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You are here: www.tdi.texas.gov . pubs . consumer . cb105

How the Affordable Care Act Affects You

(March 2016)

(En Español)

Individual Coverage | Seniors | Businesses | Get Help from TDI

Most people must have health insurance that meets federal coverage standards or pay a tax penalty. Health plans provided by your employer and most state or federal government health plans usually satisfy this requirement.

If you can’t get health insurance through your job or through a government program, you can buy an individual plan.

Individual Coverage

You can buy directly from companies and insurance agents or brokers. You can also buy health coverage through the federal health insurance marketplace at HealthCare.gov or by calling 1-800-318-2596. For lists of companies and HMOs selling individual plans in Texas, visit the Texas Department of Insurance TexasHealthOptions.com website. 

Open enrollment. You usually must buy health insurance during an open enrollment period. The open enrollment period is from November 1 to January 31 each year. You can buy health insurance any time of the year, however, if you get married, get a divorce, or have a baby.

Preexisting conditions. Health insurance companies may not deny you coverage or charge you more because of a preexisting health condition. In determining how much to charge you, companies may consider only your age, where you live, whether you use tobacco, and whether the coverage you’re buying is for an individual or a family.

Tax penalty. If you don't get coverage, you'll have to pay a tax penalty. You pay the penalty when you file your federal income taxes. For more information about tax penalties, visit the HealthCare.gov fees page.

Subsidies. You might be able to get a subsidy to help pay for your coverage. For more information about subsidies, visit the HealthCare.gov subsidies page

Preventive services, immunizations, and screenings. If you're insured, you can get some preventive services for free. Depending on your age and gender, you also may get free annual check-ups, blood pressure and diabetes tests, mammograms, cancer screenings, and flu shots. For more information about free services, visit the HealthCare.gov preventive health services page

No dollar limits. Insurance plans can’t put dollar limits on the amount they will pay for your health care. They may limit the number of times you can get some services in a year, however.

Staying on a parents' plan. Children may stay on their parents' health plans until age 26. Your children may stay on your plan even if they’re married, but the law doesn’t require coverage of your children’s spouses or dependents. In Texas, dependent grandchildren may stay on a grandparent’s health plan until age 25.

Seniors

Prescription help.  Seniors on Medicare and in the "donut hole" get a discount on some prescription drugs. The donut hole is a coverage gap during which some Medicare prescription drug plans won't cover your drug costs.

Preventive services, immunizations, and screenings. You may get free preventive services, including an annual wellness exam and flu shots.

Businesses

Tax penalties.  Businesses with more than 50 full-time employees, including full-time equivalent employees, must pay a penalty if it doesn’t offer health insurance and any full-time employee gets a subsidy through the insurance marketplace. Full-time is defined as an employee working an average of at least 30 hours a week. Every 120 hours worked in a month by part-time employees counts as a full-time equivalent.

There’s no penalty for small businesses that don't offer health insurance.

Automatic enrollment. Businesses with more than 200 employees must automatically enroll employees in a health plan. Employees can choose not to participate in the employer’s health plan. However, if they don’t have other health insurance, they’ll probably have to pay a tax penalty.

Small businesses. Businesses with 50 or fewer employees may buy coverage through the Small Business Health Options Program (SHOP). Small businesses with 25 or fewer full-time employees that buy coverage through SHOP can get tax credits if they pay at least 50 percent of their employees' premiums and pay average annual wages below $50,000.

Get Help from TDI

For insurance questions or for help with an insurance-related complaint, call the Consumer Help Line at 1-800-252-3439 or visit our website.

Visit HelpInsure.com to shop for automobile, homeowners, condo, and renters insurance, and TexasHealthOptions.com to learn more about health insurance and your options for coverage.

The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.



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Last updated: 03/25/2016

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Translation by WorldLingo