Use our Health plan shopping guide for tips on buying health insurance.
State mandated benefits and consumer choice plans
Texas law requires that health insurance companies and HMOs cover certain benefits, called state mandated health benefits. Different plans are subject to different sets of state mandated benefits.
Texas allows health insurance companies and HMOs that offer plans with all the state mandated benefits to also offer consumer choice plans. These plans may exclude or limit certain state mandated benefits.
Federal health care reform
The Affordable Care Act generally requires plans to cover a minimum package of essential health benefits (EHB), which includes the state mandated benefits. Health plans are very limited in their ability to offer consumer choice plans that limit the state mandates.
Two of Texas’ requirements for HMO plans exceed federal EHB requirements so they may still be limited in a consumer choice plan:
- Texas law requires HMOs to provide certain “basic health care services,” including rehabilitation benefits without limits. Federal law allows plans to have limits. A consumer choice HMO plan may have limits, such as covering only 25 visits for rehabilitation services per year.
- Texas law limits an HMO's use of copayment, deductible, and coinsurance (called cost sharing-requirements). But a consumer choice HMO plan may have cost-sharing requirements. For example, a consumer choice HMO plan may impose a $5,000 deductible for in-network services, which exceeds the normal Texas limit.
Ask about your plan
Insurance companies and HMOs must tell you if you are buying a consumer choice plan, identify the benefits that have been limited, and get your acknowledgement. You can also review your Summary of Benefits and Coverage (SBC) to see the cost sharing and limits that apply to each type of service covered under your plan.
If you want more detail than is provided in the SBC, Texas law requires health insurance companies and HMOs to give you more specific information about benefits, exclusions, terms and conditions, preauthorization requirements, and service area. Ask for your plan’s Texas mandated summary plan description. If you want even more information, you can ask for your actual insurance policy/certificate or HMO evidence of coverage.