Obamacare in Texas

What is Obamacare?

Obamacare , officially called the Affordable Care Act (ACA), is legislation passed in 2010. The law's main purpose is to extend health-care coverage to almost all Americans, especially those who don't have health insurance through their work, those who find themselves excluded from health insurance plans due to "pre-existing conditions," and those who otherwise aren't covered. The law requires everyone to be covered under a health-care plan, and imposes certain coverage rules on health insurers.

To get a simple overview in less than 3 minutes, watch this video -- or just read on to see how Obamacare may affect you as a Texan.

How does Obamacare change things for me in Texas?

If you already have health insurance - say, through your job or your spouse's job, or Medicare, or some other health insurance - chances are you don't have to change a thing. Where the Affordable Care Act (ACA) comes in is when you don't have health insurance -- that's when you could end up paying a penalty. The government set up a health insurance Marketplace to help you get coverage at a price you can afford. But you may be able to avoid the government Marketplace by shopping for health insurance through a licensed insurance broker such as eHealth, where you may have a wider selection of plans.

Do I have to get Obamacare in Texas?

You must have health insurance, but it doesn't have to be through the government. You can go to the federal health insurance Marketplace website online, or you can contact a licensed insurance broker such as eHealth. If you're eligible for a subsidy, you can go through the federal Marketplace, or an authorized web broker like eHealth can help you enroll in a subsidy-eligible plan through a non-government site.

You generally don't have to get Obamacare in Texas if you have health coverage such as:

  • Health insurance through your job
  • COBRA
  • Medicare Part A or Part C (Medicare Advantage)
  • Medicaid
  • A retirement-based health plan
  • TRICARE (health insurance for military members and their families)
  • United States Department of Veterans Affairs (VA) benefits
  • An individual health plan (sold outside the government Marketplace)
  • CHIP (Children’s Health Insurance Program)

Please note that the coverage you have must include certain benefits to meet the ACA guidelines. Among these guidelines are the 10 essential health benefits listed below.

There may be other health insurance that's acceptable as well. If you're in doubt, you can call the government's Marketplace Call Center (contact information below). However, if you don't have health insurance, you need to get it or you could face a possible penalty.

What if I don't sign up for Obamacare? Will I pay a penalty?

If you don't have health insurance and you don't sign up through the health insurance Marketplace, you could have to pay a tax penalty. Here's how that works:

If you didn't have health insurance in 2015, and if you're not eligible for an exemption, you could pay the higher of these penalties per person in your household:

  • $325 per person with your federal taxes
  • 2% of your annual income. If your income is below a certain amount, called a threshold, you won't have to pay this penalty.

Note that this penalty will go up in the 2016 tax year, and each year after that, adjusted for inflation.

To learn more about exemptions, you can contact the health insurance Marketplace:

  • Online at Healthcare.gov
  • By calling 1-800-318-2596 (TTY users call 1-855-889-4325). Representatives are available 24 hours a day, 7 days a week, except on certain holidays.

Who can get Obamacare in Texas?

Eligibility for Obamacare in Texas is fairly far-reaching. You need to live in the United States (the ACA is basically nation-wide) and be a U.S. citizen, national, or legal resident. You can't be in prison and get Obamacare; you'll have to wait until you're released. The Texas Department of Criminal Justice has information about health coverage for prisoners.

Texans who have Medicare can't use the Marketplace to get a health or dental plan. Find out about your Medicare health plan options.

Can I apply if I'm an immigrant?

You can apply, but only people in certain situations will qualify.

Here are just a few of the situations that may qualify you for Obamacare if you're not a U.S. citizen.

  • You're a refugee.
  • You have a green card (you're a lawful permanent resident).
  • You're a lawful temporary resident.
  • You hold a certain visa, such as a student visa, or a H1, H-2A, or H-2B worker visa.
  • You're a member of a federally recognized Indian tribe.
  • You have applied for asylum and have been granted employment authorization, or you're under age 14 and applied for asylum at least 160 days ago.

Those are just some examples. For more information on applying if you're not a U.S. citizen, here's an official government website.

What if I have a pre-existing condition?

If you have a health problem, according to ACA rules, no insurer can deny you coverage solely because of that health problem. But if you smoke, you might have to pay a higher monthly premium.

Types and levels of health insurance

The government's health exchange Marketplace includes several kinds of plans, and each plan can have up to four levels.

Types of plans

There are several different kinds of plans available for individuals and families in the Marketplace. Here's a sampling:

  • Health Maintenance Organization (HMO) plans generally require you to use doctors within the plan's network, except in emergencies. Your primary care doctor will provide most of your care. If you need to see a specialist, you'll typically need a referral.
  • Preferred Provider Organization (PPO) plans usually let you see doctors outside the plan's network, but often charge more if you go outside the network. You aren't required to have a primary care doctor and typically don’t need a referral to use out-of-network doctors, although you may pay more.
  • Point of Service (POS) plans, like PPOs, usually charge less when you use doctors and services within the plan's network. They're different from PPOs in that you typically need a referral from your primary care provider if you want to see a specialist.
Plan "metal" levels

The health insurance Marketplace assigns "metallic" names to the various levels of coverage, ranging from the highest rate of coverage (platinum) to the lowest rate of coverage (bronze). The higher the rate of coverage, the higher your monthly premium is likely to be.

  • Platinum plans cover about 90% of your health-care costs on average, and you pay the rest (about 10%).
  • Gold plans cover about 80% of your health-care costs on average, and you pay the rest (about 20%).
  • Silver plans cover about 70% of your health-care costs on average, and you pay the rest (about 30%).
  • Bronze plans cover about 60% of your health-care costs on average, and you pay the rest (about 40%).

Catastrophic is a separate category, available only to people who are either under 30 years old or have a hardship exemption. You may qualify for a hardship exemption if your situation interferes with your ability to get health insurance; for example, if you're homeless (or were homeless recently) you may qualify. Catastrophic plans generally cover less than 60% of your health-care costs on average and premiums are usually lower than standard health plans, but you may have to pay a substantial deductible before the plan pays for your care.

10 essential health benefits

No matter what type of health insurance you have, federal law now requires it to carry the following coverage (in Texas and all states):

  • Emergency services
  • Prescription drugs
  • Ambulatory patient services (this generally means you don't need an overnight stay a hospital)
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Pediatric services (for children), including dental and vision care
  • Mental health and substance abuse services
  • Preventive and wellness services, including chronic disease management
  • Rehabilitative/habilitative services and devices

How do I get Obamacare in Texas?

Some Americans who need health insurance can use state-based health exchanges. For those states -- like Texas -- that haven't set up such a system, you can apply through the federal health insurance Marketplace.

You can also get health insurance through a licensed insurance broker such as eHealth. For Texas (and other states using the federal Marketplace), you can even apply for a government subsidy through eHealth’s easy-to-use website instead of using a government-run website.

During the open enrollment period or a special enrollment period, you can apply for Obamacare in any of these ways:

  • Online at Healthcare.gov.
  • Over the phone: Anytime of the day or night, any day of the week, you can reach a live government representative at 1-800-318-2596 (TTY: 1-855-889-4325), except on certain federal holidays.
  • By mail: You can send a paper application in the mail.
  • In person: Federal Marketplace representatives can help you enroll. To contact representatives in your area, click here or call the phone number above.
  • Online through a licensed insurance broker such as eHealth.

Getting help paying for Obamacare in Texas through subsidies

Some Texas residents may qualify for help paying for health insurance. People often call this help a "subsidy." There are at least a couple of different kinds of subsidies you might qualify for in Texas: premium tax credits and out-of-pocket savings subsidies.

Premium tax credits

If your household income is below a certain amount, you can get a subsidy in the form of a "premium tax credit" to help pay for health insurance if you qualify. And if you do qualify, you get to decide whether to have the government help pay your monthly premium (making it an "advanced premium tax credit"), or have the government give you the tax credit when you file your federal tax return.

Qualifying for a premium tax credit in Texas

Here's how it works. First, you need to know your household income level. It might help to have your last federal tax return available.

To qualify, you must:

  • Not be claimed as a dependent on anyone's tax return
  • Have an income of less than 400% of the Federal Poverty Level (about $47,000 for a single person or $95,000 for a family of four in 2015), but not less than 100% of the Federal Poverty Level.
  • File a joint return, if you're married
  • Be enrolled in a plan through the health insurance Marketplace
  • Pay your health insurance premiums
  • Not qualify for other minimum essential coverage (including Medicaid)
Out-of-pocket savings subsidies

Another kind of help that some people refer to as a subsidy is something the government calls out-of-pocket savings.

If you qualify for a tax credit as described above, and your income is below a certain level, you might be able to get help paying your health-care out-of-pocket costs, such as copayments and deductibles. If your household income falls between 100% and 250% of the federal poverty line, you might qualify. These savings are available only when you have a "Silver" plan (see description above).

Do I qualify for a subsidy in Texas?

Want to find out if you might qualify for a subsidy? Just use eHealth's subsidy calculator to get an estimate.

There are other ways to get help with health-care costs in Texas if you qualify. Here are a couple of examples:

Read more about Obamacare health insurance subsidies.

When can I sign up for Obamacare in Texas?

Generally, you can only sign up for Obamacare during the open enrollment period (from November 1st, 2015 through January 31st, 2016).

  • If you successfully apply by December 15th, your coverage will usually start January 1st.
  • If you successfully apply between December 16th and January 15th, your coverage will usually start February 1st.
  • If you successfully apply between January 16th and January 31st, your coverage will usually start March 1st.

The exact coverage start dates will depend on the policies and procedures of the health insurance company you choose and other factors such as whether your application had any errors.

In certain situations, you may qualify for a special enrollment period -- generally if there's been a big change in your life such as one of the events listed below.

  • You got married or divorced
  • You had or adopted a child
  • You lost your health coverage (for example, when you lost your job)
  • You permanently move to a new area with different coverage options

There is a specific set of events that the government calls "qualifying life events." When one of these events happens, you may qualify for a special enrollment period, when you are allowed to apply for health insurance outside the open enrollment period using either the federal Marketplace or independent brokers like eHealth.

If you think you might qualify for a Special Enrollment Period, feel free to fill out this form and get a customized quote.

How much will Obamacare cost me in Texas?

Your costs will depend on the health insurance plan you select. Remember to take into account not only the monthly premium, but the copayment, coinsurance, deductible, and out-of-pocket maximum amounts.

Here's an interactive price index that eHealth has developed so you can get an idea of the average monthly cost of plans in your state. Just follow this link and click on Texas on the map. Then click Single or Family under Household Size to see the range of average monthly costs. You can typically expect to pay somewhere within that range, depending on the plan and coverage details.

For more information about Obamacare costs, click here.

Obamacare plans for small businesses in Texas

If you have a small business in Texas -- like an independent business that you own -- you may also be affected by the Affordable Care Act.

Under the law, you don't have to provide health insurance if you have fewer than 50 full-time or full-time-equivalent employees. But if you do provide this coverage, you may qualify for a tax credit.

How can I get more information?

To watch a quick video (less than 3 minutes) that gives an easy-to-understand overview, click here. If you'd like to dig deeper and get more facts about Obamacare, you visit our ACA resource center, or you can download the latest Obamacare eBook for free by clicking here.

To compare plans right away, and find a plan that works for you, just use our no-obligation plan comparison tool.

This article is for general informational purposes only, and may not always apply to your specific situation or insurance policy. You should always carefully read the plan information and benefits for any insurance plan you are considering. A licensed insurance agent can help you understand the specifics of a policy and determine what insurance is appropriate for your specific situation.