Individual Health
Plans
provided by Texas Department of Insurance
(link
here)
please see page for updates
Insurance companies and HMOs
sometimes sell coverage
directly to individuals.
These policies can cover the
purchasing individual only
or include a spouse and
dependents. Individual plans
can be a good option if
you’re self-employed or work
for a company that doesn’t
offer a health plan.
In general, individual plans
cost more, and may cover
fewer conditions, than
employer-sponsored plans or
other group plans. Group
plans achieve lower rates by
spreading the risk of claims
over a greater number of
people.
The following are common
types of coverage you can
usually buy as an
individual:
-
HMO plans
– Managed care plans
offered by HMOs that pay
for covered health
services as long as you
use your particular
HMO’s network of
providers or receive
preauthorization for
obtaining care outside
the network.
-
Major medical
policies –
Policies that cover
hospital stays and
physician services in
and out of the hospital.
Major medical policies
also may be offered as
PPO plans.
-
Hospital
surgical policies
– Policies that cover
only expenses directly
related to hospital and
surgical services, such
as daily room, surgery,
and doctor charges.
-
Hospital
indemnity policies
– Policies that pay up
to a fixed amount for
each day you are in the
hospital.
-
Specified or
dread disease policies
– Policies that only
cover specific illnesses
detailed in the policy,
such as cancer or AIDS.
This coverage also may
be offered as a rider to
extend the other types
of individual coverage.
-
Short term
policies –
Policies that only last
for a specified length
of time, not to exceed
12 months. Short-term
policies are most often
purchased as a
“fill-the-gap” measure
by people who lose
coverage for some reason
but expect to gain it
back.
Carriers have the right to
evaluate your medical
history and other health
factors when deciding to
offer individual plans. The
carrier may deny your
application based on health
factors or only offer a plan
with an “exclusionary rider”
eliminating benefits for
certain conditions.
Note: As a
rule, it’s better to buy one
comprehensive HMO or major
medical policy. If you need
more coverage, these plans
often allow you to add
benefits. The other types of
individual plans may cost
less, but they usually
provide fewer benefits or
may duplicate coverage you
already have.
Covering dependents
If a plan covers dependents,
such as children and
grandchildren, they are
eligible for dependent
health care coverage until
the age of 25. State law
requires plans to provide
comparable coverage for a
dependent if the enrolled
parent is required to
provide medical child
support under a court order.
The plan may not require the
child to live within the
service are or to live with
the parent.
Children with mental or
physical disabilities who
cannot financially support
themselves may be covered
indefinitely. The plan may
require evidence of
disability.
Policies that include
maternity coverage, and
those that allow dependent
coverage, must also provide
automatic coverage for any
newborn child for the first
31 days. You must notify
your carrier if you wish to
continue coverage for the
child beyond this period.
Large-employer plans also
must provide coverage for
certain dependent students
over the age of 25. However,
except for emergency care
and authorized referrals, an
HMO plan can require
dependent students to return
to the plan’s service area
to receive health care
services.
If two spouses are covered
by separate health plans,
and both plans cover their
dependents, the “birthday
rule” takes effect. This
means the plan of the parent
who has the earlier birthday
in the calendar year pays
first. For example, the plan
of a parent whose birthday
is July 3 would pay for a
child’s health care before
the plan of the other parent
born on July 4. However, if
the first parent’s plan
reaches its benefits
maximum, the second plan can
take effect. In the event of
a divorce, a court usually
determines which parent’s
plan is a dependent’s
primary coverage.
