As an adult, you generally get to make your own healthcare decisions—that includes decisions about your actual healthcare as well as decisions about what type of health insurance you obtain, what providers you see, and what services you get.

Health Insurance

First things first—you can stay on your parents’ health insurance until you turn 26, so keep that in mind when determining whether you want to or need to obtain your own health insurance.

When it comes to health insurance, you should aim to understand your options and what your plan covers. That is easier said than done! You can obtain insurance from a variety of sources—your employer, your school, the government, or directly through an insurance broker. You might be eligible for Medicaid if you earn $1,616 or less per month, or if you are a veteran, you may want to proceed with TRICARE health insurance. You may also qualify for COBRA healthcare continuation coverage after you leave employment, so you should explore all your options. Insurance plans are generally one of three types:

• Health Maintenance Organization (HMO) plans – These plans typically require you to use doctors within the plan’s “network,” so you should first confirm that your desired doctor is within network rather than out of network. With an HMO, your primary care doctor will provide most of your care, but if you need to see a specialist, you’ll typically need a referral.
• Preferred Provider Organization (PPO) plans – These plans usually let you see doctors outside the plan’s network, but charge more for out-of-network care. You aren’t required to have a primary care doctor and generally don’t need a referral to use out-of-network doctors.
• Point of Service (POS) plans – These plans usually charge less when you use doctors within the plan’s network (similar to a PPO), but you typically need a referral from your primary care provider if you want to see a specialist (similar to an HMO).

Pro tip: Open enrollment for health insurance occurs once a year, typically between November 1 and December 15, but you may be able to enroll at other times if you have a life event like starting a new job or new school or getting married or divorced.

When deciding on a plan, you should also review the terms of the policy so you understand what will be covered and what you will be on the hook for, including:

• Premium – This is the amount you pay for health insurance every month. Your premium will vary based on who the insurance covers (maybe a spouse or children?) and the amount of coverage you get. You pay this every month even if you don’t see any doctors.
• Deductible – This is the amount you pay for healthcare costs before your insurance starts to pay. As a simple example, if you have a $2,000 deductible and your only healthcare cost is a $5,000 surgery, you would pay $2,000 and then your insurance would start paying.
• Coverage and coinsurance – Plans often range from covering about 60% of costs to about 90% of costs. Your coinsurance is the amount you continue to pay (meaning the part insurance doesn’t cover). Continuing the simple example above, let’s say you have an in-network doctor visit after your surgery (so you already paid the full deductible). If the visit would normally cost $100 and your plan covers 70% of costs in-network, you would pay $30 coinsurance and your plan would cover $70.
  • Coverage and coinsurance under PPO and POS plans is often better when using in-network doctors and services, and this could mean a difference of hundreds or thousands of dollars!
• Copay – This is a fixed amount you pay for a particular service. For example, a visit to your doctor may cost $20 every time you go. Copays do not count toward your deductible.
• Maximum – This is the maximum amount your insurance company will pay toward your healthcare.

DID YOU KNOW? Under the Affordable Care Act, no insurer can deny you coverage solely because of a pre-existing health problem. However, if you smoke, you might have to pay a higher monthly premium.

How do you get healthcare if you need it? 

Receiving healthcare and getting access to physicians can sometimes seem like a daunting, perhaps impossible task.

First things first, it’s important to have a primary care physician (PCP). There are many resources online to find a PCP who is taking new patients. A lot of these resources, as well as your health insurance provider’s website, will be able to tell you whether a provider is in-network or out-of-network. If you have an HMO, your PCP must give you a referral to a specialist, but if you have a PPO or POS plan, you can generally use those same resources to find specialists.

To prepare for an appointment with a doctor, you should gather your medical history because doctors will ask you about your height and weight, prescriptions you take, your family history of certain conditions, medical conditions you have had, and everything in between! Make sure to bring your photo identification and health insurance card with you to your appointment. And, most importantly, be prepared to speak up and advocate for yourself. No one knows how you’re feeling better than you!

Help! I don’t have health insurance but I have a health emergency!

If you are in dire need of medical attention, you can go to any hospital and that hospital will treat you, but the treatment is not free. You will be charged, and the hospital may also file a “hospital lien” against your personal assets (but not your home!) under the Texas Property Code. Regardless of how much it costs, if you need to go to the hospital, go. Many hospitals offer payment plans and are willing to write off significant portions of medical bills if you explain your financial situation to the billing office.

Setting expectations

It may take several weeks or potentially months before you see a bill from the hospital or a service provider. Do not be alarmed, but also do not be fooled into thinking there is no charge. It’s coming…

What are my legal rights as a patient?

• You have the right to control your treatment, refuse treatment, make informed consent, and create advanced directives.
• You have privacy rights under the Health Insurance Portability and Accountability Act (HIPAA) and the Texas Medical Records Privacy Act, which prevent your confidential medical information from being shared with unauthorized people and give you the right to obtain a copy of your health information.
• You have a right, with respect to certain healthcare facilities, to obtain an itemized bill that breaks out the cost into descriptions of different products and services and what you owe for that specific product or service.
• You have the right to be free from discrimination while receiving healthcare.

If you’re interested in learning more, please visit the resources below:

• Texas Young Lawyers Association, Healthcare Patients’ Legal Rights and Responsibilities (LINK TO COME ONCE POSTED)