Houston Texas Health Insurance, Affordable Health Care Insurance in Texas

Understanding how health coverage works and finding a health plan that meets your needs at a reasonable price can be difficult and frustrating. This publication provides general information about the kinds of health care coverage available in Texas. It can help you evaluate different health plans, ask the right questions, avoid common mistakes, and know what to do if you have a problem with your coverage.

Health Plan Basics
When people talk about health care coverage, they are usually referring to health plans offered by traditional insurance companies and health maintenance organizations (HMOs). These plans may pay for most, and sometimes all, of the treatment costs for sicknesses and injuries. Health plans can generally be classified as one of two types, "fee for service" or "managed care."

Many people obtain 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 health coverage directly from an agent or carrier. The type of plan you have and how you obtained it usually determines the benefits that are included, how you access and receive medical care, and what you´ll have to pay out of pocket.

Fee For Service Plans
Fee-for-service plans, often called "indemnity plans," are sold by traditional insurance companies. With a 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 health care costs for medical conditions covered by the policy and deemed "medically necessary."

Often your provider will have an established relationship with your insurer, and will bill the company directly for its share of the costs. In some cases, however, you will have to pay the full bill up front and then file a claim with your insurance company for reimbursement. Texas law requires companies to pay claims promptly, but it may take several weeks for your reimbursement. With a fee-for-service plan, you will pay:

Premiums
A premium is a set fee to participate in the plan. You´ll have to pay premiums for as long as you have coverage. The premium amount is determined by the coverage included in your plan, the plan´s features, and the health risk factors of you or your group´s members. 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 the premium costs, but 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 contribute toward your health care costs. If you have a 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 carriers offer high-deductible options for plans. In general, the higher your deductible, the lower your premium.

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 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. Note: Most fee-for-service plans will pay only up to a maximum amount, such as $1 million, during your lifetime toward your total medical expenses or for certain medical conditions. This is called a "lifetime maximum."/p>

Managed Care Plans
Managed care plans are a different approach to health coverage. Managed care plans use "networks" of selected doctors, hospitals, clinics, and other health care providers that have contracted with the plan to provide comprehensive health services to the plan´s members. Some managed care plans require you to seek routine care only from providers within the plan´s particular network. Others pay for care from any provider, but offer financial incentives for using providers within the network.

In general, managed care plans are more affordable than fee-for-service plans that offer comparable levels of coverage. Managed care networks provide a built-in clientele for network providers, allowing them to charge lower rates. And the networks can reduce overhead by centralizing billing and administrative functions. Managed care plans won´t pay for services not deemed medically necessary.

Prescription Drugs
If the plan covers prescription drugs, it may have a list, called a "formulary," which specifies the drugs it will cover. In addition, managed care plans control costs by emphasizing preventive care in an attempt to avoid serious medical conditions that would later require more expensive treatment. In general, the trade-off for managed care is reduced choice for increased affordability.

Point of Service
Point of Service (POS) are also administered by HMOs, but allow members the option of going outside the network for care without having to receive prior approval from a network physician. Inside the network, the POS plan operates like an HMO. If you go outside the network, a POS plan works like a fee-for-service plan. You´ll have to pay a higher share of the cost of out-of-network care, however. A POS plan may exclude the option for out-of-network care for certain medical conditions. POS coverage is often offered as a "rider," or special policy add-on, to existing HMO coverage for an added fee. The POS option involves an HMO evidence of coverage for the in-network services and an insurance company certificate of coverage for the out-of-network benefits.

Thus, plan members have a "dual contract" for the POS plan. Accordingly, inside the network, the POS plan operates as specified in the HMO evidence of coverage and, outside the network, it works as specified in the insurance carrier´s certificate of coverage.

Preferred Provider Organizaton (PPO)
Preferred Provider Organization (PPO) generally offer the most choice of any type of managed care plan. PPO plans are similar in concept to POS plans, except that they´re administered by insurance companies. You´re free to receive health care from any provider, but you pay lower deductibles and less in coinsurance if you use providers in the PPO´s network. PPO networks tend to be more loosely organized than HMO networks, and the law prohibits PPOs from requiring you to select a primary care physician. Also, unlike in an HMO, PPO physicians aren´t paid flat fees for their patients. Instead, providers agree to charge the sponsoring insurer a contracted rate. With a managed care plan you will pay

Copayments are amounts you pay each time you receive a covered medical service, such as a doctor visit or a prescription drug. Most managed care plans usually have a maximum out-of-pocket expense that you´ll have to pay in copays and deductibles over a certain period, usually a year. When you reach this amount, your plan will pay 100 percent of all further costs. Coinsurance. This is the percentage of the cost for health care services that you must pay, after you´ve met your deductible. Coinsurance usually only applies to out-of-network care in PPO and POS plans. Avoiding or reducing coinsurance is a common incentive for remaining inside a managed care network.

	Fee for Service	Managed Care
	Fee for Service	Preferred Provider Option (PPO)	Point of Service (POS)	HMO
More choice, may be more expensive, Less choice, may be less expensive
Summary	Total choice of health care provider	Choice of provider, financial incentive to stay in network	Choice of provider, financial incentive to stay in network	Choice of provider primarily limited to network
Primary care physician (decides necessary treatment)	No	No	Yes, for in-network services	Yes
Geographic restrictions	Coverage available anywhere you live or travel in U.S.	Coverage available anywhere you live or travel in U.S.	In-network coverage is limited to a specific service area in state; limited benefits while traveling	Coverage is limited to a specific service area in state; limited benefits while traveling
Filing claims	Provider often bills insurer each time you receive care; at times, however, you will have to pay in full and file for reimbursement	You usually don´t have to file in-network claims; you may have to pay out-of-network providers in full and file for reimbursement	You usually don´t have to file in-network claims; you may have to pay out-of-network providers in full and file for reimbursement	You usually don´t have to file claims
Average annual premiums	Generally highest of four options	Usually lower than fee for service	Usually lower than PPO	Generally lowest of all options, but may depend on employer plan
Deductibles	Yes	Yes	Usually only for out-of-network care	Depends on plan
Copayments	Possibly	Yes, if in network	Yes, if in network	Yes
Coinsurance	Often required, or often offered for lower premium	Often required, or often offered for lower premium	Yes	Possibly

Individual Health Plans
Insurance companies and HMOs sometimes sell coverage directly to individuals, in much the same way that auto insurance is sold. These policies can cover the purchasing individual only or include a spouse and dependents. Individual plans can be a good option if you´re self-employed or work for a company that doesn´t offer a health plan.

In general, individual plans cost more, and may cover fewer conditions, than employer-sponsored plans or other group plans. Group plans achieve lower rates by spreading the risk of claims over a greater number of people. Add the fact that employers often contribute 50 percent or more toward workers´ plan costs and the price of individual coverage can seem even more expensive. Many of the mandated benefits are contained in an individual policy. However, the carrier may offer riders that modify, expand, or restrict an individual policy.

The following are common types of health care coverage you usually can buy as an individual:

Carriers have the right to evaluate your medical history and other health factors when deciding to offer individual plans. The carrier may deny your application based on health factors, or only offer a plan with an "exclusionary rider" eliminating benefits for certain conditions.

Note: As a rule, it´s better to buy one comprehensive HMO or major medical policy. If you need more coverage, these plans often allow you to add benefits. The other types of individual plans may cost less, but they usually provide fewer benefits or may duplicate coverage that you already have.

Covering dependents
If a plan covers dependents, such as children and grandchildren, they are eligible for dependent health care coverage until the age of 25. State law requires plans to provide comparable coverage for a dependent if the enrolled parent is required to provide medical child support under a court order. The plan may not require the child to live within the service are or to live with the parent. Children with mental or physical disabilities who cannot financially support themselves may be covered indefinitely. The plan may require evidence of disability.

Maternity
Policies that include maternity coverage, and those that allow dependent coverage, must also provide automatic coverage for any newborn child for the first 31 days. After this period, you must notify your carrier if you wish to continue coverage for the child.

Students
Large-employer plans also must provide coverage for certain dependent students over the age of 25. However, except for emergency care and authorized referrals, an HMO plan can require dependent students to return to the plan´s service area to receive health care services./p>

Birthday Rule
If two spouses are covered by separate health plans, and both plans cover their dependents, the "birthday rule" takes effect. This means the plan of the parent who has the earlier birthday in the calendar year pays first. For example, the plan of a parent whose birthday is July 3 would pay for a child´s health care before the plan of the other parent born on July 4. However, if the first parent´s plan reaches its benefits maximum, the second plan can take effect. In the event of a divorce, a court usually determines which parent´s plan is a dependent´s primary coverage.

Health Plan Benefits
Benefits vary from one plan to another. Health plans are classified as either

A state-mandated plan provides certain required minimum features and coverage’s. To make health coverage more affordable, Texas law allows carriers to also offer consumer choice plans that do not include all of the state-mandated benefits. Consumer choice plans are required to provide members with a disclosure statement and a list describing the benefits that are not covered. To be certain of the coverage’s you have with any plan; however, you should refer to your policy or explanation of coverage.

Although consumer choice plans also may be called "standard plans," be careful not to interpret the term to mean that the coverage’s provided are "standardized." Each carrier´s consumer choice plan may be different - and, in fact, a carrier may offer several different consumer choice plans.

The following charts show the minimum required benefits for consumer choice and state-mandated health plans. The requirements are different according to whether the plan is an individual, small-employer, or large-employer plan, and whether it is administered by an insurer or an HMO.

Notes: "SMP" denotes a state-mandated plan; "CCP" denotes a consumer choice plan. Benefits labeled "Yes" must be included as part of the plan; benefits labeled "No" are not required; benefits labeled "Offer" must be offered, but you may decline any or all of them if you wish.

Minimum required benefits for consumer choice and state-mandated health plans.

Minimum required benefits in individual health plans
Benefit	Fee for Service Plan		HMO
Benefit	SMP	CCP	SMP	CCP
Mammography	Yes	Yes	Yes	Yes
Emergency care	Yes, if PPO	Yes, if PPO	Yes	Yes
Alzheimer´s disease (certain requirements if coverage for Alzheimer´s disease is provided)	Yes	Yes	Yes	Yes
Oral contraceptives (if prescription drugs are covered)	Yes	No	Yes	No
Contraceptive drugs and devices	Yes	No	Yes	No
Diabetes equipment and supplies	Yes	Yes	Yes	Yes
Guidelines for diabetes care	Yes	No	Yes	No
Childhood immunizations	Yes	Yes	Yes	Yes
Telehealth and telemedicine	Yes	No	Yes	No
Hearing screenings	Yes	Yes	Yes	Yes
Certain therapies for children with developmental delays	Offer	No	Yes	No
Maternity minimum stay (if maternity is covered)	Yes	Yes, federal	Yes	Yes, federal
Prostate testing	Yes	Yes	Yes	Yes
Reconstructive surgery incident to mastectomy	Yes	Yes, federal	Yes	Yes, federal
Mastectomy minimum stay	Yes	No	Yes	No
Off-label drug use	Yes	No	Yes	No
Acquired brain injury	Yes	No	Yes	No
Detection of colorectal cancer	Yes	Yes	Yes	Yes
Reconstructive surgery for craniofacial abnormalities in a child	Yes	Yes	Yes	Yes
Mental/nervous disorders with demonstrable organic disease	Yes	No	Yes	Yes
Transplant donor coverage (certain requirements if transplant coverage is provided)	Yes	No	No	No
Complications of pregnancy	Yes	Yes	Yes	Yes

Minimum required benefits in small-employer health plans
Benefit	Fee for Service Plan		HMO
Benefit	SMP	CCP	SMP	CCP
In vitro fertilization	Offer	No	Offer	No
HIV, AIDS, or related infection	Yes	No	Yes	No
Chemical dependency, chemical dependency treatment facility	Yes	No	Yes	No
Serious mental illness	Offer	No	Offer	No
Treatment of mental or emotional illness	Yes	No	Yes	Yes
Inpatient mental health, psychiatric day treatment facility	Yes	No	Yes	No
Speech and hearing	Offer	No	Offer	No
Mammography	Yes	Yes	Yes	Yes
Home health care	Offer	No	Yes	Yes
Emergency care (only stabilization)	Yes, if PPO	Yes, if PPO	Yes	Yes
Crisis stabilization unit and residential treatment center for children and adolescents	Yes	No	Yes	No
Alzheimer´s disease (certain requirements if coverage for Alzheimer´s disease is provided)	Yes	Yes	Yes	Yes
PKU treatment (if prescription drugs are covered)	Yes	Yes	Yes	Yes
Oral contraceptives (if prescription drugs are covered)	Yes	No	Yes	No
Contraceptive drugs and devices	Yes	No	Yes	No
Bone mass measurement for osteoporosis	Yes	No	Yes	No
Maternity minimum stay (if maternity is covered)	Yes, state & federal	Yes, federal	Yes, state & federal	Yes, federal
Prostate testing	No	No	No	No
Reconstructive surgery incident to mastectomy	Yes, state & federal	Yes, federal	Yes, state & federal	Yes, federal
Acquired brain injury	Yes	No	Yes	No
Complications of pregnancy	Yes	Yes	Yes	Yes

Minimum required benefits in large-employer health plans
Benefit	Fee for Service Plan		HMO
Benefit	SMP	CCP	SMP	CCP
In vitro fertilization	Yes	No	Yes	No
HIV, AIDS, or related infections	Yes	No	Yes	No
Chemical dependency, chemical dependency treatment facility	Yes	No	Yes	No
Serious mental illness	Yes	Yes	Yes	Yes
Outpatient treatment of mental or emotional illness	Offer	No	Yes	Yes
Inpatient mental health, psychiatric day treatment facility	Yes	No	Yes	No
Speech and hearing	Offer	No	Yes	No
Mammography	Yes	Yes	Yes	Yes
Home health care	Yes	No	Yes	Yes
Emergency care	Yes, if PPO	Yes, if PPO	Yes	Yes
Crisis stabilization unit and residential treatment center for children and adolescents	Yes	No	Yes	No
Alzheimer´s disease (certain requirements if coverage for Alzheimer´s disease is provided)	Yes	Yes	Yes	Yes
PKU treatment	Yes	Yes	Yes	Yes
Mastectomy minimum stay	Yes	No	Yes	No
Drug formulary, continuation of benefits	Yes	No	Yes	No
Oral contraceptives	Yes	No	Yes	No
Contraceptive drugs and devices	Yes	No	Yes	No
TMJ, coverage for person unable to undergo dental treatment in an office setting or under local anesthesia	Yes	No	Yes	No
Bone mass measurement for osteoporosis	Yes	No	Yes	No
Childhood immunizations	Yes	Yes	Yes	Yes
Telehealth and telemedecine	Yes	No	Yes	No
Hearing screenings	Yes	Yes	Yes	Yes
Certain therapies for children with developmental delays	Offer	No	Yes	No
Maternity minimum stay, if maternity is covered	Yes	Yes, federal	Yes	Yes, federal
Prostate testing	Yes	Yes	Yes	Yes
Diabetes equipment and supplies	Yes	Yes	Yes	Yes
Guidelines for diabetes care	Yes	No	Yes	No
Reconstructive surgery incident to mastectomy	Yes	Yes, federal	Yes	Yes, federal
Off-label drug use	Yes	No	Yes	No
Acquired brain injury	Yes	No	Yes	No
Detection of colorectal cancer	Yes	Yes	Yes	Yes
Reconstructive surgery for craniofacial abnormalities in a child	Yes	Yes	Yes	Yes
Point of service coverage	No	No	Yes	Yes
Complications of pregnancy	Yes	Yes	Yes	Yes

Federally mandated benefits
In addition, the following benefits are required by federal law: Maternity and newborn coverage If maternity benefits are covered, a group health plans with more than 15 employees must provide for a minimum hospital stay of 48 hours after an uncomplicated vaginal delivery, and a minimum stay of 96 hours after an uncomplicated cesarean birth.

A carrier may not deny benefits on the grounds that a pregnancy is a "pre-existing condition." In addition, the law requires that any plans that have maternity benefits must automatically extend coverage to the newborn for 31 days. To continue coverage beyond 31 days, you must notify your plan administrator during this period and pay any additional required premiums.

A carrier may not exclude or limit initial coverage of a newborn child because of premature birth, accident, illness, or congenital medical conditions. This includes providing reconstructive surgery for craniofacial abnormalities for a child younger than 18 who has been continually covered by a health plan.

A benefit covering "complications of pregnancy" may help if your plan does not include a maternity benefit. Miscarriages or non-elective cesarean births are considered complications. In most cases, management of a difficult birth is not considered a complication, and is only covered by plans with maternity benefits. Mastectomy benefits Plans that offer mastectomy coverage must also provide for reconstructive surgery of the breast on which the operation was performed, as well as the other breast if needed for a symmetrical appearance. This coverage may be subject to deductibles, copayments, and coinsurance that are consistent with other benefits under the plan. The benefit must also cover prosthesis and treatment of complications at all stages of mastectomy, including lymphedemas.

Limitation of Coverage

Utilization Review
Carriers can deny payment for any treatment, or the continuation of any treatment, if they deem that it is not "medically necessary." Many health plans perform "utilization review" before non-emergency medical procedures are approved. The review must be conducted by an appropriate physician, dentist, or other health care provider, and any decision denying treatment must include a medical reason. State law requires the criteria used to approve or deny requested services or treatments to be objective, medically (clinically) valid, compatible with established health care principles, and flexible enough to allow deviation from standard guidelines when justified on a case-by-case basis.

If you have an unresolved complaint about a utilization review for an individual, small-employer, or large-employer plan, you may file a complaint with TDI. If you have a complaint about a self-funded plan, contact the U.S. Department of Labor.

To reduce the chance of a claims problem, read your policy or benefits booklet carefully. Be sure you meet all of the plan´s requirements, and keep copies of all correspondence with your carrier and health care provider.

Approval of treatment is not the same as approval for payment. You may still need to file a claim after the procedure. Carriers can refuse payment for portions of approved treatment if they are found to be "unnecessary expenses."

Pre-existing conditions and waiting periods
If you currently have a medical problem, or have had one in the recent past, it may meet a plan´s definition of a "pre-existing condition." Most plans will require you to wait a period of months, or sometimes years, before paying benefits for treatment related to this condition.

You must disclose any pre-existing conditions in your application for any health plan. Failure to do so could jeopardize future claims or invalidate the policy. Carriers may define a pre-existing condition as any condition for which you´ve received medical advice, care, diagnosis, or treatment during a specified period of time before the plan takes effect. In addition, individual plans can define a pre-existing condition as one where you´ve shown the existence of symptoms likely to cause you to seek diagnosis or care during the period before the plan begins.

Typically, individual plans consider your medical history for the previous five years to determine whether you have a pre-existing condition. Employer-sponsored plans typically consider the previous six months, while other group plans usually look at the previous 12 months.

An individual carrier may decline to cover you entirely on the grounds of a pre-existing condition, or the carrier may insist on a special policy "rider" that excludes treatment for the condition. Group carriers may not insist on a pre-existing condition exclusion rider. The maximum pre-existing waiting period for an individual health plan is two years. The maximum wait for employer-sponsored health plans is one year. You may have to wait up to two years for pre-existing conditions to be covered if you have coverage through a group plan that´s not sponsored by an employer.

Some plans may require a standard waiting period before new members are eligible to receive any benefits, regardless of whether they have a pre-existing condition or not. If this is the case, your pre-existing condition wait begins with the start of the waiting period.

For example, if your plan has a waiting period of three months and a pre-existing condition waiting period of one year, a new member would be eligible to receive benefits for a pre-existing condition nine months after the waiting period ends.

HMOs have an "affiliation period" that works in much the same way as a waiting period for pre-existing conditions in indemnity plans. However, the affiliation period may not be longer than 90 days.

Reducing pre-existing condition waits if you´re switching from one health plan to another, or have a recent history of health coverage; the law has some provisions that can shorten your pre-existing waiting period under the new plan. However, these rules do not apply if you are switching from one form of individual coverage to another. The amount of time you spent covered under a previous health plan is "creditable" toward any new plan´s waiting period, as long as there is no gap in coverage greater than 63 days. For example, if you´ve been covered by one health plan for the past six months, and then switch to a new plan with a pre-existing condition wait of one year, your previous coverage "credits," and you only have to wait six months. The following table summarizes how health plans handle pre-existing conditions:

Shopping for Coverage
When considering a health plan, be sure you understand the full extent of the coverage that is included. If you have more than one option, choose the one with the highest level of coverage you can afford. The higher a plan´s deductibles, co pays, and coinsurance, the more you can usually save on premiums. However, you´ll also have to pay more out of pocket for claims.

Consider factors other than cost. A carrier´s financial rating and history of consumer complaints are other important considerations. Also make sure your carrier is licensed by TDI. It is illegal to sell unlicensed health coverage in Texas. Guaranty associations play the claims of licensed carriers that become insolvent. If your company isn´t licensed, your claims could go unpaid. You can learn a company´s financial rating from an independent rating organization, its complaints history, and its license status by calling TDI´s Consumer Help Line or by visiting our website

It´s a good idea to ask your friends, family, and physician for recommendations. Be sure you learn the answers to these questions about any health plan you´re considering:

· Are there limits on medicines, referrals to specialists, or the types of treatment or surgery available?

· Are there benefit limits per person, family, illness, treatment and/or hospital stay?

Additional precautions
Additional precautions when you apply for coverage be sure you fill out the application accurately and completely. If you knowingly provide incorrect, incomplete, or misleading information, especially about a pre-existing condition, your coverage could be canceled or your benefits denied.

When purchasing an individual plan, never sign a blank policy application, and verify any information filled in by an agent. Make payments by check or money order payable directly to the insurance company or HMO, not the agent, and insist on a signed receipt on the carrier´s letterhead. Make sure you have the full name, address and phone number for both your agent and your carrier.

Never pay more than two month´s premiums until you have received a copy of your policy, HMO subscriber certificate, or group membership certificate. State law requires that you have a 10-day "free-look" to evaluate any individual coverage policy, during which you can change your mind and receive a refund. If you return a policy, send it by certified mail, return receipt requested.

Health Plan Rates
Health Plan Rates Texas, like most states, has no authority to regulate or approve health plan rates - with the sole exception of small-employer plans, where the state has a cap on annual premium rate increases. Otherwise, insurance companies and HMOs set their own premiums. Small-employer and large-employer plans are required to give 60 days’ notice before any increase takes effect.

· The coverage’s included. The more conditions your plan covers, the greater the carrier´s risk. Premium rates increase accordingly.

· Amount of the deductibles. Plans with higher deductible plans have lower premiums.

· Number of covered dependents. Adding a spouse or dependent children to your plan will raise your premiums.

· Number of group plan participants. Group plans are usually much less expensive than individual plans. As group size increases, administrative costs per plan member decline. Also, smaller groups and individuals tend to buy health coverage based on participants´ targeted needs, increasing the likelihood of claims. This type of "custom tailoring" is less likely as claims risk is distributed across a larger population.

· Claims experience. Having filed claims in the past is an indicator that you will likely file more claims in the future. If you or the members of your group plan to file claims, expect a premium increase at the plan´s term of renewal.

· Age. Older people can reasonably be expected to require more, and more expensive, health care. Your premium will reflect your age, or the ages of the members in your group plan.

· Gender. Females generally incur higher medical costs than males at younger ages, particularly during childbearing years. This variance diminishes with age until medical costs for males begin to exceed those for females in the late 50s and early 60s. Younger, proportionately more female plan members, or older, proportionately more male, will increase rates.

· Health costs vary by region due to differences in cost of living, medical practices, and the amount of medical competition in the area.

· Industry. If you are in an employer-sponsored plan, your rates may be affected by the nature of your profession. Some industries have higher medical claims costs than others because of working conditions and the prevalence of accidents. High employee turnover in some industries can also result in higher administrative costs for the carrier. Handling rate increases

Rising health coverage costs tend to impact policyholders of individual plans more than any other, as there is no employer or other plan sponsor to help bear the cost. If your premiums are increasing beyond your ability to pay, you may be able to save money by asking your carrier to revise an individual plan.

Options to reduce your individual plan´s premiums may include accepting higher deductibles or co pays, increasing your maximum out-of-pocket payment, or changing your coverage. Be sure that you don´t drop an essential coverage, however. Before making any changes to your plan, find out if your carrier will allow you to add back any dropped benefits later.

If you´re unable to reach a good deal on your current plans, you may want to switch to a new plan or carrier entirely. Remember, if you have, or recently had, a medical condition, you may encounter problems finding new coverage. If you join an individual coverage plan, your medical history may result in restrictions on the new policy. If a serious medical condition is the cause of rate increases that you cannot afford, and you must have treatment, you may have to join the Texas Health Insurance Risk Pool or seek coverage through other government programs. Important! Always try to keep your current coverage until new coverage takes effect. Most companies do not begin coverage until they approve your application and deliver your policy. Gaps in coverage leave you vulnerable in the case of emergency sickness or injury and can result in longer waiting periods before pre-existing conditions are covered by a new plan.

f you are concerned about the size of certain physician fees and hospital charges check with your plan to see if the provider´s estimate of how much the treatment will cost is within the "usual and customary" range, keep a record of whom you talk to and when, and get a second opinion if surgery is involved. Also, don´t be afraid to challenge a physician or provider about the costs of tests or services:

Request an itemized bill and review it. Question billings you do not understand. If the explanation doesn´t make sense, check with your plan. Check whether your physician or provider included the proper treatment or procedure code. An improper code may result in the wrong amount being listed. Tell your insurance company or health benefit plan administrator if you think certain charges are incorrect or you were charged for a service never received. Check your county medical association. Grievance committees at the county level accept complaints against physicians or providers and work as go-betweens in fee disputes.

Losing Coverage
If your coverage is through an insurance company, and the company becomes insolvent, valid claims are covered by a state guaranty association up to a certain amount. However, the guaranty association does not cover HMOs, MEWAs, valid self-funded ERISA health benefit plans, and fraternal benefit societies.

>HMOs must keep cash and securities on deposit with the state, as well as maintain an internal financial cushion, to pay claims if they become insolvent. In the event an HMO becomes unable to pay its claims, state law authorizes the Commissioner of Insurance to assign its members to another licensed HMO in the area. State law requires individual health carrier plans that cover hospital, medical, and surgical expenses to be "guaranteed renewable," meaning your carrier cannot arbitrarily deny renewal for your policy, including on the grounds of health-related factors. However, a carrier can legally cancel your coverage for various reasons, including but not limited to

· intentionally misrepresenting personal information in your policy application

In addition, a carrier may discontinue a particular plan as long as it drops the plan for all policyholders. However, in this case the carrier must offer the policyholders who lose coverage the right to purchase any other plan the carrier offers. If a carrier withdraws from the Texas market entirely, it may not re-enter the market for five years.

Late payment of premiums on an individual policy could cause you to lose your coverage and benefits. Some carriers may accept late payments. However, many carriers will require that you reapply for the coverage - and repeat the underwriting process - before you can be reinstated.

Reinstated coverage will only cover health expenses due to an accident if the accident occurs after reinstatement. It will only cover expenses due to illness if the illness begins more than 10 days after reinstatement. When a carrier reinstates a policy, it may also attach riders excluding certain coverage. The exclusions may be permanent or for a specified period of time.

Under an individual policy, death of an insured spouse does not necessarily terminate coverage. The surviving spouse becomes the insured. If you lose coverage due to a change in marital status, you are entitled to your own individual policy. You don´t have to prove you´re in good health to receive the new policy.

If you have a group health plan, you can lose your coverage for various reasons, including but not limited to

Continuation of group coverage is required for certain dependents for up to three years if termination of coverage is due to death, retirement or divorce. To qualify, a dependent must have been covered by the group policy for one year or be an infant less than 1 year old. Dependent benefits are the same as those provided by the group health policy. Continuation of coverage will end early if dependents obtain new coverage, premiums are not paid or the group policy is terminated. COBRA protection

COBRA protection
If you lose your group coverage for employment-related reasons, you may be able to keep your coverage for a limited time, although your employer will no longer continue any contribution toward your premium.

The federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act) gives employees, and in some cases retired employees, the right to continue group health coverage for a period of 18 months for themselves, and up to 36 months for spouses or any dependent children. COBRA generally only applies to employees who lose coverage because of reduced work hours or lose their job for reasons other than "gross misconduct."

COBRA applies to all employer health benefit plans with 20 or more employees, except plans sponsored by the federal government and certain church-related organizations. COBRA also enables a spouse and dependent children to continue coverage when an employee is entitled to Medicare, divorces, or dies. Employee´s children qualify for continued coverage under COBRA if they lose "dependent child" status under the rules of the health benefit plan. An employee, spouse, or dependent child has 60 days after qualifying for COBRA coverage to decide whether to take it. If accepted, the cost to the employee, spouse, or dependent child is the full premium, plus a 2 percent administrative fee. Depending on the situation, coverage may continue for 18 to 36 months, but may be slightly longer in some situations.

If you elect continuation of HMO coverage through COBRA and move out of the service area, you will be covered only for emergency services. For more information, call the Dallas office of the U.S. Department of Labor´s Employee Benefits Security Administration

If you meet certain criteria, Texas law requires your group plan to allow you to continue coverage for six months. The six-month "continuation period" begins after any federal COBRA extension period ends, or begins immediately if COBRA coverage does not apply. Therefore, if you are eligible and opt for COBRA coverage, you may have a total of 24 months to find new health care coverage. Before the Texas continuation period ends, your group plan is also required to provide you with information on how to enroll in the Texas Health Insurance Risk Pool.

Other Coverage Options
If you don´t work for an employer that offers a health plan and cannot afford or qualify for an individual plan, there are some other options. However, this coverage is generally either very limited, very expensive, or both. Before considering these options, there are a few things you should do:

Make sure you apply with multiple insurance companies and HMOs - each has its own criteria for accepting policyholders. Look into professional organizations, churches, or trade unions that offer group plans. You may be able to get coverage if you join. If you have a health condition, check with state and national non-profit groups for people with similar conditions. If you are denied coverage based on your medical history, verify that the information the carrier has is current and correct. Many carriers use the Medical Information Bureau (MIB) to verify medical history. MIB provides its member carriers with brief coded reports of applicants´ medical history. For more information, contact MIB or visit its website

Texas Health Insurance Risk Pool
The Health Pool offers health insurance to Texans who can´t find coverage because of their medical condition and to certain individuals who have recently lost their employer-sponsored health coverage. The Health Pool is generally the most comprehensive option you will find if you can´t get traditional coverage. The policy offers major medical coverage similar to coverage offered in the commercial individual market. Premium rates are determined by the member´s age, gender, tobacco use, and residential ZIP code, without regard to health status. Premium rates may be up to twice the standard rate in the individual health insurance market. For more information, including eligibility requirements and benefits information, call Insurance Corner (281) 448-6677 or the Health Pool or visit its website

In addition to the Health Pool, there several federal, state, and local groups and agencies that offer help with health coverage or low-cost care. If you cannot afford the Health Pool, cannot qualify, or if the Pool is not able to fully meet your needs, the following agencies and programs may be able to help:

Other Health Care Coverage/Care Options
	Agency / Program	Description	Contact
Federal	Medicare	Federal health insurance program for people 65 and older and certain people under age 65 with disabilities	1-800-MEDICARE (1-800-633-4227) www.medicare.gov
	TRICARE	Health plan for active duty and certain retired U.S. military personnel	1-800-538-9552 www.tricareonline.com
	Veteran´s Administration	Offers health care for veterans	1-877-222-VETS (1-877-222-8377) www.va.gov
State	Medicaid	State/federal health insurance program for low-income Texans	877-267-2323 TTY: 866-226-1819 www.cms.hhs.gov/medicaid/
	Texas Health Steps	Provides medical and dental checkups and care to children from birth to age 21 who are on Medicaid	1-877-THSTEPS (1-877-847-8377) www.tdh.state.tx.us/thsteps/
	Children´s Health Insurance Program (CHIP)	Provides health care to children of families who earn too much money for Medicaid but can´t afford health insurance	1-800-647-6558 www.hhsc.state.tx.us/chip/
	Department of Assistive and Rehabilitative Services	Provides rehabilitative services, including vocational training, for Texans with disabilities	512-377-0500 TTY:512-407-3251 www.dars.state.tx.us
Local	Hill-Burton Program	Federally funded program that contracts with local hospitals, clinics, and nursing homes to provide free or low-cost care to individuals eligible because of income. Services vary by provider and may not be available in all areas	1-800-638-0742
Local	Indigent Health Insurance	Health care for some indigent Texas	Local county courthouse

Handling Complaints
To limit the chances of a claims dispute, study the provisions of your policy carefully. Be sure you understand any limitations or exclusions before seeking medical treatment. Be sure all benefits described to you by an agent or others are in the written policy. Your health plan covers only the medical care specifically described in the policy or HMO contract.

Remember, it´s unlikely your plan will reimburse 100 percent of your bill. The amount of your coverage will be impacted by any deductibles, coinsurance, and copayments. In addition, your carrier may have grounds for denying or limiting the size of your claim if a provider´s fees exceed "usual and customary" charges. Usual and customary charges may be based on fees charged by other physicians and providers in your area, typical fees compiled by an independent rating service, or typical fees compiled by the carrier.

Most insurance companies maintain a toll-free telephone information and complaint line, and some companies and HMOs provide special mediation or arbitration procedures for handling complaints. Here are a few suggestions for handling claim or reimbursement problems: For group coverage, contact your health plan´s benefits administrator, if one is available. If there is no benefits administrator or if you have an individual health care policy, you should contact the insurance company or HMO.

· Submit a written complaint to your health plan, insurance company or HMO specifying your concerns.

· Ask for explanations in writing and keep good records, including the names of people you talk to while trying to resolve the matter.

· Ask your health benefit plan to verify that your share of the bill (coinsurance or HMO copayments) was based on the actual bill the insurance company paid after any negotiated discount arrangement. An insurance company or HMO that refuses to base your share of the bill on actual billings is engaging in a prohibited and unfair claim settlement practice.

· If you are unable to resolve the matter, file a formal complaint with TDI.

If you wish to file a complaint with TDI, please provide the following information:

· copies (not originals) of any supporting documents, including letters, notes, invoices, canceled checks or advertising material.

· You may mail or fax your complaint or submit your complaint online on our website

· For complaints against doctors, call the Texas State Board of Medical Examiners 1-800-201-9353.

· For complaints about hospital billings, call the Texas Hospital Association 1-800-252-9403.

· For complaints against pharmacists, call the State Board of Pharmacy 512-305-8000

For More Information TDI offers a variety of insurance-related publications and services. Publications are available in alternate languages and formats and on our Web site. For printed copies of free consumer publications, call the 24-hour Publications Order Line

· For answers to general insurance questions call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday