Along with the uninsured and others seeking cheaper health insurance, millions of Americans with pre-existing medical conditions are expected to shop on the new health insurance marketplaces now open for enrollment.
For many of those patients in Texas, benefits available through Affordable Care Act are expected to be better and cheaper than those offered now through the state-run Texas Health Insurance Pool.
Starting in January, the health care law will no longer allow insurance plans to deny coverage to people with pre-existing conditions or to charge them more for insurance than others their age. Higher-income people will be able to buy coverage that they have long been denied directly from private companies that shunned customers with costly medical problems, although they likely won’t be eligible for subsidies.
The Texas Health Insurance Pool has helped cover more than 94,300 Texans since it was created in 1998, including more than 23,000 last year. But it’s closing Dec. 31 and encouraging members to sign up for marketplace coverage, which begins Jan. 1.
So is a newer, federally created pool that operates in Texas, the Pre-Existing Condition Insurance Plan, which also sunsets at the end of this year. That plan enrolled 8,829 Texans as of June 30. One of its members is Frank Rodriguez, executive director of the Latino HealthCare Forum and a health care advocate promoting the marketplace.
Rodriguez said that his “pre-existing condition” was weight-loss surgery, which he had in 2009 as a preventive measure to ward off such chronic conditions as diabetes or heart disease.
“Since then, at slightly over 6 feet tall, I’ve kept my weight under 200 pounds and I have been the most fit at any time in my life,” Rodriguez, who is 62, said at news conference to herald the marketplace’s opening. “As we say in South Austin, it was ironical” that insurers considered surgery to prevent illness a pre-existing condition, he said.
He won’t be eligible for a subsidy because of his income, he said.
Rodriguez said he pays about $400 a month in premiums. On the new marketplace, or exchange, some of the 80 plans being offered in Travis County would cost less, depending on the plan and level of coverage chosen.
For example, 50-year-olds in Travis County choosing a lower-level bronze plan would pay as little as $245.98 a month in premiums if they go with Blue Cross Blue Shield of Texas and as much as $379.42 if they choose a Superior Health Plan. At the silver level, the range in premiums is $287.76 from Humana and $492.35 with Scott & White Health Plan. For gold, it’s $328.22 with Humana and $569.66 with Blue Cross.
Rodriguez’s organization received $108,000 from the United Way for Greater Austin and Central Health to educate people about the marketplace. Also getting grants were Foundation Communities, $125,000, and Austin Interfaith, $36,000. In addition, other groups, including Enroll America, are spreading the word about the marketplace, and United Way for Greater Austin is referring people who call 211 and want in-person help to local “navigators.”
The state last month began sending letters to people covered in the Texas Health Insurance Pool, telling them about the marketplace that the federal government created when Texas declined to do so.
“Your new coverage, whether purchased through www.healthcare.gov or directly from the private insurance market, will provide more benefits than you currently have and, in most cases, at a lower cost,” the state pool’s website says. “THIP premiums, by law, are twice the cost of individual policies in the private market.”
Shoppers need to carefully study any plans before they enroll, said Steve Browning, the pool’s executive director.
“Pool policyholders should review the drug formularies offered by insurance carriers to be sure their medications, or acceptable equivalents, are offered by the plans they are considering,” he said in an email. “Same is true for the provider networks offered by the insurance plans — folks need to be sure their doctors and hospitals are included in their new plan’s network.”
The pool expects to assess the insurance industry $20.4 million this year to cover claim expenses, Browning said. “Once the pool has paid all claims and the pool is dissolved, any remaining surplus funds would be returned to the insurers on a pro rata basis.”