1. What does a health insurance plan purchased through the Affordable Care Act (ACA) cover?

A health insurance plan offered through the Affordable Care Act must cover 10 essential health benefits. These benefits include pediatric services, preventative and wellness services, prescription drugs, mental health and substance use disorder services, pregnancy and childbirth services, emergency services, hospitalization, rehabilitative services and devices, laboratory services and ambulatory patient services.

2. What are some examples of “preventative services” covered by insurance plans?

The three categories of preventative services are benefits for all adults, benefits for women and benefits for children. Examples of preventative services include blood pressure screening, diet counseling, immunization vaccines, contraception for women, breast cancer mammography screenings, infant autism screening and hearing screening for newborns.

3. What does “pregnancy and childbirth services” include? 

All health care plans must cover maternity and childbirth care before and after the birth of a child. Any health care costs for routine services do not require a copayment or coinsurance. These services include prenatal preventative screenings, delivery care and breastfeeding services.

4. What breastfeeding benefits must health insurance plans provide?

Insurance plans must provide breastfeeding equipment, support and counseling throughout the entire breastfeeding period. The insurance company is required to cover a new or rented breast pump. Additionally, the insurance plan must comply with a doctor’s breastfeeding recommendations.

5. What mental and behavioral health services are mandatory covered by insurance plans as essential health benefits?

At minimum, mental and behavioral health services must include treatments like counseling, psychotherapy, inpatient services and treatment for substance use disorder. Furthermore, plans must cover pre-existing mental and behavioral conditions including substance use disorders.

6. Can applicants purchase dental coverage in Texas through Obamacare?

Insurance plans offered through the Obamacare website do not include dental coverage automatically. However, an applicant who would like dental coverage can purchase a separate dental insurance plan or choose an insurance plan that includes dental coverage.

7. Will an insurance plan in the Gold or Platinum category provide better quality of care than a plan in the Bronze or Silver category?

Not necessarily. The division of health care costs with the insurance company establishes the category in which the plan belongs. To find out about quality of care, you can research and compare plans, providers and hospitals.

8. What is a Catastrophic health insurance plan?

A Catastrophic health insurance plan has a low premium and high deductible. It is a suitable health plan option for people who want coverage only for an emergency like a serious illness or injury.

9. Can I enroll in a Catastrophic health insurance plan?

Only two groups are eligible for a catastrophic health insurance plan. The government excuses individuals younger than 30 years of age and those who have a hardship exemption from the health insurance coverage requirement. 

10. How do I know if an insurance company will help cover the cost(s) of my prescription medication(s)?

When comparing or previewing plans, you can look at each plan’s list of covered drugs. If you have already enrolled in a plan, you can check prescription medication coverage on the insurer’s website, call the insurer or review any materials that the insurer sent to you. 

11. Can I use my regular pharmacy to fulfill my prescriptions?

You can use your pharmacy only if your health insurance plan includes in their list of “in-network pharmacies.” To find out if your pharmacy is in-network, you can call your insurance company or visit its website. If your pharmacy is not in-network, you will have to go to one that is in-network.

12. I enrolled in a plan through Texas Obamacare. When does my coverage begin?

Your coverage will begin on the start day (usually the first of the month) and after you pay your first premium directly to the insurance company.

13. I missed a premium payment on my insurance plan purchased through the ACA. Will my health insurance company end my coverage?

If you qualified for a premium tax credit and made at least one monthly premium payment, you will have a short “grace period” of time (typically 90 days) in which to pay the premium. 

14. What can I do if the insurance company terminates my plan due to non-payment?

You can request an internal appeal, which means the health insurance company will review its decision, if you believe the insurer wrongly terminated your health coverage. You may also request an external review in which a third party investigates the insurance company’s decision to terminate your coverage.

15. What will happen if I had an ACA plan last year and I did not renew or change my plan for this year?

Most likely, the insurer will automatically reenroll you in the same plan. If you would like to change your plan, you can choose a new plan before the end of January.

16. How much is the tax penalty for individuals who can afford insurance but do not enroll in a health insurance plan?

The government calculates the “individual shared responsibility payment” in one of two ways:

  • $695 per uninsured adult and $347.50 per uninsured child under 18 years of age, up to a household maximum payment of $2,085
  • 2.5 percent of household income or a maximum payment equivalent to the average price of a Bronze plan

Individuals who did not have health care coverage will have to pay the higher of these amounts.

17. If I do not qualify for savings but I still want to get health insurance and avoid the tax penalty, do I need to purchase a plan through the ACA?

No. While you may purchase a plan through the ACA, you can also purchase a plan from an insurance company, online health insurance store or insurance agent or broker.

18. How costly will my tax penalty be if I was uninsured for just a few months out of the year?

You will not have to pay the fee if you were uncovered for no more than two months. If you were uncovered for more than two months, you will pay 1/12 of the annual coverage amount for each month in which you were uninsured. 

19. Can I appeal an eligibility decision made by the ACA’s Health Insurance Marketplace?

Yes, you can appeal certain decisions including decisions about your eligibility for a Catastrophic plan, special enrollment period or lower costs based on income.

20. How do I appeal a decision regarding my eligibility for Obamacare insurance in Texas?

After applying for insurance through the ACA in Texas, you will receive an eligibility notice with some details about your period for appealing the decision. You can write a letter, mail an appeal request form or fax your appeal.