Texas Well and Healthy

For the last week or so, there’s been lots of news coverage of people enrolled in the individual insurance market getting discontinuation notices from their health insurance companies.  Up until recently, the news coverage has told only part of the story.  More and more, we are hearing that after the initial frustration of getting a cancellation notice, some people are finding that they qualify for a better plan at a lower cost through the Marketplace.

Here’s a summary of what is actually happening and why.

What is going on?

Most people get insurance through a job.  But about 5 percent of Americans purchase insurance directly from an insurance company, in what is known as the “individual market.”  Coverage in the individual market is generally the skimpiest coverage available, often with high out-of-pocket costs, no coverage of maternity care, and limited coverage of mental health, substance abuse, and prescription drugs.  The Affordable Care Act sets new minimum standards for the benefits in health insurance sold to individuals and small employers (the two markets where access to adequate coverage was lacking).  For example, plans must cover ER visits, hospitalization, prescription drugs, maternity and newborn care, and mental health care.

Grandfathered plans – those in existence when the ACA was enacted in March 2010 that haven’t changed substantially – do not have to comply with new standards.  But policies established since then must meet new standards.  In many cases, insurance companies have chosen to discontinue their non-grandfathered, individual market policies and offer enrollees new policies for 2014.

For more on what is going on, see the linked posts by the Georgetown Center on Health Insurance Reforms and the New York Times.

Some context

Routine plan changes and cancellations have always been part of the individual market.  For example, in 2009 (pre-ACA), Unicare withdrew from the Texas market and discontinued policies for 180,000 people.  Unlike policy cancellations of the past, anyone losing an individual market policy right now has access to coverage in the Marketplace that they cannot be turned down for due to pre-existing conditions and subsidies are available to help low- and middle-income families afford coverage.

Keep in mind that the plans being cancelled are ones sold after the ACA was enacted.  Plan cancellation notices are coming from insurance companies that marketed and sold products since 2010 that they knew didn’t meet the ACA standards and would eventually have to be modified to come into compliance.

It is certainly inconvenient to have to shop for a new health plan.  And it is frustrating to do that when the Marketplace website isn’t fully functional.  But consider the frustrations (or worse) inherent in possible tradeoffs, such as fighting with your insurance company to get them to cover basic care or finding out only after the diagnosis of a serious illness that you have a substandard policy that leaves you with piles of medical bills, or worse, threatens you with bankruptcy.

It is true that some people will pay more for their new plan (but others won’t; keep reading). But generally speaking, these people will be getting something for their money – coverage for benefits that weren’t available before, protection against getting dropped if they get sick, and more protection from medical bankruptcy.

Now we know the rest of the story

Some intrepid journalists have  dug a bit deeper to figure out the real coverage options for people who’ve understandably been upset by cancellation notices, and they are finding that initial claims are only part of the story.  For example, Dianne Barrett, who went from “Obamacare victim to Obamacare beneficiary” in the space of a week as journalists discovered that the $54/month plan she was losing didn’t cover hospitalization at all, leaving her at risk of bankruptcy in the case of serious illness or injury. What’s more, she is eligible for subsides that would significantly reduce her premiums to a fraction of the $591/month alternate policy quoted in the cancellation notice from her insurance company.

Also, Deborah Cavallaro, who pays $293 a month for catastrophic coverage and thought her only alternative was a  replacement plan that costs $478/month.  It turns out that in the Marketplace, which she had not explored, she has several options that would help her come out ahead compared to the coverage and premiums she has today.

Who is watching out for consumers?

One thing that seems to be an issue in some of the “debunked” stories is the misleading notices enrollees are getting from insurers that list a price for a default alternate policy and either downplay or completely fail to mention that enrollees can shop on the Marketplace instead and may qualify for subsidies to make coverage more affordable.  At the Center, we’ve seen discontinuation notices that went out to Texas enrollees that do not mention the Marketplace at all, and at least in one case, push the enrollee to renew coverage at a higher price than they’d find in the Marketplace.

Departments of Insurance in Texas and other states should ensure that any discontinuation notices sent to enrollees are clear, not misleading, and help consumers understand their range of options including potential subsidies in the Marketplace.  Some states (not Texas) have required insurers to share their cancellation letter with the Department of Insurance to better protect consumers.  If Texas consumers believe they have received a misleading or inaccurate letter, they should file a complaint with the Texas Department of Insurance online or by calling 1-800-252-3439.

Written by: Stacey Pogue, Center for Public Policy Priorities. Cross-posted from Better Texas Blog.

Screen Shot 2013-10-16 at 5.23.08 PMHere at Texas Well and Healthy we are always striving to produce easy-to-understand materials about health care reform. Our partner KidsWell knows a thing or two about providing informative and clear resources on the Affordable Care Act—their brightly colored and highly visual website does a great job of sharing resources on children’s health coverage and the ACA. Their website includes state-by-state summaries of health care reform implementation and campaigns impacting children’s health and relevant weekly highlights from all fifty states.

Visuals are often key in comprehending large amounts of data. KidsWell’s National Spotlights feature provides interactive maps showcasing developments in health policy reform that are particularly relevant to advocates with an interest in child health. KidsWell also has a powerful health care reform search tool that will help you find all the latest health care reform information. You can search by keywords, state, topic, issuing agency and other criteria. Their database is updated each week so you know you’re getting accurate, recent data.

Additionally, KidsWell coordinates over 30 children’s advocacy organizations (including us) who are working to increase health insurance coverage for our nation’s children and families. By helping advocacy organizations work together, and by using this website as a health reform information hub, KidsWell is building a lasting legacy of healthy children.

Texas Well and Healthy is proud to be a featured partner of the KidsWell Campaign this week. You can see where we are highlighted on their website’s homepage. Take a moment to visit the site and check out their resources. You won’t regret it!

Written by Liz Moskowitz, Texans Care for Children

Starting October 1, 2013 many Americans will have the opportunity to enroll in new affordable coverage options through the Health Insurance Marketplace.  With these new coverage opportunities, however, comes a new requirement that most individuals have health insurance in 2014, or pay a fee to go uninsured.  The prospect of paying a fee (or “penalty,” as it is also called) may sound intimidating, but we’re here with the good news that most people who have coverage today already meet this new requirement, and that not everyone will be subject to the fees in 2014 and beyond.  Learn more below!

What if I Already Have Insurance?  Will I Owe a Fee?fees and insurance image

In order to avoid paying a fee in 2014, an individual needs to have “minimum essential coverage.”  If you are enrolled in any of the following plans in 2014, you’ve already met this requirement and will not have to pay a fee:

  • Any Health Insurance Marketplace plan
  • Any individual insurance plan that you have today
  • Any employer plan (including COBRA and retiree plans)
  • Medicare
  • Medicaid
  • Children’s Health Insurance Program (CHIP)
  • Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program, and Spina Bifida Health Care Benefits Program)
  • Peace Corps Volunteer plans

Other plans may also qualify, so be sure to ask your health insurance provider if your plan meets the minimum essential coverage standard.

So, what doesn’t qualify as minimum essential coverage in 2014?  Plans that only cover vision, dental care, or a specific medical condition do not qualify, nor does workers’ compensation or plans that only offer discounts on medical services, for example.  Individuals who are only covered by these limited policies might consider purchasing more comprehensive coverage for 2014, or pay a fee.

What if I am Uninsured?  Who Doesn’t Have to Pay a Fee?

There are a variety of groups that won’t be responsible for paying a fee, even if they remain uninsured:

  • Individuals uninsured for a single period of less than three months
  • Low-income people for whom insurance would cost more than 8% of household income, after taking into account employer contributions or federal tax credits
  • People not required to file a tax return because their annual income is too low (about $10,000 for a single adult in 2013)
  • People who would qualify under the new federal income limits for Medicaid, but their state has chosen not to expand Medicaid eligibility
  • Members of a federally recognized Indian tribe
  • Participants in a health care sharing ministry
  • Members of a recognized religious sect with religious objections to health insurance
  • Individuals who are incarcerated
  • Non-U.S. citizens and nationals who are not lawfully present in the U.S.,

If you don’t fall into any of the categories above, you can still apply for an additional hardship exemption in the Health Insurance Marketplace.

How Much is the Fee and How Do I Pay It?

If you don’t enroll in minimum essential coverage for 2014, and you don’t fall into one of the exempt categories listed above, you may be responsible for paying a fee.

In the year 2014, an individual or family would be responsible for $95 per adult, $47.50 per child (up to $285 for a family), or 1% of income (whichever is greater).

The fees increase in 2015 and rise significantly in 2016 to $695 per adult, $347.50 per child (up to $2,085 for a family), or 2.5% of income (whichever is greater).

The fee will be pro-rated according to the number of months the individual or family goes without insurance, and will be assessed as part of the household income tax return for that year.

Please keep in mind that individuals and families who choose to pay the fee (rather than buy coverage) will also be responsible for covering all of their health care costs in a given year, and will not have the protections of health insurance to shield them from high medical bills.

Where Do I Go From Here?

If you are uninsured and want to purchase minimum essential coverage for 2014, go to www.HealthCare.gov on October 1, 2013 to check out policies available in the new Health Insurance Marketplace.  Enroll early to make sure that you and your family get the coverage you need and avoid paying a fee in 2014.

By Megan Randall, Center for Public Policy Priorities. Cross-posted from Better Texas Blog.

Starting October 1, 2013, Texans will have the opportunity to sign up for new health care coverage options through the Health Insurance Marketplace.  Coverage for new enrollees will begin as early as January, 2014, and will include a number of new consumer protections.

We know navigating health insurance plans can be daunting and the terms used can be confusing at times, so we thought it’d be helpful to review some of them before open enrollment begins in a few weeks.  Let’s get started with four important “Insurance 101” concepts.

1.      Premium – A premium is the fee that you pay to participate in your health insurance “plan” or “policy.” You or your employer may pay it on a monthly, quarterly, or yearly basis. Starting in 2014, the federal government will offer premium discounts (through tax credits) to qualifying low- and middle- income consumers shopping in the individual Health Insurance Marketplace to help make insurance more affordable.

2.      Deductible – A deductible is the amount you pay out of your own pocket for health care services before your insurance company will begin to pay its share of your health care claims.  Each year, a consumer must typically pay some kinds of health care bills up to the amount of his or her health plan’s deductible before the insurance company will begin to contribute.  Most preventive services, like check-ups and many screening tests, are the exception: they are paid for in full by the insurance company regardless of whether the enrollee has met the yearly deductible.  Deductibles are a form of “cost-sharing” between the enrollee and the insurance company.  Starting in 2014, the federal government will offer cost-sharing reductions to qualifying low-income consumers to help reduce out-of-pocket costs such as deductibles.

3.      Copayment – A copayment is the amount you must pay out-of-pocket at the time you receive a medical service or a prescription drug.  This is another form of “cost-sharing,” and may be reduced in size by federal cost-sharing reductions for qualifying low-income consumers in 2014.

4.      Pre-existing Condition – A pre-existing condition is any medical problem or illness that you had before applying for health care coverage.  Starting this October, applicants can no longer be denied coverage or charged more based on their medical history, and insurance companies can no longer impose pre-existing condition exclusion periods (in which treatment for pre-existing conditions is not covered for a number of months following enrollment).

Have additional questions about insurance jargon?  Check out these helpful resources:

Healthcare.gov Health Insurance Glossary

Texas Health Options Health Insurance Glossary

And be sure to visit www.healthcare.gov to learn more about the Health Insurance Marketplace and to prepare for October open enrollment!

Written by Megan Randall

This piece is cross-posted from the BETTER TEXAS Blog by the Center for Public Policy Priorities. The CPPP health care team will be posting several times per week leading up to Oct. 1. as part of their “Countdown to Coverage” blog series.

If you’ve been following us on Facebook or Twitter, you might have noticed that we’ve spent the last couple of weeks sharing some of the great things health care reform is already doing for Americans. How come? Well, for one, according to the Pew Research Center, 44% of Americans don’t even know if the Affordable Care Act is still in effect.  And, as a recent Texas Tribune article that summed up polling on the law concluded, even fewer Texans have a good feel for what’s in the law and how it helps them.

If you support health reform, why not help get out the word by sharing some facts about why it matters for Texans? (Those handy buttons for sharing at the bottom of this blog post make that easy.) And if you’re unsure yourself about what’s in the Affordable Care Act, click on any of the images below to go to our quick, fun video shorts, explaining each of these 4 ways the law is already helping Texans and will help still more in 2014.

1. Coverage for those with pre-existing conditions means peace of mind for many Americans who were once denied health insurance:

Beautiful Thing_Puppy

2. Preventive care’s covered. Since 2012, women haven’t had to pay out-of-pocket costs for many types of preventive care. In 2014, anyone with health insurance will receive all preventive care services at no extra cost.

Click on the image to see our video about preventive care being covered.

3. Insurers are held accountable. Now more of your premium dollars for private insurance have to go toward actual health care; insurers can’t just spend ever-growing amounts on administrative costs or CEO bonuses.

Go undercover with us in this fun video on keeping health insurance companies in check.

4. Health insurance companies can no longer deny you health care because of lifetime spending caps. So if you get really sick and need expensive treatment, you don’t have to worry about not getting the care you need.

Watch our video about why this is good news for everyone.

It’s not too late to join in this health care celebration by liking and sharing this post with your friends. Also, please stay tuned: our friends with the Center for Public Policy Priorities will be posting in this space throughout September about what’s coming up now that full implementation of the nation’s law is almost here.

Thanks, and here’s to a well and healthy Texas!

By: Liz Moskowitz and Christine Sinatra, Texans Care for Children. Special thanks to our former community educator with this campaign, Cheasty Anderson, who stars in the videos linked to above.

Texan Sally Jo Hahn is self-employed and has a history of health concerns. Finding coverage on the private insurance market has been nearly impossible. Even the state’s high-risk pool, which would have cost thousands of dollars, kept her from joining for a time.

Under the Affordable Care Act Sally Jo’s choices—and those of many other Americans—will improve greatly.

Sally Jo Hahn - Credit: AAS

Sally Jo of Austin   Credit: Austin American-Statesman

Much of the American Dream is based on our country’s historic facilitation of self-made individuals who work hard to establish their own businesses and pave their own way. Our openness to self-started businesses is something that Americans are not only known for but intensely proud of.

Self-employment offers opportunity for unique entrepreneurship and the optimal utilization of individuals’ experience. It also serves as an avenue for increased job creation. But changing jobs—finding the right fit in a position that aligns with one’s interests—is another vital piece of any dynamic economy. People need to be able to go out and do what they’re made to do.

Today, however, Americans are often deterred from starting their own businesses or changing jobs, for fear of losing the security that comes with the job they have. Concern over being denied insurance coverage because of pre-existing conditions, being charged higher premiums, or losing access to a trusted provider keeps workers in “job lock,” continuing to work in jobs they would otherwise leave—in order to maintain health coverage.

As we’ve noted before, research from the Urban Institute and Georgetown University shows health care reform can help alleviate job lock and is likely to lead to 124,000 Texans striking out on their own. Beginning in 2014, no applicant for non-group coverage may be turned down for assessed risk or health status. All health insurance policies must provide a minimum level of coverage that includes 10 Essential Health Benefits, mandating coverage in areas such as maternity and newborn care, mental health, pediatric care, and general preventative, wellness services.

New reform under the ACA offers Texans and many other Americans the opportunity to venture out on their own and try something new. Workers will now feel more secure starting new endeavors that cater to their unique skillsets and experience, without the worry and concern that they cannot access quality, affordable health care for themselves and their families.

Written by: Hannah Guernsey, Children’s Defense Fund – Texas

AnneUnless our state takes action soon, come Jan. 1, 2014, Texas adults just below the poverty line, such as parents in a family of 4 living on $23,000 a year, will have no access to affordable health care under the Affordable Care Act.  But their neighbors with a family of 4 living on $29,000 a year—just above poverty—would qualify for sliding-scale premium assistance and reduced out-of-pocket costs in the new health insurance marketplace.

While our leadership has been steadfast in their refusal to accept the opportunity to cover this group of Texans, our legislators had been relatively silent on the issue, minus a few press conferences. But for the first time during the 2013 legislative session, a committee of lawmakers met last week to discuss Medicaid Expansion, which is estimated to cover an estimated 1.1 million uninsured low-income parents and other adults in 2014.

Two very different bills were heard in last week’s hearing–HB 3376 by House Appropriations Committee vice chairman Rep. Sylvester Turner, and HB 3791 by Rep. John Zerwas, who serves as the chairman of the HAC subcommittee on health and human services.  CPPP joined dozens of organizations and individual Texas family consumers in testifying on both bills.

CPPP supported Rep. Turner’s bill, which is a straightforward directive to implement the coverage for our poorest uninsured adults.  We shared with legislators Census data showing Texas is home to more than 800,000 uninsured U.S. citizen workers with incomes below the ACA Medicaid threshold (138 percent of the federal poverty income limit).  Those uninsured Texas workers are highly concentrated in the retail, food service/hotel, health care, and construction sectors.  Our testimony also showed the wide range of jobs in Texas that have typical wages that would qualify a worker for the ACA’s Medicaid coverage, either as a childless adult or as a parent.

We testified in a neutral position on Rep. Zerwas’ bill because it mixes in one bill proposals we strongly support with ideas we fundamentally oppose.  On the plus side, Rep. Zerwas’ bill could provide the framework for an Arkansas-style conservative compromise, which CPPP supports.  However, the bill also calls for Texas to ask Congress for a Medicaid block grant, which we oppose, and includes a “Plan C” fall-back proposal to cover only about 30,000 of the estimated 1.1 million Texans.  Because Arkansas lawmakers and federal Medicaid officials have now succeeded in reaching a deal to ensure the poorest adults are not left out of coverage in 2014, there is just no excuse for Texas not to reach the same goal and have care choices available for all in January 2014.

To get involved and stay informed about advocacy on the ACA Medicaid coverage opportunity—and general work to move Texas forward to cover the uninsured—sign our CPPP pledge here and share it with your family and friends. You can also sign up for emails from the Texas Well and Healthy campaign.  If your organization wants to take a stand, check out the Cover Texas Now Coalition, a partner in that campaign.

Watch testimony from more members of the Texas Well and Healthy campaign at last week’s hearing.

Written by Anne Dunkelburg, Center for Public Policy Priorities. Cross-posted from the Better Texas Blog

Dear Affordable Care Act,

Happy birthday, old friend! I can’t believe it was just three years ago that you were born – and I can’t believe in just three years what a difference you’ve made in our lives. You’re a wonderful, wonderful law, and I can’t thank you enough. My pre-existing conditions don’t count against me anymore. My health care access is protected. As a woman, my birth control is free! Children are guaranteed free preventive care, and I know that senior citizens on Medicare are seeing their out-of-pocket prescription drug expenses shrink every year. Our health is safer in your hands because of so many of your wonderful provisions.

Of course, the picture isn’t all rosy. In state after state, your dream of expanding Medicaid to all low-income citizens is becoming a reality, but here in Texas we’re fighting hard to make it happen. But you know what? I think we’ll win. I think we’ll win because of you, Affordable Care Act. Because for the first time in our nation’s history you have allowed people to think of health care access as a right, rather than a privilege. Because you have prioritized the radical goal of expanding coverage even to the sickest and poorest among us.  In doing so, you have spelled out the logic of a system that protects the poor and the sick and the needy – as my mother used to say, “an ounce of prevention is worth a pound of cure,” and those pounds of cure have been adding up in a major way for American consumers. It’s time to spend some time with those ounces of prevention.

The Medicaid Expansion will happen – it has to happen – because in the end it means so much not just for individuals, but for us as a state, and for us as a nation. It means freedom and prosperity and a healthy future for the American people.

So thanks, Affordable Care Act. Thanks for protecting us, and thanks for letting us dream. We here in Texas will keep fighting to make your promise a reality: accessible, affordable health care for all. Happy birthday.

With love,

Texas Well and Healthy

Written by: Cheasty Anderson and cross-posted from MomsRising blog

Screen Shot 2013-02-13 at 3.33.52 PMNo matter what time of the day it is, someone, somewhere, is talking about health care reform. There’s a reason why it’s such a hot topic and will continue to be in the future. The new health care reform affects a lot of people, small business owners included. Though a lot of attention is being paid to the new law, that doesn’t always make it easier to understand. That’s where we come in!

If you own a small business, we want to make sure all your health care reform questions are answered. That’s why we’re partnering with Small Business Majority and the Rio Grande Valley Hispanic Chamber of Commerce to host two interactive presentations. We’ll help answer questions like:

-       Does a small business owner have to provide healthcare for their employees?

-       Who will qualify for tax credits?

-       What will this mean for my business’s bottom-line?

The event is FREE and sponsored by the McAllen Hispanic Chamber of Commerce. All the important info is below, and you can also download the event’s flyer here. We look forward to seeing you and working together to create a well and healthy Texas!

Location: Rio Grande Valley Hispanic Chamber of Commerce 3313 N. McColl Rd

McAllen, Texas 78501

Date:         Tuesday, February 26th, 2013

Time:        9 am or 1 pm (both covering same material)

The FREE events, open to all small business owners and self- employed individuals, will feature a panel of experts who will discuss the topics of the new healthcare law that are most relevant to small businesses, their employees, and their dependents.

These include tax credits, the state’s work in preparing for a federally-facilitated health insurance exchange, wellness grants, cost containment, and changes on the horizon regarding employee and dependent healthcare benefits.  The sessions will also offer small business owners a chance to provide the panel with ideas and suggestions on how to proceed with implementing healthcare reform, especially as Texas prepares to embrace a federally-facilitated health insurance exchange and moves forward with implementation.  A question and answer period will follow the presentation.

Small businesses are the foundation for the Texas economy and we must take “care” of our businesses and employees the best way possible!

For more information on these events, please contact the Rio Grande Valley Hispanic Chamber of Commerce by calling 956-928-0060 or emailing chamber@rgvhcc.com.


Written by Courtney Watson, Children Defense Fund


Image from Flickr Creative Commons

Dear Cheasty,

I am a veteran of the Vietnam War and I get my health care through the VA. Is the Affordable Care Act going to make me buy insurance, too? I don’t think it should, because I already get all my health care at the VA.


Vexed Veteran


Dear Veteran,

I think we can safely take the “vexed” out of your name, because the Affordable Care Act will not affect the health care you already receive from the Veterans Health Administration. If you get health care from the VA, you are NOT required to purchase additional insurance. If you want  to buy additional coverage, you are welcome to do so (it won’t compromise your existing VA benefits), but nothing in the law requires you to buy insurance. Hooray!

So that’s the quick and dirty: if you are eligible for VA health care, you will remain eligible. Nor does the Act change the TRICARE or TRICARE for Life benefits your family may receive. But let’s look at some other situations veterans find themselves in.

For veterans who are NOT eligible for VA health care and do not get insurance through an employer, they and their families may qualify for tax credits and subsidies that make purchasing health insurance easier and more affordable. Starting January 1, 2014, those veterans, just like every other uninsured Americna, can shop for insurance on the Health Insurance Exchange, and hopefully get some help finding coverage they can afford.

Well, what about veterans who get insurance coverage through an employer, you might ask? What then?

In that case, veterans will benefit from the consumer protections in the Affordable Care Act. To sum it up, you will get preventive care with no co-pays, you won’t have lifetime or annual caps on your insurance benefits, and you won’t have to worry about being denied insurance (or charged more!) because of pre-existing conditions. If you want to know about additional benefits under the ACA, click here to read all about it.

So there you have it, Veteran. If you get health coverage through the VA, nothing will change for you in 2014. But if you know other veterans who don’t, the Affordable Care Act will be able to help them get access to better, more affordable coverage for them and their families. I hope this explanation has helped put you ‘at ease,’ soldier. (Haha.)


To a well and healthy Texas,

Cheasty Anderson

Do you have more questions about health reform? Email Cheasty at anderson@cppp.org