When applying for health insurance in Texas, you want to ensure that your policy covers all health conditions you may experience. From a slip and fall to a serious health condition, a great policy should provide the policyholder with the coverage they need at a price they can afford. But are all policies the same? If you purchase a health insurance policy on the open market, will you receive the same coverage options as if you find an Affordable Care Act policy in the Marketplace? We intend to answer these questions as we dig into what an insurance policy should cover and if there is a difference between insurance providers when you purchase your health insurance policy.
What are the Different Types of Health Insurance?
Within the world of health insurance, you can obtain coverage through various sources. Each method has a different way of applying and stipulations for qualification. You can find group insurance, shopping on the individual market, or the ACA Marketplace.
- Group – Health insurance through an employer. Keep in mind that some employers require a probationary period before an employee can obtain health insurance under their policy. Contact your employer for how your benefit plan works.
- Individual Market – Health insurance on the open market directly from an insurance company. There is a list of companies that sell on the open market. Some are not available in every state. The downfall of purchasing directly is that you lose the tax credit benefit you would have if you filed with a marketplace plan.
- Marketplace – Health insurance through the Affordable Care Act. This is the most common way to apply for health insurance if you are not obtaining it through your employer.
These policies require an applicant to wait for an Open Enrollment Period (OEP). This is usually at the end of the year, from November 1 through January 15 of the following year. With an employer, it can be after a time period with the company. As an applicant, you can enroll outside of OEP if you have a qualifying event, such as a child’s birth, getting married, or moving into a new zip code.
Are All Health Insurance Providers the Same?
As you shop for health insurance in Texas on your own, you will quickly find that not all insurance providers are the same. Many will focus on one particular area that can benefit an individual or family. This is why shopping a Marketplace plan can be appealing to many, a few checkboxes, and the shopping is done for you.
Insurance policies can be broken down by factors such as:
Who they cover. You can find a policy covering you, your spouse, your children, or an entire family.
How much you can afford. This can be built around deductibles primarily. Just bear in mind, the less you pay now, the more you will have to pay later.
Coverage Area. Your policy will always be broken down to where you live. Your doctors will operate within a geographical circle around your address, called your network. Using these doctors will give you the best benefit. However, seeing a doctor outside of your network will either leave you paying higher costs or without coverage.
What they cover. This will be a list of benefits that your policy will cover. It also lists the conditions and procedures it will not. You need to read your outline of benefits carefully because it can be limited by your deductible, your coverage area, or even omitted from coverage altogether.
How Can I Find a Policy That Covers Everything?
First, the bad news. You won’t be able to find a policy that will cover you 100 percent for all situations. There will always be some out-of-pocket expenses for health insurance coverage.
However, under the Affordable Care Act in the Marketplace, health insurance policies have certain requirements. These are called the ten essential health benefits.
The ten essential benefits are the minimum requirements under Obamacare for health insurance in Austin. While each insurance company may vary on deductibles, copays, and out-of-pocket maximums, they must provide these ten benefits to all patients:
- Ambulatory patient services – You can receive outpatient care without being admitted to a hospital.
- Emergency services
- Hospitalization – This includes surgery and overnight hospital stays.
- Pregnancy, maternity, and newborn care – You receive both before and after-birth care.
- Mental health and substance use disorder services – This benefit will include behavioral health treatment, including counseling and psychotherapy.
- Prescription drugs
- Rehabilitative and habilitative services and devices – This benefit includes services and devices to assist those with injuries, disabilities, or chronic conditions in recovering mental and physical abilities.
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care – However, this does not includeadult dental and vision coverage; they are not considered essential health benefits.
As we read above, many coverages come automatically with every policy. The Federal government mandates this for all health insurance policies: group, individual, or Marketplace. This means if you have an insurance policy, these ten health benefits must be given under your health insurance policy—including maternity, prescription drugs, and therapy.
Is Coverage for Therapy Different than Normal Healthcare?
Recent studies show that 21% of U.S. adults were affected by mental illness; that’s 1 in 5 adults. Almost half, 42.6%, received treatment for their condition. While not the greatest, it is a good start. It is good to know that the Affordable Care Act has therapy coverage mandated to care for those with such ailments.
All Marketplace plans must cover for:
- Treatment for behavioral health, including counseling.
- Inpatient services for mental and behavioral health.
- Substance abuse treatment.
There are no pre-existing clauses or limits to care provided, and benefits cannot be more restrictive as compared to general health care. They also cannot vary deductibles and copayments based on treatment type. All care must align with the care received under Affordable Care Act guidelines.
One of the primary goals of insurance is to meet the insured’s needs. Mental health is often overlooked and misunderstood. Under an Affordable Care Act policy, therapy is covered. It is part of all insurance plans as their basic coverage. There are no waiting periods, increased premiums, or riders attached to a policy.
If you need further assistance understanding how therapy is covered under the Affordable Care Act, contact Cover Mile. Our professionals are ready to assist you with finding the best health insurance policy in Austin to meet your family’s needs. Our licensed insurance agents are prepared to assist you! Call us today.