Now available to Texans that have A Pre-Existing Condition and have been declined. THIS IS NOT A DISCOUNT PLAN but the Government Guarantee Issue Health Insurance.
THE PCIP PLAN ENDED IN FEBRUARY 2013….YOUR NEXT CHANCE IS OCTOBER 2013. BOOKMARK THIS PAGE AND CALL ME IN OCTOBER 2013.512-963-5000 SCOTT
This public/private partnership enables presently without insurance small companies to gain access to quality health plans in an affordable cost. Healthy Texas plans are supplied by private service providers and taking part MultiShare programs. TDI is presently dealing with MultiShare programs to finalize contracts for his or her participation in Healthy Texas.
Enrollees in Healthy Texas select from private health plans which have been approved by TDI. In compliance using the needs from the Healthy Texas program established in Chapter 1508 from the Texas Insurance Code, TDI has contracted with Celtic Insurance Provider and U . s . Health care to become taking part health plans within the Healthy Texas program.
Companies thinking about Healthy Texas can function directly with one of these service providers or by having an agent. Go to the taking part carrier’s websites to explore available plans in order to apply.
Almost 6 000 0000 Texans don’t have medical health insurance. Getting medical health insurance and use of a normal supply of care have consistently been proven to guide to higher health status. Mainly due to the cost, medical health insurance is especially a hardship on Texas small company proprietors to supply for their employees. Using the awareness that you will find many competing focal points for limited condition funds, the 81st Legislature passed legislation creating the Healthy Texas program that enables for proper focusing on of condition dollars to where they’re most needed and may perform the most good – low-earnings, without insurance small company employees.
Healthy Texas is made for without insurance working Texans. It’s a program produced by Texans for Texas. It’s not a subsidy program it develops the present employer-based insurance model. The legislation that produced Healthy Texas incorporated needs for small company proprietors to sign up in Healthy Texas. Visit our FAQ page for a listing of participation needs.
Healthy Texas fosters economic development by helping small companies attract better employees and enabling these phones keep employees healthy by supplying use of quality health plans in an affordable cost.
For that employer and also the enrollee, the plan will operate like every private market plan. Behind the curtain, Healthy Texas utilizes a condition-funded pool to pay taking part service providers or MultiShare programs for above average healthcare claims costs.
Healthy Texas is made to pay service providers or MultiShare programs for 80 % from the costs if the individual’s total claims fall between $5,000 and $75,000 inside a twelve months. Following the enrollee meets their deductible and/or coinsurance needs, the plan covers 100 % of claims below the $5,000 threshold and above $75,000, as much as the annual benefit limit. The plan also covers the rest of the 20 % of costs between your $5,000 and $75,000.
This method enables the condition to leverage both private and public funds. It minimizes additional administrative costs because they build around the existing employer-based medical health insurance model by creating an infrastructure suitable for insurance exchange models.
The Healthy Texas program develops six many years of research carried out through the Texas Department of Insurance (TDI) with the government funded Condition Planning Grant (SPG). Since before summer 2001, TDI took part in the SPG program which was made to help taking part states develop methods to considerably reduce their quantity of without insurance people. Underneath the the grant, that was approved through the Health Assets and Services Administration (HRSA), Texas collected both qualitative and quantitative data through a number of survey and research activities. The data collected within the research phase was for use to build up choices for growing medical health insurance to without insurance Texans.
Identifying Small Employer Qualifications
Q. How do you know should i be a little employer?
A. The initial step in identifying if your small company is qualified for Healthy Texas would be to determine if it’s a little employer. For select few insurance reasons, Texas law defines a small company as you with 2-50 “eligible” employees. The word “eligible employees” identifies which employees should be counted for identifying if the business qualifies to buy small employer insurance and just how many employees must enroll to be able to meet “minimum participation requirements”. The word is determined in ways to really make it simpler for smaller businesses to be eligible for a insurance by excluding certain employees (for example individuals who curently have insurance) in the count of “eligible” employees. The meaning doesn’t stop a company from enrolling some non-qualified employees within the plan. To find out should you become qualified as a little employer, qualified employees:
Must work on least 30 hrs per week.
Might be a sole proprietor, someone or perhaps an independent contractor.
Workers are not qualified when they:
Are temporary, periodic or substitute.
Happen to be included in another group health benefit plan – like a spouse’s health plan.
Elect to not be covered underneath the employer’s health benefit plan, but they are covered under State medicaid programs, CHAMPUS, Medicare insurance or any other federal program.
Are covered within benefit plan established internationally.
A business’ proprietors count as qualified employees. A couple your business count as two separate employees. Neither from the employees is qualified for coverage like a dependent from the other. A company might want to offer part-time employees Healthy Texas coverage, but part-time workers are not counted as “eligible” employees for identifying an employers’ status like a small company.
Good examples for Identifying Small Employer Qualifications
Example 1: Smith’s Cabinet Makers utilizes 75 employees. 15 workers are either part-time or periodic employees therefore, they aren’t qualified for coverage. Ten from the remaining 60 employees have chosen ‘t be covered underneath the employer’s group health plan since they’re covered under State medicaid programs. The rest of the 50 employees work on least 30 hrs per week and therefore are qualified for healthcare coverage. Though Smith’s Cabinet Makers utilizes an overall total of 75 employees, only 50 workers are qualified for coverage, therefore which makes it a little employer. Smith’s Cabinet Makers may therefore make use of the Healthy Texas qualifications criteria to find out if it’s qualified for Healthy Texas.
Total employees: 75
Part-time or periodic employees ?15
Employees not choosing coverage who are handled by another plan ?10
Final amount of remaining employees
Example 2: Joe’s Grooming is really a sole proprietorship that utilizes 3 employees such as the owner. Two employees work 30 hrs per week while Joe works 20 hrs per week. Since a couple of the 3 employees satisfy the small employer qualifications needs, Joe’s Grooming is recognized as a little employer. Joe’s Grooming may therefore make use of the Healthy Texas qualifications criteria to find out if it’s qualified for Healthy Texas.
Total employees: 3
Part-time or periodic employees?1
Final amount of remaining employees 2
Example 3: Sunshine Coffee House utilizes 10 employees. Five workers are part-some time and aren’t qualified for coverage. Four from the remaining workers are covered under Medicare insurance departing the dog owner because the only qualified worker. Because the clients are considered just one-person employer, it’s not a little employer and wouldn’t be qualified for Healthy Texas coverage.
Part-time or periodic employees?5
Employees not choosing coverage who are handled by another plan ?4
Final amount of remaining employees 1
Q. Is really a sole proprietor or single-person business qualified for Healthy Texas?
A. A sole proprietorship is qualified for Healthy Texas whether it has several employees and a minimum of a couple of its employees satisfy the legal meaning of “eligible worker.” Just one-person clients are not qualified for Healthy Texas.
Identifying Healthy Texas Qualifications
Q. How do you determine if I’m qualified for Healthy Texas?
A. Once a company meets criteria that need considering a little employer, the business should also satisfy the following needs to become qualified to provide Healthy Texas:
The business is situated in Texas
The business utilizes 2-50 qualified employees
A company mustn’t have given group insurance 12 several weeks just before using for Healthy Texas. However, if the employer offered an agenda and led under typically $50 per worker monthly and also the being approved benefit plan’s annual obtain the most level was under $50,000, the business nevertheless might be qualified for Healthy Texas
A minimum of 30 % of qualified employees must receive annual wages at or below 300 percent from the Federal Poverty Level ($32,670 for an individual this year)
A minimum of 60 % of qualified employees must want to take part in this program
The business be forced to pay a minimum of 50% from the premium for workers
A company must offer coverage to loved ones of employees and
Each worker should be a citizen or national from the U . s . States or perhaps is an alien legitimately contained in the U . s . States.
Incidentally, though not needed to, a company may:
Pay any degree of premium contribution made with respect to loved ones of employees
Offer coverage to part-time employees as well as their loved ones and
Pay any degree of premium contribution made with respect to part-time employees as well as their loved ones.
Q. Exactly why is Healthy Texas only accessible to small companies who haven’t provided medical health insurance going back 12 several weeks?
A. Healthy Texas is made to target individuals employees who’re completely without insurance. The business qualification needs usually are meant to make sure that companies don’t drop existing coverage in support of the product. The Legislature established participation needs and could consider revisions later on.
Healthy Texas Service providers and Agents
Q. Who’re the service providers supplying Healthy Texas coverage?
A. The 2 taking part Healthy Texas service providers are Celtic Insurance Provider and U . s . Health care.
Q. Can any agent or broker sell Healthy Texas?
A. No. A real estate agent or broker should be hired with a Healthy Texas company just before selling the Healthy Texas health benefit plans.
Q. Do you know the marketing needs for agents and health plans?
A. All Healthy Texas ads utilized by the taking part service providers as well as their agents should be in compliance with relevant laws and rules. TDI looks at the ads utilized by the taking part service providers and also the taking part carriers’ agents just before posting to make sure legal and regulating compliance.
Q. How are Healthy Texas agents paid out?
A. Taking part service providers figure out how agents are paid out. Commissions are compensated based on the relevant laws and rules.
Q. Will MultiShare programs be taking part with Healthy Texas?
A. Yes, additionally towards the two Healthy Texas commercial insurance companies, MultiShare programs could also provide Healthy Texas coverage. To be able to provide coverage, MultiShare programs must first apply with TDI after which be selected to promote the Healthy Texas Program. If selected, the MultiShare program will give you Healthy Texas coverage to small companies within its service area. The MultiShare benefit designs will change from individuals plans provided by the commercial service providers for the reason that the MultiShare plans concentrate on a member’s wellness and primary and preventative care with limited hospitalization benefits.
Using for Healthy Texas
Q. How do you make an application for Healthy Texas?
A. A little employer may apply either directly and among the Healthy Texas service providers or by having an agent or broker hired by among the Healthy Texas service providers.
Q. Is really a sleek application in position that delivers the little employer the chance to find out qualifications just before enrollment?
A. Yes. Companies are needed to submit a brief verification form that determines qualifications and enables an interest rate quote to become produced. Once a company constitutes a decision about buying a proper Texas plan, a far more detailed application is finished.
Q. When can one enroll for Healthy Texas?
A. Healthy Texas started enrollment in nov 2010. To use, companies may speak to a Healthy Texas company or perhaps an hired agent.
Q. Exactly what is a MultiShare program?
A. MultiShare programs (known to as “regional and native healthcare programs” under Texas Safety and health Code Chapter 75) really are a development of condition legislation. The healthcare plans provided by MultiShare programs offer fundamental health benefit coverage created for the little employer employing 2 to 50 employees.
One MultiShare program distinction is the fact that, to be able to make its healthcare plans less expensive for that small employer, this program healthcare costs for that lower-wage workers are split one of the worker, employer, and public or philanthropic funding sources.
Q. The way MultiShare programs engage in Healthy Texas?
A. Additionally towards the two Healthy Texas commercial insurance companies, MultiShare programs could also provide Healthy Texas coverage. To be able to provide coverage, such programs must first apply with TDI after which be selected to promote the Healthy Texas Program. If selected, the MultiShare program will give you Healthy Texas coverage to small companies within its service area. The MultiShare benefit designs will change from individuals plans provided by the commercial service providers for the reason that the MultiShare plans concentrate on a member’s wellness and primary and preventative care with limited hospitalization benefits.
Q. Are MultiShare health plans just like conventional major medical insurance plans?
A. No. Unlike conventional major medical insurance plans which offer comprehensive coverage, MultiShare plans concentrate on a member’s wellness and primary and preventative care. The plans don’t provide comprehensive coverage of health nor perform the plans assume the entire risk for that member’s healthcare needs.
Q. Are program healthcare costs compensated entirely through the worker?
A. No. As noted within the MultiShare program description, to be able to result in the MultiShare Program’s healthcare plans less expensive for that small employer, this program healthcare costs for that lower-wage workers are split one of the worker, employer and public or philanthropic funding sources.
Q. Perform the MultiShare program healthcare plans provide limitless use of companies and limitless coverage?
A. No. MultiShare program healthcare plans offer limited coverage and limited provider network access.
Q. Where’s MultiShare healthcare coverage offered within the condition?
A. MultiShare healthcare coverage emerges with the TexHealth Coalition, composed of six regional MultiShare programs. The six regions symbolized within the coalition include Brazos Valley, Central Texas, El Paso County, Galveston County, Harris County and North Texas. Each region offers TexHealth coverage with various benefit plans. Up to now, fundamental essentials only places that MultiShare healthcare plans can be found. A few of these MultiShare programs are operational plus some are not offering coverage.
Q. What qualifications should be met for any small employer to be eligible for a TexHealth coverage?
A. Each regional MultiShare plan is promoting its very own qualifications needs. An over-all review of individuals qualifications needs over the MultiShare plans are the following:
Business should be situated inside the geographic region where application for coverage happens (i.e., business should be situated in Travis, Hays or Williamson County to become qualified for coverage offered with the Central Texas Health Coalition (TexHealth Central Texas)
Should have 2-50 qualified employees, such as the business proprietor
Mustn’t have offered group coverage of health in the earlier 12 several weeks
Should have 60% of qualified employees sign up for the program’s plan
Must provide evidence of employer group status and worker qualifications through Condition Unemployment Tax Authority or Census (payroll ledger qualified 1099 worker ought to be around the payroll ledger) and
Be forced to pay 50% of program healthcare costs for qualified employees or less if money is acquired to aid program healthcare cost subsidies.
Should be worker (W-2 or 1099) of enrolled group
Must work the minimum quantity of hrs needed through the relevant health coalition (weekly minimum hour requirement varies by coalition member)
Should be a Texas resident but may live outdoors from the coalition member’s service area
Might not be receiving government health advantages, ( i.e. State medicaid programs, Medicare insurance, SSI, County Indigent Care programs, etc.) and
12-month pre-existing condition exclusion with 6-month think back period.
Q. Would be the MultiShare programs controlled by TDI?
A. The MultiShare programs aren’t controlled by TDI. Section 75.103 from the Texas Safety and health Code provides that, towards the extent approved by federal law, the regulating body of the regional or local healthcare program may establish or facilitate the establishment of self-funded health benefit plans or may facilitate the supply of health benefit coverage through health savings accounts and deductible plans.
Since Texas MultiShare programs are self-funded health benefit plans, TDI might have less authority to manage coverage of health established pursuant to §75.103 since the regulating such coverage might be preempted by federal law. To look for the extent of regulating authority TDI has on the particular kind of coverage, it might be essential to think about the specific federal law to which the policy was established, and also the degree that that federal law preempts condition regulation.
A MultiShare program has legal authority to contract directly with healthcare companies inside the limitations from the taking part county or areas to supply healthcare services straight to a little employer’s employees and loved ones. The statute particularly provides that the MultiShare program isn’t an insurance provider or HMO and isn’t susceptible to TDI regulation.
Cost Discussing Accounts (CSAs)
Q. Exactly what is a Cost Discussing Account?
A. Cost Discussing Accounts (CSAs) provide qualified Healthy Texas enrollees with subsidies that enrollees can choose to use with the idea to assist in paying for out-of-pocket expenses for example insurance deductibles, co-insurance and copays, in order to lessen the worker share of rates.
Q. What’s the reason for a CSA?
A. CSAs help ease the first financial cost discussing burden for individuals who haven’t formerly utilized insurance-type items. They’re structured to ensure that enrollee financial participation needs increase incrementally with time. CSAs are made to:
Increase use of affordable care
Increase appropriate utilization of healthcare via a medical home and
Promote a culture of insurance.
Q. Who’s qualified for any CSA?
A. A functional individual, 18-64 years old and qualified for healthcare coverage via a taking part employer, is qualified for any CSA. The person worker should be without insurance during the time of application and also the individual’s salary should be comparable to or below 300% from the Federal Poverty Level ($32,670). To ensure that a company to provide a CSA to the employees, the business mustn’t have offered group insurance policy in the past 6-to-year. If the employer discontinues participation having a health plan offering a CSA, the person is no more qualified to sign up.
Q. Just how much does Healthy Texas cost and just how are rates determined?
A. One reason for Healthy Texas would be to provide small companies with use of quality health benefit plans in an affordable cost. Healthy Texas service providers are only able to use age, gender and business place to rate a little employer group, thus rates vary in line with the group. Healthy Texas benefit plans are made to lower premium costs by typically one-third by using this modified rating practice as well as consequently of other Healthy Texas program features. For instance, Healthy Texas benefit plans should be offered at a price that reflects the lower financial risk exposure that is a result of accessibility to the Healthy Texas premium stabilization fund. Healthy Texas rates are susceptible to TDI approval. Rate tables can be found around the Healthy Texas insurers’ websites.
Q. What kinds of benefits does Healthy Texas cover?
A. Healthy Texas supplies a benefit package which includes inpatient hospital services, outpatient hospital services, maternity, physician services and prescription drug benefits. Legally, Healthy Texas benefit plans are exempt from certain mandated benefit needs. TDI produced a typical benefit package that taking part service providers must offer.
Q. Are pre-existing conditions excluded?
A. Yes. In line with presently allowed market practices, a pre-existing condition provision is incorporated in benefit plans offered with the program. The supply enables for any 12-month pre-existing condition exclusion having a 6-month look into the employee’s health background.
Q. What’s the premium stabilization fund and just how do you use it?
A. Healthy Texas utilizes a condition premium stabilization fund (fund) to pay taking part service providers and MultiShare programs for being approved healthcare claims costs within statutorily established limits. The fund helps you to safeguard medical health insurance service providers against deficits because of suddenly high claims costs or perhaps an suddenly high amount of claims. The fund is made to pay a taking part medical health insurance company 80 % from the costs if the individual’s total claims fall between $5,000 and $75,000 inside a twelve months.
Administration of Healthy Texas
Q. Who supervises Healthy Texas?
A. TDI may be the condition agency accountable for applying and giving this program. TDI runs the premium stabilization fund and perform administrative procedures, while commercial service providers and MultiShare programs supply the health plans. In the employer’s and enrollee’s perspectives, the plan works like every private market plan.
Condition Continuation of Coverage and COBRA Coverage
Q. Is condition continuation of coverage and COBRA open to Healthy Texas enrollees?
A. Continuation of coverage needs that affect Healthy Texas overlap with individuals that affect the big and small employer market. A Proper Texas employer’s worker wouldn’t be qualified for condition continuation of coverage or COBRA when the worker is ended for cause.
A Proper Texas enrollee (worker or dependent) would be eligible for a condition continuation of coverage and COBRA if:
The little employer has 20 or even more employees and employment is ended either through the worker or employer. In cases like this, the worker and dependent may elect COBRA coverage for 18 several weeks upon termination after which, once COBRA coverage is finished, the worker and dependent may make an application for condition continuation of coverage for six several weeks. The worker and dependent could be eligible for coverage through COBRA and condition continuation of coverage for any total of 24 several weeks upon termination from employment.
The little employer has under 20 employees and employment is ended either through the worker or employer. In cases like this, the worker and dependent may elect the state’s Continuation of Coverage for nine several weeks. The worker and dependent don’t be eligible for a COBRA.
A Proper Texas enrollee doesn’t be eligible for a COBRA and condition continuation of coverage if the employer terminates coverage using its Healthy Texas company or even the company terminates coverage using the small employer. At either point, the employer’s group coverage could be ended. An worker who leaves employment following the employer or company terminates group coverage wouldn’t be qualified for COBRA or continuation of coverage no matter the employee’s conditions for departing employment.
When the Healthy Texas Company decides to discontinue Healthy Texas coverage, it has to provide advance notice towards the department and also to each covered employer, and should offer to every employer during the time of discontinuation the choice to buy other small employer coverage provided by the company.
If the worker is ended for cause, the worker isn’t qualified for COBRA or condition continuation of coverage.
Federal Health Reform’s (FHR) Effect on Healthy Texas
Q. The way federal health reform impact Healthy Texas?
A. Although federal health reform (FHR) consists of far-reaching medical health insurance market reforms, together with a risk-distributing reinsurance mechanism, it will little to deal with the immediate concerns of Texas’ small companies concerning the ease of access and cost of medical health insurance within the comprehensive method in which Healthy Texas, produced through the Texas Legislature, does. Healthy Texas utilizes a condition-funded method of lower the price of medical health insurance coverage, therefore addressing the most important concern elevated by small companies about medical health insurance coverage. By doing this, it remains a viable and valuable program for Texas. Healthy Texas will fully trust federal health reform.