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The Employer’s Texas Health Insurance Buyer’s Guide

Group Benefits

Understanding Coverage Options When Offering Health Insurance

America’s health care system has changed dramatically in the past decade. The Affordable Care Act (ACA) turned the industry on its head, and with it created a slew of laws many health insurance recipients still aren’t aware of. And more changes will likely come soon, bringing new regulations employers should be aware of. Buying health insurance for your company’s group can be complicated. Not understanding coverage options can lead to costly surprise out-of-pocket expenses for your employees. It is therefore imperative that you understand the options and what to look for in a group health insurance plan. Unfortunately, keeping up to date with the complicated structure of the ACA and other changes in the laws isn’t something the average person or company has time to do. That’s where we can help. At PCI, we have over 20 years of industry experience, and are well versed in the changing healthcare laws. To give you a general overview of what to expect from your employer health insurance plan, we have put together a Health Insurance Buyer’s Guide for your convenience.

The Health Insurance Buyer’s Guide Covers Aspects Such as:

  • ACA insurance guidelines
  • In and Out of Network Medications
  • What type of plan are you looking at and why that matters
  • How to figure out if your employees’ current doctors are in network
  • What do office visits include under the new plan?
  • What kind of support does your carrier and Agent of Record offer?
Let’s dive right into these questions so you can get the answers and support you need to make an informed decision and answer your employees’ questions. Remember, the more you learn about your group’s insurance plan options, the better decisions you’ll make for your budget, your employees, and your company.

Does our new group health insurance plan need to meet ACA guidelines?

What is the penalty if it doesn’t? While the ACA individual mandate was repealed in 2017 and Texas does not require individuals to have health insurance, state law does require plans to cover specific benefits, which vary by plan. Federal law still requires individual and small group plans to cover essential benefits. Read more about group health insurance plans for small and large companies.

Requirements under law demand each plan to include:

These benefits are also known as the minimum essential benefits (MEC).
  • Ambulatory patient services (out-patient services)
  • Emergency services (emergency room trips)
  • Hospitalization (treatment for inpatient care)
  • Maternity and newborn care (prenatal care all the way through to post-delivery care)
  • Mental health services and addiction treatment
  • Prescription drugs (limitations apply)
  • Rehabilitative services and equipment
  • Laboratory service
  • Preventative care services, wellness, and chronic disease treatment
  • Pediatric services

What type of plan is being offered?

There are several types of plans available for insurance. These include:
  • Exclusive Provider Organization Plan (EPO)
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Reference Based Pricing (RBP)


As a member of an EPO plan, covered individuals have access to hospitals and doctors that are within the network, but they are prohibited from going out of network for care. This plan offers no out-of-network benefits with the exception of a true emergency. Referrals generally are not needed for care.


HMO’s give access to a limited number of hospitals and doctors. Its network consists of providers that are agreeing to lower their rates for certain patients with an HMO plan without sacrificing on the quality and benefits of the service. However, they are only covered in network. Referrals are required for care.


PPO plans are the most popular medical insurance plans available. They allow covered individuals to visit in-network physicians and healthcare providers without obtaining a referral from their primary care physician. This is one of the greatest benefits offered by PPOs over the other types of plans.


Also known as reference based pricing. This is typically only found in partially self-funded or fully self-funded plans. To cut healthcare costs, some companies switch to RBP plans, which sets caps on what the plan will pay for covered services based on a chosen reference or metric point. It can be a cost-effective option, if done right.

Are preferred doctors in network?

One very important question your employees should ask before signing up for a health insurance plan is if their doctors are in network. As we can see from the various insurance plans offered, in most plans a doctor must be in network for services to be covered. Any doctor out of the network can cost a high out-of-pocket fee. Don’t rely strictly on what is seen on the carrier’s website. Instead, contact the insurance provider for a direct answer.

How are office visits covered?

  • Does the insurance plan include comprehensive coverage? Some plans have expensive copays, and it is important employees signing up understand what those fees are and what they can expect if an office visit includes laboratory tests and more. A copay test is a great way to avoid balanced billing later.

What drugs are covered by the network?

One question that often arises with new plans for medical coverage is “are the prescription medications I’m taking covered by the network?” An insurance plan’s formulary will list the drugs covered by the plan, but it is important employees look at this list before they sign up for coverage. The formulary will provide a full list of the drugs that are covered, so be sure your employees give that a thorough look through. Additionally, they may want to investigate if their prescription medications require prior authorization. Some carriers provide easier authorization than others, which can save your employees time and hassle. Understanding the tier group medication falls under will also help your employees understand the co-pay costs (if applicable) they will have to pay as well. Clearly, the lower the co-pay the better the plan is.

Get to know your group’s health insurance carrier

It is important employees recognize what their carrier offers in way of extra services:
  • Will the carrier fight every claim or are they willing to pay out to patients quickly and easily? The process of understanding these carriers and their track record isn’t always easy.
  • Does the health insurance carrier offer a wellness program to not only benefit the health of those covered, which helps keep your workforce strong, but also decrease their premiums? Some carriers offer a 15% discount, gift cards or other incentives for participating in their wellness program.

How Primary Care Insurance Solutions Can Help

Specializing in medical insurance benefits for employees, Houston’s Primary Care Insurance Solutions takes the headache out of finding carriers and understanding complicated health insurance plans and laws. We can do all of this for you at no charge to you. Contact us today to learn more about our service.

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