost for out-of-network providers should be the same as if they are in-network.

 

Click to view a health plan types comparison chart

We’ve created a comparison chart to help you decide which type of health plan is best for you.

How much will my health plan cost?

Health insurance pays for some of your costs and you pay for other costs out-of-pocket. Here’s how:

    Premium

    • A premium is a certain amount of money you pay each month for your health insurance.
    • The amount is based on your age, where you live, and if you use tobacco.

    Deductible

    • A deductible is what you pay every year before your health plan pays for most covered medical bills. For example, if your deductible is $500, your health plan won’t pay anything until you’ve paid $500.
    • The deductible may not apply to certain services like routine doctor visits.
    • Some plans have more than one deductible. For example, you may have one deductible for in-network care and another one for out-of-network care.
    • If your plan covers your family, each family member has an individual deductible. There is also an overall deductible for the family. Once the family deductible is met, the individual deductibles no longer apply.

    Copayment (copay)

    • A copay is the fixed amount you must pay for a service covered by your plan. For example, your health plan may require you to pay $25 to see your primary care physician (PCP) or $40 to see a specialist.
    • Plans usually don't count copays toward your deductible.

    Coinsurance

    • Coinsurance is the percentage of the cost you pay after you meet your deductible. For example, your health plan may require you to pay 20% of the cost of a service and it will pay the other 80%.
    • Coinsurance may be higher for out-of-network services or supplies.

    An out-of-pocket limit is the maximum amount you pay for covered health care services in a plan year. If you meet that limit, your health plan will pay 100% of all covered costs for the rest of the plan year.

    *️⃣ For examples of how cost-sharing works, read How Cost-Sharing Works in Health Insurance.

    What will my health plan cover?

    Health benefits are regulated by both the federal government and individual state governments. The federal government requires that individual and small group plans cover certain Essential Health Benefits (EHBs). EHBs are broken down into 10 categories:

    1. Ambulatory patient services
    2. Emergency services
    3. Hospitalization and surgery
    4. Maternity and newborn care
    5. Mental health and substance use disorder services
    6. Prescription drugs
    7. Rehabilitative and habilitative services and devices
    8. Lab services
    9. Preventative and wellness services and chronic disease management
    10. Pediatric services
    benefit

    Besides the federal requirements listed above, Texas requires that health plans provide other coverage benefits for consumers. Some of the state requirements do not apply to self-funded health plans or others that are exempted from state law by ERISA.

    *️⃣  To learn more, read Know Your Coverage: EHBs and Mandated Health Benefits.

    Terms to Know

    Coinsurance – Coinsurance is the percentage of the cost you pay after you meet your deductible.

    Copayment (copay) – A copay is the fixed amount you must pay for a service covered by your plan.

    Coverage/Benefits – The health care services that the health plan will pay for if you get hurt or sick. Coverage and benefits can include preventive care.

    Deductible – A deductible is what you pay every year before your health plan pays for most covered medical bills.

    In-network – Health care services provided by a doctor or hospital that has an agreement with your health plan. You will usually pay less for in-network services.

    Out-of-network – Health care services provided by a doctor or hospital that does not have an agreement with your health plan.

    Policy – A contract between you and the insurance company. The policy tells you what’s covered and what the insurance company is required to pay.

    Premium – A premium is a certain amount of money you pay each month for your health insurance.

    Primary care physician (PCP) – Your personal doctor that provides basic health care services and coordinates your care by referring you to specialists.