Frequently Asked Questions | TexHealth Central Texas

Why do I need TexHealth Central Texas coverage?
Is this considered group vs. private/individual insurance?
Is this for an individual employee only? If so, when do you anticipate spouse/family will be allowed to participate?
Can a 1099 subcontractor participate in the program? If so, what are the minimum requirements?
What happens if I exceed my annual maximum benefits?
What is my effective date of coverage?
What is a deductible? And how much is the deductible?
What does co-insurance and co-pay mean?
Does the TexHealth plan cover Pre-existing Conditions?
What happens if an employee leaves the company or the 1099 subcontractor no longer works with the employer?
If I’m laid off or terminated when will my TexHealth coverage end too?
Who provides funding of the TexHealth share and for how long?
Who owns TexHealth? Is it owned by United Health Care (UHC)?
How is the monthly payment handled?
Will the cost go up each year? If so, how much?
Is this a Health Maintenance Organization where I have to get permission to go to a specialist?
Is there a chance I can be cancelled?
Can I add Catastrophic Major Medical coverage to my TexHealth Plan?

Q: Why do I need TexHealth Central Texas coverage?

A: To provide you, the small business employer, and your employees with a low cost health benefit plan that gives you peace of mind knowing that most of your medical bills will be covered in time of need. The TexHealth program is preventive in nature and is intended to keep you healthy. It provides a free annual physical allowing you to prevent any serious illness from becoming a chronic condition.

Q: Is this considered group vs. private/individual insurance?

A: This is a Group health benefits program. To participate at least 60% of eligible employees must join.

Q: Is this for an individual employee only? If so, when do you anticipate spouse/family will be allowed to participate?

A: TexHealth is an employee-only Plan. At some point in the future dependents may be allowed to participate.

Q: Can a 1099 subcontractor participate in the program? If so, what are the minimum requirements?

A: Yes, a 1099 subcontractor may be eligible to participate if they meet the eligibility criteria and the employer agrees to pay a portion of their monthly fee. If the subcontractor is a licensed business entity with 2 to 50 employees, it may qualify to have its own TexHealth Plan.

Q: What happens if I exceed my annual maximum benefits?

A: TexHealth will work with you to find alternative coverage and/or doctors and hospitals that will continue to treat you based on certain requirements.

Q: What is my effective date of coverage?

A: Upon acceptance of your completed application, you will receive a letter and Identification Card from United Healthcare. The effective dates of coverage are included. If you do not receive your card by the effective date, please go online to www.myuhc.com and print a temporary ID card.

Q: What is a deductible? And how much is the deductible?

A: Your “deductible” is the amount you must pay toward a medical bill before TexHealth pays. Your TexHealth calendar year deductible is $250. Click on Glossary for a list of common health insurance terms.

Q: What does co-insurance and co-pay mean?

A: Co-insurance is a percentage of covered medical expenses that you must pay as a portion of your medical bill after the deductible has been met. After the deductible, TexHealth will pay 80 percent of a medical bill, and you pay 20 percent. Co-pay is a specific out of pocket dollar amount you pay when you go to a service provider. This payment is made at the time of service (for example a doctor office visit). Click on Glossary for a list of common health insurance terms.

Q: Does the TexHealth plan cover Pre-existing Conditions?

A: Yes. A pre-existing condition illness or symptom, diagnosed, treated or recommended for treatment within the 6 months prior to becoming eligible for TexHealth is covered after a 12 month waiting period unless it is Asthma, Diabetes or Hypertension. If you have asthma, diabetes or hypertension the 12-month waiting period is waived if you actively participate in the care management program. Please click on Pre-existing Conditions Policy for more information.

Q: What happens if an employee leaves the company or the 1099 subcontractor no longer works with the employer?

A. The employee or subcontractor may extend coverage for 3 additional months. The employer group is not affected by the loss of members as far as the 60% participation rule is concerned. The group agreement is for 12 months and at the end of the 12 months, the group must again meet all requirements, including the 60% participation rule to renew the Plan.

Q: If I’m laid off or terminated when will my TexHealth coverage end too?

A: TexHealth coverage will continue for up to 3 months after a lay off or termination, but you will have to pay both your share and the employer’s monthly share.

Q Who provides funding of the TexHealth share and for how long?

A. The TexHealth share is provided by State of Texas Department of Insurance grants and federal grants. The grants are renewable each year and are awarded for 2 to 5 years. At the end of any funding period TexHealth will find grants to continue funding the TexHealth share of the premium.

Q. Who owns TexHealth? Is it owned by United Health Care (UHC)?

A. TexHealth is owned by the Central Texas community. It is governed by a Board of Directors recruited from the community. TexHealth is a non-profit, 501(c)3 organization exempt from federal income and state taxes. This means any donation made to TexHealth can be reported to the IRS as a charitable contribution. It is not owned by UHC.

Q. How is the monthly payment handled?

A. The employer completes an electronic funds transfer (EFT) form, also known as an ACH. On the first of each month, while the TexHealth Plan is active, an automatic transfer of funds to pay the employer share and employee shares will be completed. The shares will transfer from the business checking account to the TexHealth account. For the employee, there will be payroll deductions made during the month to pay for each employee’s share on the first of the following month.

Q. Will the cost go up each year? If so, how much?

A. The cost is anticipated to rise each year but not by double-digit percentages. Doing your part to help keep rates low is important. You can do your part by taking advantage of the benefits and programs available to help manage your health. Go for your free annual physical, visit myuhc.com often to learn about healthy diets, exercise programs and other benefits to help you live a healthy lifestyle.

Q. Is this a Health Maintenance Organization where I have to get permission to go to a specialist?

A.TexHealth is a PPO (Preferred Provider Organization). In TexHealth you may go to any physician or hospital as long as they are in the United Health Care Choice Plus network. You can search for a physician by clicking on “Physician Search” on the home page. You may also do a physician search on www.myuhc.com. In the Choice Plus provider network you have access to UHC providers across the USA.

Q. Is there a chance I can be cancelled?

A. An employer group enters into a one-year contract with TexHealth. Even if the number of enrolled members drops below 60%, TexHealth will not cancel the contract. However, on the anniversary date all eligibility criteria must be met to continue the Plan.

An employee membership may be cancelled under specific circumstances.

If a member cannot maintain a satisfactory physician-patient relationship.
Aggressive behavior toward TexHealth or United Healthcare employees or providers
Failure to actively participate in a care management program prescribed by TexHealth or your physician

Q. Can I add Catastrophic Major Medical coverage to my TexHealth Plan?

A. Yes. You can add a catastrophic major medical plan to supplement your TexHealth coverage. You may also add Dental and Vision and other products that you may be interested in. Ask the TexHealth certified representative how to add these and other products to complement your TexHealth coverage.