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Following are common types of coverage available for an individual:
Rights in an Individual Plan
Carriers can evaluate your medical history and other health factors when offering individual plans and can deny your application based on health factors or offer a plan with an “exclusionary rider” that eliminates benefits for certain conditions.
Although other types of individual plans may cost less, generally it’s best to buy a comprehensive HMO or major-medical policy, which usually provides more benefits and often allows you to add benefits as needed.
COVERING DEPENDENTS
Health plans vary on how they address dependent coverage, but as a general rule, children and grandchildren are eligible for dependent health-care coverage until their 26th birthday. Exceptions exist for children with mental or physical disabilities who cannot support themselves financially; they may be covered indefinitely, but evidence of the disability may be required. Policies must provide automatic coverage for newborn children for the first 31 days, after which the insured parent must notify the carrier about continuing coverage.
Self-funded plans may offer dependent coverage, but they are not required to do so by state law except when the enrolled parent is ordered by a court to provide medical child support. For this situation, state law requires plans of all kinds to provide comparable coverage for a dependent even if the child does not live with the parent or within the service area.
Large-employer plans with dependent coverage provide coverage for children up to age 26, even if they are away at college; however, an HMO plan can require dependent students to return to the plan’s service area to receive health-care services except in cases of emergency care and authorized referrals.
— Birthday Rule
If spouses are covered by separate health plans and both cover their shared dependents, 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 January 5, 1977, would pay for a child’s health care before the plan of the other parent whose birthday is March 1, 1976. However, if the first parent’s plan reaches its benefits maximum, the second plan will take effect. In the event of a divorce, a court will determine which parent’s plan is a dependent’s primary coverage.
HEALTH PLAN BENEFITS
Clearly benefits vary from one plan to another, but all of them are classified as “state-mandated plans” or “consumer-choice plans.” A state-mandated plan provides required minimum features and coverages, but it may not be the cheapest option. For that reason, consumer-choice plans, also known as “standard plans,” are allowed by Texas law to make health coverage more affordable, but they may not include all of the state-mandated benefits. These plans are required, however, to provide a disclosure statement and a list describing any benefits not covered. Although called standard plans, consumer-choice plans do not provided “standardized” coverage because each carrier’s plan may be different and one carrier may have several different options within this category.
FEDERALLY MANDATED BENEFITS
Beyond the benefits required by state law, health plans must follow federal laws in regard to offering coverage for maternity and newborn and mastectomy services.
— Maternity and Newborn Coverage
No carrier may deny benefits for services related to a pregnancy on the grounds that it is a “pre-existing condition.” A group health plan with more than 15 employees must provide for minimum hospital stays for the delivering mother. For a natural birth or “uncomplicated vaginal delivery,” the insured is guaranteed a minimum of 48 hours. The minimum stay for an uncomplicated cesarean birth is 96 hours.
In most cases, management of a difficult birth is covered by plans with maternity benefits and is not considered a “complication of pregnancy.” Complications that may not be covered include miscarriages or nonelective cesarean births, for which obtaining a “complications of pregnancy” benefit may help if your plan does not have extensive maternity benefits.
- HMO plans pay for covered health services from in-network providers or others authorized through prior referrals.
- Major-medical policies may be offered as PPO plans and cover hospital stays and physician services in and out of the hospital.
- Hospital-surgical policies only cover expenses directly related to hospital and surgical services, not everyday preventive care.
- Hospital-indemnity policies pay up to a maximum fixed amount each day during a hospital stay.
- Specified or dread-disease policies most often are offered as an extension of other individual coverage and cover only specific conditions, such as cancer or AIDS, detailed in the particular policy.
- Short-term policies last a specified length of time, not to exceed 12 months. This mostly is meant for people who lose coverage but expect to gain it back within a reasonable amount of time.
Rights in an Individual Plan
Carriers can evaluate your medical history and other health factors when offering individual plans and can deny your application based on health factors or offer a plan with an “exclusionary rider” that eliminates benefits for certain conditions.
Although other types of individual plans may cost less, generally it’s best to buy a comprehensive HMO or major-medical policy, which usually provides more benefits and often allows you to add benefits as needed.
COVERING DEPENDENTS
Health plans vary on how they address dependent coverage, but as a general rule, children and grandchildren are eligible for dependent health-care coverage until their 26th birthday. Exceptions exist for children with mental or physical disabilities who cannot support themselves financially; they may be covered indefinitely, but evidence of the disability may be required. Policies must provide automatic coverage for newborn children for the first 31 days, after which the insured parent must notify the carrier about continuing coverage.
Self-funded plans may offer dependent coverage, but they are not required to do so by state law except when the enrolled parent is ordered by a court to provide medical child support. For this situation, state law requires plans of all kinds to provide comparable coverage for a dependent even if the child does not live with the parent or within the service area.
Large-employer plans with dependent coverage provide coverage for children up to age 26, even if they are away at college; however, an HMO plan can require dependent students to return to the plan’s service area to receive health-care services except in cases of emergency care and authorized referrals.
— Birthday Rule
If spouses are covered by separate health plans and both cover their shared dependents, 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 January 5, 1977, would pay for a child’s health care before the plan of the other parent whose birthday is March 1, 1976. However, if the first parent’s plan reaches its benefits maximum, the second plan will take effect. In the event of a divorce, a court will determine which parent’s plan is a dependent’s primary coverage.
HEALTH PLAN BENEFITS
Clearly benefits vary from one plan to another, but all of them are classified as “state-mandated plans” or “consumer-choice plans.” A state-mandated plan provides required minimum features and coverages, but it may not be the cheapest option. For that reason, consumer-choice plans, also known as “standard plans,” are allowed by Texas law to make health coverage more affordable, but they may not include all of the state-mandated benefits. These plans are required, however, to provide a disclosure statement and a list describing any benefits not covered. Although called standard plans, consumer-choice plans do not provided “standardized” coverage because each carrier’s plan may be different and one carrier may have several different options within this category.
FEDERALLY MANDATED BENEFITS
Beyond the benefits required by state law, health plans must follow federal laws in regard to offering coverage for maternity and newborn and mastectomy services.
— Maternity and Newborn Coverage
No carrier may deny benefits for services related to a pregnancy on the grounds that it is a “pre-existing condition.” A group health plan with more than 15 employees must provide for minimum hospital stays for the delivering mother. For a natural birth or “uncomplicated vaginal delivery,” the insured is guaranteed a minimum of 48 hours. The minimum stay for an uncomplicated cesarean birth is 96 hours.
In most cases, management of a difficult birth is covered by plans with maternity benefits and is not considered a “complication of pregnancy.” Complications that may not be covered include miscarriages or nonelective cesarean births, for which obtaining a “complications of pregnancy” benefit may help if your plan does not have extensive maternity benefits.
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