How Healthy Texas Works

From the enrollees perspective, the Healthy Texas plan will operate like any private market plan. Healthy Texas is designed to reimburse carriers for 80 percent of the costs if an individual’s total claims fall between $5,000 and $75,000 in a calendar year. UnitedHealthcare will cover the rest. This allows the state to leverage public and private funds.

Per Person
Annual Claims Costs

$75,000+ UnitedHealthcare pays 100%
$5,000-$75,000 Healthy Texas pays 80% / UnitedHealthcare pays 20%
$0-$5,000 UnitedHealthcare pays 100% (after co-payment and deductible requirements are met)

Enrollees receive the same type of benefits they’d receive from any private market plan, including:

  • Choice of $500 or $1,500 Deductible
  • No Out-of-Network benefits, except for emergencies
  • $750,000 annual benefit maximum – subject to change in subsequent years to comply with federal health care reform
  • Out-of-Pocket Maximum (includes deductible) $2,000 or $3,000
  • $25 copayment for PCP and Specialist office visits
  • No copayment for preventive service visits
  • Lab/X-ray covered at deductible/coinsurance
  • 20% coinsurance for hospitalization, surgery
  • $125 Emergency Room copayment
  • Rx included – $10/$25/$50, 2x mail order ($200 or $500 deductible)