Blog Archive


Aetna is pulling out of Texas

Aetna is one of the few individual health insurance companies in Texas selling individual health insurance plans/ family health insurance plans for 2017. Aetna is also one of the even fewer companies offering an EPO provider network. An EPO provider network does not require referrals for specialist like other health insurance carrier’s HMO provider networks do. For 2018 Aetna has just announced that they will be pulling out of Texas as well as many other states.

If you currently have an Aetna health insurance policy then your current coverage will not be impacted until December 31, 2017. You will be unable to renew your policy for 2018. You will need to select another health insurance plan during the annual open enrollment period.

The open enrollment period for 2018 will begin November 1, 2017. Aetna is notifying their members that they will qualify for a special enrollment period due to “loss of coverage” which will allow them until December 31, 2017 to select another individual health insurance carrier. We at Texas Medical Plans do not recommend waiting until then to secure new health insurance coverage for 2018.

Our recommendation is that Aetna members contact their health insurance agent no later than December 15,2017 to ensure they have new coverage effective January 1, 2018. If you are an Aetna member without a trusted health insurance agent please contact our office, Texas Medical Plans, for assistance at (512)847-3164.

Aetna has also recently been in the news for their data breach that has impacted 522 Texas residents. Please read more here.


CMS issues final rule to increase choices and encourage stability in health insurance market for 2018

The Centers for Medicare & Medicaid Services (CMS) reports the follow (visit the CMS website for the full report):

Today, CMS, issued the final Market Stabilization rule, to help lower premiums and stabilize individual and small group markets and increase choices for Americans. Individuals obtaining coverage in the Marketplace created by the Affordable Care Act have faced double-digit premium increases, fewer plans to choose from, and a market that continues to be threatened by insurance issuer exits.* The CMS rule is designed to provide some relief for patients and issuers now.

“CMS is committed to ensuring access to high quality affordable healthcare for all Americans and these actions are necessary to increase patient choices and to lower premiums,” said CMS Administrator Seema Verma. “While these steps will help stabilize the individual and small group markets, they are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.”

The final rule makes several policy changes to improve the market and promote stability, including:

  • 2018 Annual Open Enrollment Period: The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to enroll in coverage prior to the beginning of the year.
  • Reduce Fraud, Waste, and Abuse: The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums.
  • Promote Continuous Coverage: The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year. This is intended to address gaming and encourage individuals to maintain continuous coverage throughout the year, which will have a positive impact on the risk pool.
  • Ensure More Choices for Consumers: For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers, and to continue offering existing plans.
  • Empower States & Reduce Duplication: The final rule reduces waste of taxpayer dollars by eliminating duplicative review of network adequacy by the federal government. The rule returns oversight of network adequacy to states that are best positioned to evaluate network adequacy.

CMS also made a number of other announcements today regarding the process that issuers must follow to meet the law’s requirements for the 2018 plan year. The additional guidance released includes updates that would make the guidance consistent with today’s final rule and information needed by issuers in order to have their plans certified for 2018, including: Key Dates for 2017; Issuer Guidance on Uniform Rate Review Timeline; Good Faith Compliance Guidance; QHP Certification Guidance for States; and Final Actuarial Value (AV) Calculator for 2018 and Methodology.

The final rule can be found, here:


Immediate steps to take after you have enrolled in health insurance

You are enrolled in health insurance, so what is next? If you have chosen an individual health insurance plan or a group health insurance plan and completed your health insurance application these are important steps to take:

  1. Make you’re your health insurance first month’s premium payment. Typically, your first month’s premium payment is collected at the time you complete your health insurance application, however some insurance carriers will allow you to make the initial premium payment after you submit your application. Contact your insurance carrier to pay your first month’s premium immediately. Your individual health insurance policy WILL NOT go into effect until the initial payment is received and processed. Confirm that your bank records show that your health insurance premium payments have been received by your health insurance carrier.
    1. Initial premium payments MUST BE received before the effective date for your policy to be issued. Health insurance carriers will not send insurance cards until they have received the first premium payment. Keep in mind that during the annual open enrollment period processing times are longer. This means it takes longer to process your payment and longer for you to receive your insurance cards.
    2. Your monthly health insurance premium payments must be received and processed prior to the month that you want coverage. This means that if you go to see your in-network doctor on April 1st, then your premium for April must be submitted and processed by your health insurance carrier no later than March 31st. If you do not make payments on time you take the risk of not being able to verify your insurance when you need to use it and potentially take the risk that your insurance policy will be terminated for non-payment.
  2. Terminate other insurance. Just because you received a letter that your plan is going away or premiums are going up does not mean that your other insurance will automatically cancel and that they won’t draft your account.
    1. If you are on automatic payments call the insurance carrier or login to your online member portal and cancel those immediately. Usually this request must be received several days before the draft date in order to cancel the automatic payments.
    2. Cancel your old policy with your previous health insurance carrier for the day prior to your new health insurance effective date. For example: if your new health insurance policy with Blue Cross Blue Shield of Texas starts January 1st then you need to cancel your old Blue Cross Blue Shield of Texas health insurance policy and make sure they have stopped any automatic payments.
    3. Some carriers will automatically renew your policy into something similar, so it is important to make sure that they are not “mapping” you into another plan. You may need to request that they cancel the policy they are “mapping” you into as well.
    4. If your health insurance is through, also known as the Marketplace or the Exchange then depending on your application selections you may be automatically rolled into another plan each year. This plan may or may not meet your medical needs, so we advise that you actively reviewing your health insurance every year. Your application answers may also affect tax credits received. It is important that you are updating your application each year to ensure it is correct and current.
  3. Create an online account. Most insurance carriers have a member website or member phone app where you can create an account. Member online accounts allow you to access you and your family’s health insurance information. This information can be temporary ID cards, provider networks, online payment options, and claims information. Providers like Blue Cross Blue Shield have even added a “call a doctor” benefit through MD LIVE that you can access online. It may seem like a pain to add another account to your array of accounts, but these online health insurance tools are truly beneficial. You have almost everything regarding your health insurance at your fingertips. This allows you to avoid long hold times to contact the insurance carrier.
  4. Not truly happy with your health insurance? You have until January 31st to make changes to your health insurance. Be certain you know how your insurance works, your benefits and your coverage area. If your insurance does not meet your needs, we can help you explore alternatives. Call us at (512)847-3164.

Know how to use your insurance

You have enrolled in a health insurance plan, now what? Health insurance can be confusing and overwhelming, so here are a few tips to help you use your health insurance correctly.

  1. KNOW YOUR NETWORK! Check doctors, hospitals, and urgent care in-network. Be proactive about your medical needs and check for the doctor’s and facilities that are close to you that are in your health insurance network. Each insurance carrier has an online tool where you can search providers by name, specialty, location. This is useful to have so that you know exactly where you can go in the event of an emergency.
    1. Each carrier has a multiple “networks”, so know what network you are in i.e. Blue Cross Blue Shield Blue Advantage HMO, Aetna Rosebud EPO or HMO, Memorial Hermann HMO or PPO, United Healthcare Choice, PHCS, Humana HMOx San Antonio/Houston, etc.
    2. When confirming your network with your provider ensure that you are using the specific network to confirm. Sometimes it may be best to speak to a providers billing or managed care representative (the person that handles their insurance contracts) to ensure you are receiving the correct information.
  2. Get established with a primary doctor. If you are having to switch doctors or have not established a relationship with a primary doctor in your network get an appointment now.
    1. Some doctor’s will only see new patients on certain days, so it can take a while to get an appointment. You want to be certain that you your doctor is the right fit for you.
    2. If you have enrolled in an HMO we recommend that you find out what your primary doctor’s referral process is like if you need to be referred to a specialist.
    1. Make sure that you review your health insurance carrier’s prescription drug formulary for any medications you take. This will give you an idea of what your costs will be.
    2. Make sure that you are also going to pharmacy’s that are in your health insurance carriers network.
  4. Not truly happy with your health insurance? You have until January 31st to make changes to your health insurance. Be certain you know how your insurance works, your benefits and your coverage area. If your insurance does not meet your needs, we can help you explore alternatives. Call us at (512) 847-3164.

Medicare Announces 2017 Premiums and Deductibles

The Centers for Medicare and Medicaid Services announced Thursday, new premiums and out of pocket costs for 2017. This information comes after some beneficiaries have already made plan choices for 2017 based upon 2016 figures for out of pocket costs and premiums. Medicare is notorious for announcing changes late in the game, well after the year’s OEP/AEP (Open Enrollment Period/ Annual Election Period) have already begun.

The annual Medicare Part B deductible for all Medicare beneficiaries for 2017 will increase to $183, up from $166 in 2016. This is the deductible that anyone with a Standard Medicare Supplement Plan G is responsible for before their supplement plan’s benefits are triggered. For those who have Medicare Supplement Plan F, the plan will continue to cover the Part B deductible in full for the member.

The Part B premium rates will increase for about 30 percent of beneficiaries. The new monthly Medicare Part B premium for 2017 will be $134, up from $121.80 in 2016; an increase of 10 percent. Most beneficiaries will be protected from the hold harmless provision which locks in their Part B rate. Those protected are beneficiaries are those already receiving Social Security, and dual eligible participants having their premiums paid by Medicaid. Seniors that are newly eligible for Medicare in 2017 and those that are not receiving Social Security and being billed directly for Medicare will have to pay the higher premium.

In addition to increased Part B premiums and Part B annual deductible, Medicare has also increased other out of pocket costs such as the Part A deductible and per day costs for skilled nursing and Part A coinsurance. People with Medicare Supplement plans typically have benefits to cover these costs. The agents at Texas Medical Plans can review your Medicare Supplement policy benefits to see if you are effected by some or all of these changes. A Licensed agent can help you make an informed decision about you supplement policy and review it regularly to help you stay ahead of Medicare changes for years to come.


How will a Trump Presidency affect Obamacare and health insurance?

Donald Trump has promised that he will repeal and replace the Affordable Care Act, Obamacare, as the Unites States President. This change is possible, but to get a true repeal and replace he needs 60 votes in the Senate. It may be more plausible that he will implement the series of measures he proposed during his campaign through smaller legislative changes.

Even if Trump moves to change the Affordable Care Act and repeal Obamacare this will not happen overnight. The Affordable Care Act was written into law two years and three months after President Barak Obama took office. It took another four years for the Affordable Care Act to be implemented into individual health insurance and group health insurance.

In January 2011 pieces of the Affordable Care Act were implemented into new health insurance plans. Amongst the first of the changes we saw were adding preventative / wellness benefits, the elimination of coverage caps, and the ability to leave children on a parents individual health insurance or group health insurance policy until they are twenty-six years of age.

Other pieces of the Affordable Care Act that were implemented in 2014 were that individual health insurance plans and group health insurance plans removed waiting periods, they covered pre-existing conditions, and the medical loss ratio (MLR). Pieces of the Affordable Care Act are still not implemented today. More than seven years after the law was written we are still in the implementation phase.

People want to know; will President Donald Trump get rid of Obamacare and will insurance go back to the way it was. The simple answer is there is no way to know. Even if he does make changes to Obamacare we may not see those changes until years later.

The GOP has a replacement plan to Obamacare detailed out in their A Better Way – Health Care Policy Paper, By The Numbers, and Fact Sheet.

What we at Texas Medical Plans have seen is that for most people looking at individual health insurance plans have fewer health insurance companies to choose from, monthly health insurance premiums have increased, and the health care provider networks continue to change. We have worked hard in 2016 to explore all the available options for your health insurance needs in 2017. There are other options available outside of Obamacare. If you are healthy it may be better to pay the health insurance tax penalty and get medical insurance that covers less than Obamacare. A Healthcare sharing ministry or accident plan may be a better fit for you in 2017. If you are a small business owner or our self-employed then you might be able to set up health insurance through your business as a group health insurance plan. It is now simple to set up a group with one or two people. Group health insurance plans can offer you a PPO again and access to a Nationwide network at possibly a better price than individual health insurance.

We welcome the opportunity to review all your options and will make recommendations to fit your budget. Call us at (512)847-3164. See more on our YouTube, Facebook, or Instagram pages.


Insurance and Health Plan Options Grid

  Cost Covers Pre Existing Covers Pregnancy Satisfies Insurance Mandate Can have Subsidized Premiums PPO HMO Details
Affordable Care Act Indivudal & Family $-$$$ check-markYes check-markYes check-markNo Penalty check-markMust Qualify x-markNo check-markYes ObamaCare
Qualified Health Plan (QHP)
Group Employer or Small Business $$$ check-markYes check-markYes check-markNo Penalty x-markNo, but may be deductible check-markYes check-markYes Qualified Health Plan (QHP)
Major Medical – Short Term $$ x-markNo x-markNo x-markPenalty x-markNo check-markYes x-markNo Covers Major Occurrences
NON-Qualified Health Plan
Limited Benefit $$ x-markNo x-markNo x-markPenalty x-markNo check-markYes x-markNo Covers Minor Occurrences
NON-Qualified Health Plan
Accident Only $ x-markNo x-markNo x-markPenalty x-markNo dollar-signCash dollar-signCash Covers Accidents Only
NON-Qualified Health Plan
Specified Disease
(Cancer/ Heart Attack/Stroke)
$ x-markNo x-markNo x-markPenalty x-markNo dollar-signCash dollar-signCash  Covers Specified Diseases Only
NON-Qualified Health Plan
Healthcare Sharing Ministry $$ x-markWaiting Period check-markRestrictions Apply check-markReligious Exemption x-markNo check-markYes x-markNo Must abide by religious principles
NON-Qualified Health Plan
Not Insurance, No Guarantees



ObamaCare is falling apart

The next ObamaCare Open Enrollment Period begins one week before the presidential election, and it ends about a week after our next president is inaugurated. November 1st is going to bring more bad news for Obamacare with even higher rate increases than we have seen in the past years. The next president is going to inherit this crisis.

Many insurers are already proposing substantial increases or others say they are going to leave the market all together. With all of the uncertainty you should know that there are alternatives to the ObamaCare marketplace exchanges for some. These options include short-term major medical plans, health care sharing ministries and small group employer plans.

Many analysts have said that the first five years of ObamaCare would be a struggle. They warned that the market could take years to balance out to a point that we would start really seeing reduced costs for health care and better outcomes for patients. They were right, as we enter the fourth year of open public and federal exchanges; things are still only getting worse.

As ObamaCare continues to fall apart, agents and brokers are working harder than ever to present clients with viable alternatives to the Affordable Care Act (ACA) plans that more and more people just cannot see as an affordable option anymore.


Health Insurance Changes for 2017

Health Insurance rate increases for 2017 are estimated to be the highest yet with Blue Cross Blue Shield reporting a potential 58% health insurance premium rate increase and Humana a 45% potential health insurance rate increase on their individual market plans. Since the Affordable Care Act (ACA) was signed into law in 2014 we have seen health insurance premiums quickly rise, health insurance plans become limited, and health care provider networks shrink. Some companies, like United Healthcare, have opted to leave the individual health insurance market all together in Texas; that includes plans on and off the health insurance Marketplace also known as the health care exchange or You can read more about the 2017 health insurance changes here

What does this mean for you? 

You need to shop plans every year. We tell our clients that they need to create a reoccurring event in their calendar to be talking to us about their health insurance options around the end of November/beginning of December every year. We also caution our clients about health insurance plans that seem too good to be true because more than likely they are. 


As the changes keep coming, so do the “alternative” health insurance options other agents offer called limited benefit plans. They are simply that – plans offering limited benefits. Sometimes we enroll clients in these plans because they are the best fit for them, but often times they are not the best option and leave people paying tax penalties at the end of the year for not having the required insurance (Qualified Health Plan). 

What are we doing? 

Right now, outside of the open enrollment period (November 1st through January 31st), we are moving as many clients as possible to a Humana Group/Employer sponsored health insurance plan. Humana is leading the group health insurance industry by removing the group health insurance employee participation requirements and the group health insurance employer contribution requirements for small groups that the other group health insurance carriers have in place. Humana has made it so easy to enroll as a group that you simply need a Tax ID and one employee in addition to the owner. Humana’s group health insurance premium rates are usually better than what we see on the individual health insurance market and Humana offers incentives to start saving an additional 10% by your second month of coverage. 


To gear up for the 2017 health insurance open enrollment period November 1st throughJanuary 31st we are contracting with every health insurance carrier in Texas in order to offer our clients the best possible health insurance coverage, staying current on health care changes, and maintaining transparency with our clients. Things in the health insurance industry are constantly changing and we continue to adapt. What makes us different from most insurance agents is that we are a collaborative team that works to solve obstacles before they even come up. We have daily strategy meetings to ensure that we are doing the best for our clients. Our clients have been trusting us since 1983. That trust is in our actions. Even though the health insurance premiums go up, the insurance carriers continue to bring our income down and sometimes don’t pay us at all . . .  We continue to survive the health insurance changes alongside our clients because of the hard work and integrity we put into doing business. We truly value our client relationships and our clients truly value our expertise. 


Are You Sure About Your Insurance?

The Washington Examiner (7/7) reports that a study published in Health Affairs revealed that “health insurance plans offered both on and off the Obamacare marketplaces fall far short in helping patients access doctors.” Researchers directed “secret shoppers” to call physicians “listed on directories provided by California Blue Cross Blue Shield” and found that the shoppers “were unable to set up appointments with nearly three in four of the providers.” The callers were not able to reach about 20 percent of 743 physicians listed. According to the Examiner, “in another 30 percent of the cases, the specialty listed in the provider directory didn’t match the specialty stated by the receptionist at the practice.” The findings support “complaints that insurance plans provided through the Affordable Care Act’s online marketplaces offer limited choices of doctors.

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