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Introduction | Instant Health Quote | Health Basics | Health Benefits |
Group vs Individual | Links
Health Plan Benefits
Benefits vary from one plan to another. Health plans are classified as either "state-mandated plans" or "consumer choice plans." A state-mandated plan provides certain required minimum features and coverages. To make health coverage more affordable, Texas law allows carriers to also offer consumer choice plans that do not include all of the state-mandated benefits. Consumer choice plans are required to provide members with a disclosure statement and a list describing the benefits that are not covered. To be certain of the coverages you have with any plan, however, you should refer to your policy or explanation of coverage.
Although consumer choice plans also may be called "standard plans," be careful not to interpret the term to mean that the coverages provided are "standardized." Each carrier's consumer choice plan may be different - and, in fact, a carrier may offer several different consumer choice plans.
The following charts show the minimum required benefits for consumer choice and state-mandated health plans. The requirements are different according to whether the plan is an individual, small-employer, or large-employer plan, and whether it is administered by an insurer or an HMO.
Notes: "SMP" denotes a state-mandated plan; "CCP" denotes a consumer choice plan. Benefits labeled "Yes" must be included as part of the plan; benefits labeled "No" are not required; benefits labeled "Offer" must be offered, but you may decline any or all of them if you wish.
| Minimum required benefits in individual health plans |
| Benefit |
Fee for Service Plan |
HMO |
| SMP |
CCP |
SMP |
CCP |
| Mammography |
Yes |
Yes |
Yes |
Yes |
| Emergency care |
Yes, if PPO |
Yes, if PPO |
Yes |
Yes |
| Alzheimer's disease (certain requirements if coverage for Alzheimer's disease is provided) |
Yes |
Yes |
Yes |
Yes |
| Oral contraceptives (if prescription drugs are covered) |
Yes |
No |
Yes |
No |
| Contraceptive drugs and devices |
Yes |
No |
Yes |
No |
| Diabetes equipment and supplies |
Yes |
Yes |
Yes |
Yes |
| Guidelines for diabetes care |
Yes |
No |
Yes |
No |
| Childhood immunizations |
Yes |
Yes |
Yes |
Yes |
| Telehealth and telemedecine |
Yes |
No |
Yes |
No |
| Hearing screenings |
Yes |
Yes |
Yes |
Yes |
| Certain therapies for children with developmental delays |
Offer |
No |
Yes |
No |
| Maternity minimum stay (if maternity is covered) |
Yes |
Yes, federal |
Yes |
Yes, federal |
| Prostate testing |
Yes |
Yes |
Yes |
Yes |
| Reconstructive surgery incident to mastectomy |
Yes |
Yes, federal |
Yes |
Yes, federal |
| Mastectomy minimum stay |
Yes |
No |
Yes |
No |
| Off-label drug use |
Yes |
No |
Yes |
No |
| Acquired brain injury |
Yes |
No |
Yes |
No |
| Detection of colorectal cancer |
Yes |
Yes |
Yes |
Yes |
| Reconstructive surgery for craniofacial abnormalities in a child |
Yes |
Yes |
Yes |
Yes |
| Mental/nervous disorders with demonstrable organic disease |
Yes |
No |
Yes |
Yes |
| Transplant donor coverage (certain requirements if transplant coverage is provided) |
Yes |
No |
No |
No |
| Complications of pregnancy |
Yes |
Yes |
Yes |
Yes |
| Minimum required benefits in small-employer health plans |
| Benefit |
Fee for Service Plan |
HMO |
| SMP |
CCP |
SMP |
CCP |
| In vitro fertilization |
Offer |
No |
Offer |
No |
| HIV, AIDS, or related infection |
Yes |
No |
Yes |
No |
| Chemical dependency, chemical dependency treatment facility |
Yes |
No |
Yes |
No |
| Serious mental illness |
Offer |
No |
Offer |
No |
| Treatment of mental or emotional illness |
Yes |
No |
Yes |
Yes |
| Inpatient mental health, psychiatric day treatment facility |
Yes |
No |
Yes |
No |
| Speech and hearing |
Offer |
No |
Offer |
No |
| Mammography |
Yes |
Yes |
Yes |
Yes |
| Home health care |
Offer |
No |
Yes |
Yes |
| Emergency care (only stabilization) |
Yes, if PPO |
Yes, if PPO |
Yes |
Yes |
| Crisis stabilization unit and residential treatment center for children and adolescents |
Yes |
No |
Yes |
No |
| Alzheimer's disease (certain requirements if coverage for Alzheimer's disease is provided) |
Yes |
Yes |
Yes |
Yes |
| PKU treatment (if prescription drugs are covered) |
Yes |
Yes |
Yes |
Yes |
| Oral contraceptives (if prescription drugs are covered) |
Yes |
No |
Yes |
No |
| Contraceptive drugs and devices |
Yes |
No |
Yes |
No |
| Bone mass measurement for osteoporosis |
Yes |
No |
Yes |
No |
| Maternity minimum stay (if maternity is covered) |
Yes, state & federal |
Yes, federal |
Yes, state & federal |
Yes, federal |
| Prostate testing |
No |
No |
No |
No |
| Reconstructive surgery incident to mastectomy |
Yes, state & federal |
Yes, federal |
Yes, state & federal |
Yes, federal |
| Acquired brain injury |
Yes |
No |
Yes |
No |
| Complications of pregnancy |
Yes |
Yes |
Yes |
Yes |
| Minimum required benefits in large-employer health plans |
| Benefit |
Fee for Service Plan |
HMO |
| SMP |
CCP |
SMP |
CCP |
| In vitro fertilization |
Yes |
No |
Yes |
No |
| HIV, AIDS, or related infections |
Yes |
No |
Yes |
No |
| Chemical dependency, chemical dependency treatment facility |
Yes |
No |
Yes |
No |
| Serious mental illness |
Yes |
Yes |
Yes |
Yes |
| Outpatient treatment of mental or emotional illness |
Offer |
No |
Yes |
Yes |
| Inpatient mental health, psychiatric day treatment facility |
Yes |
No |
Yes |
No |
| Speech and hearing |
Offer |
No |
Yes |
No |
| Mammography |
Yes |
Yes |
Yes |
Yes |
| Home health care |
Yes |
No |
Yes |
Yes |
| Emergency care |
Yes, if PPO |
Yes, if PPO |
Yes |
Yes |
| Crisis stabilization unit and residential treatment center for children and adolescents |
Yes |
No |
Yes |
No |
| Alzheimer's disease (certain requirements if coverage for Alzheimer's disease is provided) |
Yes |
Yes |
Yes |
Yes |
| PKU treatment |
Yes |
Yes |
Yes |
Yes |
| Mastectomy minimum stay |
Yes |
No |
Yes |
No |
| Drug formulary, continuation of benefits |
Yes |
No |
Yes |
No |
| Oral contraceptives |
Yes |
No |
Yes |
No |
| Contraceptive drugs and devices |
Yes |
No |
Yes |
No |
| TMJ, coverage for person unable to undergo dental treatment in an office setting or under local anesthesia |
Yes |
No |
Yes |
No |
| Bone mass measurement for osteoporosis |
Yes |
No |
Yes |
No |
| Childhood immunizations |
Yes |
Yes |
Yes |
Yes |
| Telehealth and telemedecine |
Yes |
No |
Yes |
No |
| Hearing screenings |
Yes |
Yes |
Yes |
Yes |
| Certain therapies for children with developmental delays |
Offer |
No |
Yes |
No |
| Maternity minimum stay, if maternity is covered |
Yes |
Yes, federal |
Yes |
Yes, federal |
| Prostate testing |
Yes |
Yes |
Yes |
Yes |
| Diabetes equipment and supplies |
Yes |
Yes |
Yes |
Yes |
| Guidelines for diabetes care |
Yes |
No |
Yes |
No |
| Reconstructive surgery incident to mastectomy |
Yes |
Yes, federal |
Yes |
Yes, federal |
| Off-label drug use |
Yes |
No |
Yes |
No |
| Acquired brain injury |
Yes |
No |
Yes |
No |
| Detection of colorectal cancer |
Yes |
Yes |
Yes |
Yes |
| Reconstructive surgery for craniofacial abnormalities in a child |
Yes |
Yes |
Yes |
Yes |
| Point of service coverage |
No |
No |
Yes |
Yes |
| Complications of pregnancy |
Yes |
Yes |
Yes |
Yes |
Federally mandated benefits
In addition, the following benefits are required by federal law:
-
Maternity and newborn coverage
If maternity benefits are covered, a group health plans with more than 15 employees must provide for a minimum hospital stay of 48 hours after an uncomplicated vaginal delivery, and a minimum stay of 96 hours after an uncomplicated cesarean birth.
A carrier may not deny benefits on the grounds that a pregnancy is a "pre-existing condition."
In addition, the law requires that any plans that have maternity benefits must automatically extend coverage to the newborn for 31 days. To continue coverage beyond 31 days, you must notify your plan administrator during this period and pay any additional required premiums.
A carrier may not exclude or limit initial coverage of a newborn child because of premature birth, accident, illness, or congenital medical conditions. This includes providing reconstructive surgery for craniofacial abnormalities for a child younger than 18 who has been continually covered by a health plan.
A benefit covering "complications of pregnancy" may help if your plan does not include a maternity benefit. Miscarriages or non-elective cesarean births are considered complications. In most cases, management of a difficult birth is not considered a complication, and is only covered by plans with maternity benefits.
-
Mastectomy benefits
Plans that offer mastectomy coverage must also provide for reconstructive surgery of the breast on which the operation was performed, as well as the other breast if needed for a symmetrical appearance. This coverage may be subject to deductibles, copayments, and coinsurance that are consistent with other benefits under the plan. The benefit must also cover prosthesis and treatment of complications at all stages of mastectomy, including lymphedemas.
Limitations of Coverage
Utilization review
Carriers can deny payment for any treatment, or the continuation of any treatment, if they deem that it is not "medically necessary." Many health plans perform "utilization review" before non-emergency medical procedures are approved. The review must be conducted by an appropriate physician, dentist, or other health care provider, and any decision denying treatment must include a medical reason. State law requires the criteria used to approve or deny requested services or treatments to be objective, medically (clinically) valid, compatible with established health care principles, and flexible enough to allow deviation from standard guidelines when justified on a case-by-case basis.
If you have an unresolved complaint about a utilization review for an individual, small-employer, or large-employer plan, you may file a complaint with TDI. If you have a complaint about a self-funded plan, contact the U.S. Department of Labor.
To reduce the chance of a claims problem, read your policy or benefits booklet carefully. Be sure you meet all of the plan's requirements, and keep copies of all correspondence with your carrier and health care provider.
Approval of treatment is not the same as approval for payment. You may still need to file a claim after the procedure. Carriers can refuse payment for portions of approved treatment if they are found to be "unnecessary expenses."
Pre-existing conditions and waiting periods
If you currently have a medical problem, or have had one in the recent past, it may meet a plan's definition of a "pre-existing condition." Most plans will require you to wait a period of months, or sometimes years, before paying benefits for treatment related to this condition.
You must disclose any pre-existing conditions in your application for any health plan. Failure to do so could jeopardize future claims or invalidate the policy.
Carriers may define a pre-existing condition as any condition for which you have received medical advice, care, diagnosis, or treatment during a specified period of time before the plan takes effect. In addition, individual plans can define a pre-existing condition as one where you have shown the existence of symptoms likely to cause you to seek diagnosis or care during the period before the plan begins. Typically, individual plans consider your medical history for the previous five years to determine whether you have a pre-existing condition. Employer-sponsored plans typically consider the previous six months, while other group plans usually look at the previous 12 months.
An individual carrier may decline to cover you entirely on the grounds of a pre-existing condition, or the carrier may insist on a special policy "rider" that excludes treatment for the condition. Group carriers may not insist on a pre-existing condition exclusion rider.
The maximum pre-existing waiting period for an individual health plan is two years. The maximum wait for employer-sponsored health plans is one year. You may have to wait up to two years for pre-existing conditions to be covered if you have coverage through a group plan thatýs not sponsored by an employer.
Some plans may require a standard waiting period before new members are eligible to receive any benefits, regardless of whether they have a pre-existing condition or not. If this is the case, your pre-existing condition wait begins with the start of the waiting period. For example, if your plan has a waiting period of three months and a pre-existing condition waiting period of one year, a new member would be eligible to receive benefits for a pre-existing condition nine months after the waiting period ends.
HMOs have an "affiliation period" that works in much the same way as a waiting period for pre-existing conditions in indemnity plans. However, the affiliation period may not be longer than 90 days.
Reducing or eliminating pre-existing condition waits
If you are switching from one health plan to another, or have a recent history of health coverage, the law has some provisions that can shorten your pre-existing waiting period under the new plan. However, these rules do not apply if you are switching from one form of individual coverage to another.
The amount of time you spent covered under a previous health plan is "creditable" toward any new plan's waiting period, as long as there is no gap in coverage greater than 63 days. For example, if you have been covered by one health plan for the past six months, and then switch to a new plan with a pre-existing condition wait of one year, your previous coverage "credits," and you only have to wait six months.
The following table summarizes how health plans handle pre-existing conditions:
| Pre-Existing Condition Summary |
| |
Group Plans |
Individual Plans |
| Pre-existing condition definition |
You received diagnosis, care, or treatment within six months prior to joining an employer-sponsored plan, or one year prior to joining a non-employer group plan |
You had symptoms likely to cause you to seek medical advice, diagnosis, care, or treatment, or a condition for which you received medical advice, diagnosis, care, or treatment, within five years prior to joining |
| Waiting period before a pre-existing condition is covered |
12 months for plans offered by employers; up to 24 months for non-employer plans (from churches, unions, associations, etc). |
Up to 24 months |
| If you are moving from a group plan today |
Your waiting period is reduced on a month-for-month basis. If previous coverage lasted 12 months, there is no wait for an employer group plan |
Carrier may refuse to accept you because of a pre-existing condition or may include a rider eliminating coverage for the condition; coverage is credited on a month-for-month basis |
| If you are moving from an Individual plan today |
Your waiting period is reduced on a month-for-month basis; if previous coverage lasted 12 months, there is no wait |
There is no law requiring credit for a waiting period; the new carrier may refuse to accept you, include a rider eliminating the condition from coverage, and require a full 24-month waiting period |
Long-term care
"Long-term care" refers to the type of personal care services you may need if you become unable to care for yourself because of a loss of functional capacity or cognitive impairment.
Long-term care is different from traditional medical care. Traditional medical care treats physical problems directly in an attempt to permanently cure or control them. Long-term care services, however, help a person maintain his or her ability to function, perform normal daily activities, or maintain a normal lifestyle.
In general, health plans do not cover long-term care. Some may cover short-term nursing home care, but long-term custodial care in a nursing home or at-home custodial care typically requires a special long-term care policy.
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