Frequently Asked Questions

As of October 21, 2026, non-grandfathered individual and fully insured small-group policies generally must cover the ten essential-health-benefit categories, subject to applicable transitional relief. Large-group and self-funded plans do not have the same blanket requirement to cover all ten categories, although other ACA protections can apply. Confirm the market, funding arrangement and plan status before judging compliance. Source: Texas Department of Insurance, Small employer health insurance guide: https://www.tdi.texas.gov/pubs/consumer/cb040.html

As of October 21, 2026, an Applicable Large Employer may owe an employer shared-responsibility payment if it fails to offer the required coverage, or if an offer is unaffordable or does not provide minimum value, and a full-time employee receives a Marketplace premium tax credit. Different payment rules apply to the different failures. Liability depends on the coverage month, workforce and applicable year; confirm the calculation with legal or tax counsel. Source: IRS, Employer shared responsibility provisions: https://www.irs.gov/affordable-care-act/employers/employer-shared-responsibility-provisions

Verify each important doctor, facility and location against the exact plan network, not just the carrier name. Confirm with both the carrier and provider that they participate for the proposed effective date and are accepting patients. Keep the confirmation and recheck before enrollment.

Review the Summary of Benefits and Coverage for primary care, specialist and telehealth visits. Determine whether the deductible applies before copays or coinsurance and whether labs or procedures are billed separately. Compare in-network and out-of-network rules rather than relying on the office-visit copay alone.

Check the exact plan’s formulary for each medication, dosage and formulation. Review drug tiers, deductibles, copays or coinsurance, prior authorization, step therapy and quantity limits. Separately verify the pharmacy network and specialty-pharmacy requirements with the carrier before enrollment.

Compare the exact provider network, formulary, claims and appeal procedures, customer support and renewal terms. Review employer and employee costs together, including premiums, deductibles and out-of-pocket limits. Service extras such as wellness programs should not outweigh access to needed care and medications.