Affordable Care Act Health Insurance in Texas

Note: As there are ACA-compliant plans, there are also non-ACA-compliant plans. These are plans that do not follow the standards of the ACA. A common example in Texas is short-term health insurance. Also, it is not a requirement for insurance companies to sell their products on the Texas Health Marketplace. Hence, some insurers may sell both on and off the Marketplace; others choose to stay out of the Marketplace completely.

In 2022, ACA expanded coverage benefits to new demographic groups and the Texas senate introduced the new insurance rate review process, with a goal of increasing the benefits for those Texans who are truly in need of affordable coverage. This resulted in an influx of insurers that previously offered ACA plans off-marketplace, to join the Texas health marketplace and offer even more selection for the ACA plan shopper.

What is Considered ACA Insurance?

All health insurance that meets the definition of an ACA-compliant plan is considered ACA Insurance. In order to be considered Affordable Care Act compliant, health insurance plans must follow minimum requirements:

The ACA insurer must cover the 10 essential health benefits (EHB):
1. Ambulatory patient services;
2. Emergency services;
3. Hospitalization;
4. Laboratory services;
5. Mental health and substance use disorder services, like behavioral health treatment;
6. Child health services, including oral and vision care.
7. Pregnancy, maternity, and newborn care;
8. Prescription drugs;
9. Preventive and wellness services and chronic disease management; and
10. Rehabilitative and habilitative services and devices.
ACA insurer cannot deny coverage based on pre-existing conditions or medical history
ACA insurer should not have annual or lifetime coverage maximums
Annual maximum out-of-pocket amount is locked in for a year and all costs of the essential health benefits are applied to this amount (unlike alternative health plans, where some of your payments might not count towards the "max out of pocket").

Here are the recent historical ACA max out-of-pocket numbers (before applying any government discounts (aka Subsidies). With the subsidies, the max out-of-pocket may be significantly lowered:

2022 - $8,700 for individual plan and $17,400 for a family
2021 - $8,550 / $17,100
2020 - $8,150 / $16,300
2019 - $7,900 / $15,800
2018 - $7,350 / $14,700

What is the Purpose of ACA Health Insurance in Texas?

The purpose of the ACA insurance in Texas is to provide Texans with health insurance coverage that meets and/or exceeds the stringent rules of the federal Affordable Care Act (ACA). The most important feature of ACA-compliant insurance is that it guarantees acceptance regardless of pre-existing conditions.

Additionally, ACA provides a way for the lower income Texans to obtain health insurance with extensive preventive features, at a fraction of the full cost. The amount of government subsidies (discounts) is based on the income level.

In 2021, significant savings were realized by 92% of the insurance plans purchased on the Texas health marketplace, through the use of advanced premium tax credits (APTC), and 57% of Texans received cost-sharing reductions (CSR).

What is ACA Insurance for?

ACA insurance is for individuals to have access to quality and comprehensive healthcare in every state, including Texas. It does this by ensuring that your pre-existing condition or medical history is not considered when you apply for coverage. It also makes plans affordable to low income earners by providing premium subsidies and cost-sharing reductions.

What are the Types of ACA Health Insurance?

There are two types of ACA health insurance in Texas:

Group - which is usually acquired through an employer or an affiliation to some group, and
Individual - which is usually purchased through the Texas health marketplace, an insurance agent or agency through authorized portals.

Both of these types may be further subdivided into four additional sub-types:

Exclusive Provider Organization (EPO) plan: Here, you are covered if you use the services of the medical professionals (hospitals, physicians, or specialists) in the plan's network, except if there is an emergency.
Health Maintenance Organization Plan (HMO) plan: HMOs consist of a network of providers that give you access to various medical services. Under this plan, your coverage is limited to care from doctors that work for the HMO. Hence, it does not cover out-of-network care unless it is an emergency. A common eligibility requirement of HMO plans is that you reside or work around its service area. HMOs usually offer integrated care and prevention services.
Point-Of-Service (POS) plan: Using a health professional from the plan's network makes you pay less. You have to get a referral from your doctor to see a specialist.
Preferred Provider Organization (PPO) plan: PPO plan allows you to pay less for using their network healthcare providers. Using physicians or specialists outside their network without referral attracts extra expenses.

Do You Need ACA Health Insurance in Texas?

Yes, you need health insurance that is compliant with Affordable Care Act rules, especially if you have been unable to obtain coverage for your medical needs through other means. ACA-compliant insurance provides the most comprehensive health coverage on the market and does not discriminate against pre-existing conditions or medical history. So, if you have any pre-existing conditions that you would like to be treated for, then ACA insurance is your best option. If you are among the Texans who qualify for subsidies, you may also be able to get ACA coverage at a significant discount.

Contact a licensed agent in Texas to consider your options with ACA health insurance. Alternatively, you can visit the health insurance Marketplace to check out the various plans yourself, and then reach out to a health insurance agent with questions. Agent's assistance with determining your needs and finding an appropriate plan does not cost you anything extra.

Why Do You Need ACA Health Insurance?

There are several benefits to having ACA insurance:

ACA insurance allows you to buy health coverage based on your income level, which affords a lot of lower-income Texans an opportunity to have comprehensive medical coverage at the fraction of a cost.
ACA insurance also does not discriminate against pre-existing conditions, which is a plus for anyone who has an unfortunate hiccup in their medical past and is struggling to get coverage because of it.
Your insurer cannot limit yearly or lifetime coverage expenses for your plan's essential health benefits. This means that your insurer cannot fix a dollar limit on how much they spend on your essential benefits. And they cannot fix a yearly dollar limit on how much they can spend on your coverage.
ACA provides access to comprehensive health coverage, which comprises preventive services and treatment services.
ACA-compliant insurance is the only type of Texas major health insurance that is guaranteed to accept you, if you apply.

How Much ACA Health Insurance Do You Need?

As with most insurance products, how much ACA insurance you need depends on your actual and anticipated medical needs. A thought process during the determination of your ACA insurance needs should be along the following lines:

Do you have any current medical conditions that require ongoing treatment? This influences how much co-pay you might be willing to pay for each visit.
Do you have any medical procedures planned for the near future? Let's say you need to get surgeries on both knees in one year - this would mean that you can benefit from a lower deductible plan, since you are guaranteed to max it out.
Are you a generally healthy young individual without pre-existing conditions, who only needs coverage in case of a medical emergency? In this case, an ACA plan is your best option only if you qualify for significant subsidies through the Texas Health Marketplace, and as a result you are able to get coverage for low cost. Without the subsidies, there may be other more affordable and more widely acceptable options of health coverage on the Texas health market.

The ACA Marketplace provides subsidies and cost-sharing reduction benefits for low-income Texans, which makes plans affordable. You can check if you are eligible for subsidies based on your income. You can also use the income calculator to figure out your best estimate.

Whenever making an insurance decision, it is best to talk this over with a Texas-licensed health insurance agent, who can assess your needs and give a recommendation based on your particular life scenario.

What ACA Insurance Coverage Do You Need?

Deciding what ACA insurance coverage you need or should get largely depends on what you can afford and your projected needs. For instance, if you have surgeries planned for the year, you might want the lowest deductible. Generally, four metal levels prescribe how much cost will be shared between you and the insurance company. Expect to pay more for the plans that provide more coverage. The metal tiers are:

Bronze plan - where you pay around 40% of costs
Silver plan - you pay around 30% of the costs
Gold plan - you pay about 20% of the costs
Platinum plan - you pay approximately 10% of costs

In determining what ACA coverage you need, talk to a licensed insurance agent in Texas. An agent will provide you with all the necessary information and factors to consider and guide you to make the best decision. Make sure to ask your agent a lot of questions. The health insurance agent's professional help in Texas does not cost the insured (you) anything extra.

Is ACA Insurance Required by Law in Texas?

Having ACA insurance or any type of health coverage is not required by federal or Texas state law. When the Affordable Care Act was initially introduced, it required everyone to have minimum health coverage for themselves and their families. The punishment for not having minimum health coverage was a tax penalty. However, in 2019, this tax penalty was removed, which made ACA insurance no longer a requirement in Texas.

How Does ACA Health Insurance Work in Texas?

The Affordable Care Act created a set of standards that an insurance plan must meet, to qualify to be called ACA-compliant. ACA-compliant insurance in Texas may be purchased on the Texas Health Marketplace, through an employer, or through the insurers who meet the requirements, but choose to not sell their plans on the Marketplace.

Generally, to get ACA insurance on the marketplace, you have to sign up during the open enrollment period on the Texas health insurance marketplace. Open enrollment is a period of the year when you make health coverage decisions that will take effect in the following year's insurance plan. It is usually around two months long and starts at the end of the year (normally 1 November - 15 January).

In order to qualify for coverage outside of the Open Enrollment, there is a special enrollment period. This is when you encounter a significant life event, such as getting married, having or adopting a baby, or losing your health plan.

There are companies that sell ACA health plans outside the marketplace. You can usually get these plans from the insurance company itself or agents allowed to sell those plans, through a portal linked to the marketplace.

When you get an ACA plan, your plan will inform you about the various terms of coverage. This includes your premiums and out-of-pocket costs, how the coverage works, and information of health providers within their network.

When you receive health services, the medical provider bills your insurer. If the provider is within your plan's network, your insurer ensures that you are charged the pre-negotiated (lower) rate (and not the rate that you get if you walk in without insurance). Then, your insurer handles the claim according to the terms of your policy. If there is a deductible left to pay, it may get applied. At the end of the year the deductible and benefits get reset, unless you use a carry-over provision, which allows you to carry over medical expenses from the last three months of the year into the following year.

What Does ACA Health Insurance Cover in Texas?

ACA insurance in Texas covers health by providing preventive and treatment services for physical and mental health issues. These services are called essential health services. They are available in all ACA plans. They include:

Ambulatory patient services
Emergency services
Hospitalization, including surgical procedures and overnight hospital stays
Pregnancy, maternity, and neonatal care (before and after birth)
Services for mental health and substance abuse disorder, including behavioral health treatment like counseling and psychotherapy
Prescription medications
Rehabilitative and habilitative services
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (however, adult dental and vision coverage are not part of essential health benefits)

The preventive services offered for adults, women, and children are numerous. They include immunizations, screenings, counseling/consultations, and drugs for preventing illnesses.

What is ACA Health Insurance Good for?

ACA insurance is good for getting quality and comprehensive healthcare at affordable prices, especially if government discounts (subsidies) are applied. ACA insurance provides a good alternative for health coverage for persons without insurance from their employer or other government health programs. ACA insurance is good for practically everyone. Here are a few examples of persons that should consider ACA insurance:

A person under 26 years whose parents have ACA coverage. ACA plans allow them to get health coverage under their parents' plan. They can save money in the process.
A low-income earner can get premium subsidies and other cost benefits when signing up for an ACA plan.
Young persons under 30 years or people who qualify for hardship exemption can get a catastrophic plan. This is a plan with low monthly premiums and high deductibles to cater to the worst health situations, like being severely injured or sick.
ACA insurance is the best option for a person with a pre-existing condition, like cancer, diabetes, asthma, or heart attack.

ACA insurance is good for everyone, if you can afford it. Contact a health insurance agent licensed in Texas to find out how ACA insurance can be good for you.

What Does ACA Insurance Typically Include?

Every ACA insurance plan in Texas typically includes what is called essential health benefits. These health benefits cut across various mental and physical health, pregnancy and neonatal, prescription medication, doctor visits or consultations, and general hospital services. The central theme around the essential health benefits is to provide every enrollee with treatment and preventive services. These benefits are:

Ambulatory patient services
Emergency services
Hospitalization, including surgical procedures and overnight hospital stays
Pregnancy, maternity, and neonatal care (before and after birth)
Services for mental health and substance abuse disorder, including behavioral health treatment like counseling and psychotherapy
Prescription medications
Rehabilitative and habilitative services
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (however, adult dental and vision coverage are not part of essential health benefits)

ACA insurance offers numerous preventive services to adults, women, and children. Such services include immunizations, screenings, counseling/consultations, and drugs for preventing illnesses.

Consider speaking to a licensed insurance agent in Texas to find out more about what ACA insurance normally covers and how it can fit your health insurance needs.

Who is Covered by ACA Health Insurance?

An individual ACA insurance in Texas covers the policyowner, who is also the insured. A family plan covers every member of the household. Group employment insurance plan covers all employees of the business listed in the policy. Also, ACA plans offer dependent child coverage that allows the health coverage of a parent to extend to their child, as long as the child is under 26 years. Married and unmarried children are eligible for coverage. It applies to all individual market and employer plans.

What Types of Items Does ACA Health Insurance Cover?

ACA insurance in Texas covers several essential health benefits (EHB), including preventive care for adults, women, and children. EHBs are created as a set of requirements, generally seen to provide comprehensive health coverage. For example, if you are involved in an accident and rushed into the emergency room, your insurance plan will cover it. It does not matter that the hospital that you get emergency care from is an out-of-network hospital. Your insurer will not require you to pay more in coinsurance or copayment.

Where the emergency treatment extends to you needing hospitalization, either through surgery or overnight hospital stay, your plan will cover it.

Also, in treating an illness, ACA insurance covers the costs of prescription drugs, including vaccines, injections, immunizations, and supplements.

Furthermore, ACA plans cover mental health and substance abuse disorders. For example, patients with opioid use disorder (OUD) will receive full treatment services through their ACA plan. This includes outpatient treatment, residential treatment, detoxification, recovery support services, and prescription drugs.

In addition, the ACA provides several preventive coverages for women, including pregnant and lactating women. Before the ACA, it was quite hard to get access to insurance plans with low premiums that provide preventive care for pregnant women. This made it hard for women in the lower income bracket to get health coverage. With the invention of ACA, women can have their plans cover different screenings and counseling. For example, you can get breast cancer screening every two years through your ACA plan.

What is NOT Covered by ACA Insurance in Texas?

There is no particular list of things that are not covered by ACA in Texas. Apart from the list of essential health benefits, plans may have different restrictions on coverage. That is, while some cover some medical expenses, others may not. Therefore, it is important to know your plan and what it covers. You can get this information by reading the exclusion section of the policy, contacting your insurance company or your insurance agent.

What Does ACA Insurance Typically Exclude?

It is usually the insurance company that determines what it will exclude from coverage. Some examples of medical expenses typically not covered by ACA insurance in Texas include:

What is an Example of ACA Health Insurance?

An example of ACA insurance in Texas is:

When an individual without insurance coverage applies and gets individual ACA coverage through the Texas health marketplace. The premium cost and the "Maximum out of pocket" amount depends on the level of income of the individual.
When an individual in Texas gets group health insurance through an employer or an organization, this coverage will meet the same requirements as the ACA plans offered on the Marketplace. This rule applies to all group plans: All group plans in Texas are ACA-compliant plans. With group plans, the premiums, deductibles, co-insurance and drug co-pays are set the same for every member of the group.

What Is the Most Common Use of ACA Insurance?

Employer-sponsored group health insurance, where every member of the group is able to get coverage at the same rate as everyone else, represents the largest part of the ACA-compliant insurance market.

Taking a broader view of ACA, including the state health marketplace, the most common use of ACA insurance is to provide health insurance coverage with a guarantee of acceptance. So, no matter what you might have in your medical history - you are guaranteed to get the coverage. If everyone has turned you down, ACA will take you. Plus, you might even qualify for a lower cost, based on your income.

Another way to look at ACA insurance is as a strategic financial instrument that can cover your future potentially high medical expenses. For example, if you find out that you need an expensive medical procedure, let's say costing hundreds of thousands of dollars, a switch from an alternative Texas health plan to an ACA plan with the lowest maximum out-of-pocket costs might be a good strategy for you. The fact that you need the surgeries is a pre-existing condition, and will bar you from full coverage from most alternative insurers, but it does not matter to ACA. It will accept you regardless.

The premium for ACA coverage will be based on your income and can vary drastically, but you will be paying for the coverage that you will be actively using - to save you a lot more money that you would have paid without it. With bills in the hundreds of thousands, if not in millions, all of them could be taken care of under the ACA-compliant plans. Lower deductible usually means a higher monthly cost, so you must compare the math of your future medical procedures and their related costs vs the math of insurance coverage that is affordable to you. After all, everyone wants to get the most amount of coverage for the least amount of money.

Talk to a Texas-licensed health insurance agent who deals with multiple types of insurance, including ACA, to go over your medical needs, to see what kind of Texas health insurance may be a better fit for your specific needs.

What is the Difference Between ACA Health Insurance and Short-Term Health Insurance?

ACA and Short-Term health insurance are two of the most popular individual health coverages in Texas. However, they are very different:

Short-term plans do not need to meet the standards of the Affordable Care Act and therefore are not required to provide comprehensive health coverage. The essential health benefits provided by ACA plans are usually not covered in short-term plans.

Common coverages that are excluded by short-term plans include maternity, mental health, and preventive care, although some short term plans (longer than 2 years) recently started offering partial preventive care and allowing pre-existing conditions after a year or more of coverage. In 2021, some short-term insurers in Texas surprised their insureds by covering the cost of Flu vaccinations and Covid testing/vaccines, while not listing it as a benefit of the plans.

Unlike the ACA health insurance plans, short-term plans are medically underwritten. This means that the short term insurer uses your health condition to determine eligibility and your level of risk. Consequently, the short-term insurance company determines if it is willing to take your level of risk as a client and bases your premium rate on your medical history. Meanwhile, ACA insurance is underwritten as a guaranteed issue.

Unlike the ACA, in Texas you can be denied short-term coverage because of a pre-existing condition. This is because short-term plans only cover your medical conditions that have not yet happened and no medical conditions you already have. Extended short-term policies (2 years or more), may cover some pre-existing conditions after one year of continuous coverage.

In the end, ACA and Short-term health insurance both offer specialized types of coverage, which can be used to cover your health insurance needs. Short-term plans are perfect for you in various situations. For example, if you just lost coverage from your former job, have outgrown coverage of your parent's plan, or if you are using short-term insurance with additional supplemental policies, to fill the coverage gaps and save on monthly premiums - compared to a non-subsidized ACA plan.

On the other hand, ACA insurance is best for an all-in-one comprehensive health coverage. ACA is straightforward and all-encompassing, every time.

Always discuss your health insurance needs with a licensed insurance professional who is knowledgeable about all current health insurance options available on the Texas market. Texas health insurance agents help you tailor the insurance solution based on your health specifics and your affordability needs, and this doesn't cost you anything extra.

Do I Need ACA Health Insurance if I Have Short-Term Insurance?

Both ACA insurance and short-term insurance provide major health coverage. Hence, if you have one, you do not need the other. However, whether you choose an ACA or short-term health insurance plan, it is vital to understand the policy terms. Before you buy, speak with a competent insurance agent who can help you choose the health plan that suits you based on your medical and financial needs.

Do I Need Dental and Vision Insurance if I Have ACA Health Insurance?

Yes. Adult dental and vision coverage are not part of the essential health benefits. Hence, getting dental and vision coverage as supplemental plans for preventive and treatment services for your teeth and eyes is advisable. They are both stand-alone plans.

If you already have ACA coverage in Texas, reach out to the licensed agent that sold you the plan to recommend the best dental and vision insurance for you. If you do not have an agent, find a trusted Texas-licensed agent to help evaluate the benefits of these plans. They can also provide guidance on which insurance company to purchase their insurance products.

Who Can Get ACA Health Insurance?

In Texas, every citizen, national, or legal resident can get ACA insurance. If you have pre-existing medical conditions and do not have active insurance coverage, you should consider getting ACA insurance.

Speak to a licensed agent in Texas to know more about getting ACA health coverage.

Who Qualifies for ACA Insurance in Texas?

Almost all legal residents of Texas are qualified for ACA insurance. To get ACA insurance, you:

Must be living in a state in the U.S.
Must either be a U.S. citizen or national, or be lawfully present in the U.S.
Must not be imprisoned
Must not have Medicare coverage

People who are "lawfully present" include immigrants, who have:

"Qualified non-citizen" immigrant status with no waiting period.
Humanitarian statuses or situations (including asylum seekers, temporary protection, special juvenile status, Convention against Torture, victims of human trafficking).
Valid non-immigrant visas.
Legal status conferred by other laws, such as temporary resident status, LIFE Act, Family Unity individuals.

If you have questions about qualifying for ACA insurance in Texas, contact a licensed health insurance agent and/or keep reading.

Who Needs ACA Insurance in Texas?

You need ACA insurance if you have pre-existing medical conditions and do not have active insurance coverage. Non-ACA-compliant insurers may deny you coverage, while ACA is guaranteed to extend your coverage.

Who Should Get ACA Insurance?

You should get ACA insurance if:

You have a pre-existing condition
You do not have health insurance from your job
You do not qualify for coverage under any government programs like Medicare, Medicaid, or CHIP
You do not have any form of health coverage
You are looking for the most comprehensive health coverage in Texas

You can get more information on who should get ACA health coverage from a licensed agent in Texas. They can help with clarifying any questions about ACA insurance.

What are The PROs and CONs of ACA Health Insurance in Texas?

First, let's cover the PROs of ACA insurance:

PROs of ACA-compliant Health Insurance:

Accessible health insurance: Practically every legal resident of Texas qualifies for an ACA health plan. This includes persons with major pre-existing conditions, like stroke or heart disease. This is because the insurer cannot deny them coverage or charge them higher premiums. The ACA has made health insurance easily accessible as a one-stop-shop by establishing the health insurance Texas Health Marketplace. You can view the various available plans, check out their costs, and find all the information you need about the different plans available. Within the first five years of the ACA, over 16 million people purchased ACA-compliant health coverage.
Affordable health insurance: ACA aims to provide low-cost quality health plans that are subject to your family income. Some individuals and families may be eligible for a government-subsidized discount based on their income relative to the Federal Poverty Level, family size, and the cost of healthcare insurance in their area. ACA also provides other monetary benefits like premium tax credit and cost-sharing discounts.
There are no time limits on ACA health plans: Before the ACA, some patients with chronic illnesses could not obtain insurance. Insurance companies imposed monetary restrictions on how much they will spend on a single customer. According to the Affordable Care Act, ACA-compliant insurance policies can no longer give coverage to their consumers with a defined dollar limit.
Access to more preventive and wellness services: Under the list of essential health benefits of the ACA, there are many preventive services for adults, women, and children. These services cut across several important health conditions. The services include screenings, assessments, counseling, preventative medications, and immunizations. These preventive services have low copays and deductibles. The aim is that by being proactive in your healthcare, you will avoid or prevent major potential health issues. The idea is that over time, healthier consumers will result in lower expenses. A diabetic screening and early treatment, for example, could help prevent costly complications down the road.
Prescription medications are less expensive: At the time of enacting the ACA, there was a promise to reduce the cost of prescription medications. There were several groups of people, especially the elderly, that could not afford the drugs prescribed to them. Under the ACA, there has been an annual increase in the number of prescription and generic drugs covered. In 2017, the Centers for Medicare and Medicaid Services (CMS) reported that Medicare enrollees have been able to save over $26.8 billion on prescription medications through the Affordable Care Act.

Now, to the CONs.

CONs of ACA-compliant Health Insurance:

There are also a few downsides to ACA insurance. They are:

Higher Premiums : Everyone is eligible for Affordable Care Act coverage, including individuals with pre-existing conditions. ACA requires that ACA-compliant insurance plans offer a broader range of benefits, which in return makes insurance companies charge higher premiums. Although lower income Texans may qualify for discounted premiums through government subsidies, a large portion of the state's population may find ACA coverage priced out of reach.
More taxes to fund the ACA : Many new taxes were created to fund the effective implementation of the Affordable Care Act. For example, there were taxes on medical devices and pharmaceutical sales. People that earn higher incomes also face higher taxes, as they help subsidize the cost of health insurance for their lower income neighbors.
You can only enroll during the open enrollment period : ACA plans are not accessible all year long, as you can only sign up for ACA health insurance during an open enrollment period (normally: 1 Nov - 15 Jan). The only time an exception is given to this application timeline is if you qualify to sign up during the special enrollment period due to a life-changing event. A life-changing event includes getting married, having a baby, losing a job, or changing your state of residence.

Generally, it is best to discuss your health insurance needs with a Texas-licensed agent, who can answer all your questions based on the current insurance market offerings.

Is ACA Insurance Worth it?

Yes, ACA insurance is worth it.

ACA insurance provides access to frequently affordable and quality healthcare.
ACA insurance does not discriminate based on a pre-existing condition that you may have.
In the process of shopping for an ACA plan, you may qualify for premium subsidies or cost-sharing reductions.

A licensed insurance agent is your best source of answers about how ACA insurance can be particularly beneficial to you.

What Happens if You Don't Have ACA Insurance?

On the one hand, there are no legal consequences for not having ACA insurance in Texas. In 2019, the government removed the tax penalty for not having minimum health coverage.

On the other, if you do not have ACA insurance, you should definitely consider getting health coverage through any of the other available ways. If you do not have access to health coverage through an employer or some group, you should speak to an insurance agent about your options.

Thankfully, Texas offers several different options that the agent can cover based on your specific medical needs. If you do not have pre-existing conditions, you have multiple paths in front of you.

If you have pre-existing conditions and you want them covered by your insurance, you need to get ACA-compliant insurance. Your chosen agent can help you get ACA coverage too.

Why is ACA Insurance Important?

ACA insurance is important because it makes health coverage accessible and affordable to practically everyone in Texas. It does not discriminate based on medical history or financial status. Through the essential health benefits provided, everyone has access to various preventive and emergency services.

What Happens When Your ACA Insurance Lapses?

When a policy is said to lapse, it means the policy is terminated because of non-payment of premium. Thus, your insurer can terminate your plan if you do not pay your monthly premiums. However, before the plan is terminated, you have a grace period. This is a short time you have to pay your monthly premiums.

In Texas you have a 90-day grace period if:

You obtained a Marketplace ACA plan,
You are eligible for premium subsidies, and
In the benefit year, you have at least paid one full month's premium

If you do not qualify for premium tax credit on the Marketplace, you usually have a grace period of 30 days. Check your policy or with your insurer for details.

When you cannot pay your premiums after the grace period, the insurance company will cancel your plan. If this happens, you can take any one of these two actions:

Appeal the cancellation: You should only appeal when you believe that the cancellation is unwarranted. You can appeal the cancellation by contacting your insurance company. If your appeal is denied, you may contact the Texas Department of Insurance by calling (800) 252-3439 or submitting an online complaint. You may also contact the Health Insurance Marketplace by calling (800) 318-2596.

Buy another plan: You can buy other health coverage. You should discuss your options with a licensed health insurance agent in Texas. For example, if the cancellation occurred shortly before the open enrollment period, you can just buy another ACA-compliant plan during the next open enrollment period. You may also qualify to buy another ACA plan during the special enrollment period. Note that while you may be eligible for special enrollment because you lost health coverage, you will not qualify for a Special Enrollment Period if the reason is only because of non-payment. Another option is purchasing a short-term plan until the next open enrollment period.

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