Safe Care and Prior Authorizations
From overtesting and overdiagnosis to overtreatment, health care waste and unsafe care contribute not only to patient harm but also to unnecessary costs. Health plans are committed to reducing these burdens by utilizing tools such as prior authorization and post-utilization review, which are designed to ensure treatments are necessary, evidence-based, and safe. However, efforts to limit or eliminate these processes negatively affect affordability, safety, and quality for everyone. By maintaining a focus on reducing waste and enhancing safety, we can ensure that Texans receive the high-quality care they deserve.
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Learn MoreMembership with TAHP is an invaluable tool for integrating, building relationships, exchanging information and best practices, and promoting your services. You will be well-armed with the most timely and accurate information, strong relationships with key Texas leaders, and access to seasoned policy and regulatory experts.
Open enrollment for health insurance typically occurs annually from November 1 to December 15. During this period, you can enroll in or make changes to your health insurance plan through the Health Insurance Marketplace at HealthCare.gov. If you miss this window, you may qualify for a Special Enrollment Period due to certain life events, such as marriage, birth of a child, or loss of other coverage.
Texans have several health insurance options, including:
- Employer-Sponsored Insurance: Coverage provided by your employer.
- Individual Plans: Purchased directly from insurance companies or through the Health Insurance Marketplace.
- Government Programs: Such as Medicaid, the Children's Health Insurance Program (CHIP), and Medicare.
- Short-Term Plans: Temporary coverage for specific periods.
Medicaid: Available to low-income individuals, families, pregnant women, the elderly, and people with disabilities. Eligibility is based on income and household size.
CHIP: Provides health coverage for children in families that earn too much to qualify for Medicaid but cannot afford private insurance.
For detailed eligibility criteria, visit the Texas Health and Human Services website.
4. What is the Health Insurance Marketplace, and how does it work in Texas?
The Health Insurance Marketplace is a platform where individuals can compare and purchase health insurance plans. In Texas, the federal government operates the Marketplace through HealthCare.gov. You can compare plans, check for subsidies, and enroll during the open enrollment period.
Yes, depending on your income and household size, you may qualify for subsidies to lower your premiums and out-of-pocket costs. These include:
- Premium Tax Credits: Reduce the amount you pay for insurance premiums.
- Cost-Sharing Reductions: Lower your out-of-pocket costs for deductibles, copayments, and coinsurance.
6. What should I consider when choosing a health insurance plan?
Consider these factors:
- Premiums
- Deductibles
- Network of doctors and hospitals
- Coverage of required medications and services
- Out-of-Pocket Maximum
A Special Enrollment Period (SEP) allows you to enroll in health insurance outside the annual open enrollment period if you experience certain life events:
- Loss of Health Coverage
- Household Changes (e.g. marriage, divorce, birth)
- Residence Changes
8. How can I find out if my doctor is covered under a specific health plan?
Most insurance companies provide online directories of in-network providers. You can also contact the insurer directly or ask your doctor’s office to verify coverage.
Several resources are available:
- HealthCare.gov or call 1-800-318-2596
- Texas Department of Insurance
- Local Navigators and Assisters offering free, in-person help