Texas Health Insurance: Find Affordable Plans

You may struggle to pay for health care in Texas, as the state ranks dead last for affordability and access to health care in The Commonwealth Fund’s 2020 Scorecard on State Health System Performance. When affordability is a significant concern, a good health insurance plan can help.

Read on to learn about your options for Affordable Care Act plans, Medicaid, Medicare, CHIP, and other pathways to insurance for Texans. This guide explains how you can get health care coverage, the cost of coverage, and how to find the best plan for you or your family’s health care needs.

• ACA enrollment: Texas has one of the highest ACA enrollment rates in the entire country. As of 2021, 1,291,972 Texans have marketplace plans.
• Open Enrollment: The standard Open Enrollment period for the Texas ACA marketplace is November 1, 2021 to January 15, 2022. If you miss this timeframe, the only way you can enroll for a health care plan in the marketplace is if you have a life qualifying event. Qualifying events include getting married, having a baby, losing or changing your job, or moving.
• Special enrollment: You may qualify for a special enrollment period if you have experienced a qualified life event (QLE) that caused you to lose coverage, if you need to make changes to your current plan (due to a life change such as getting married, having a child, or getting divorced), or if you have had a change in eligibility for Medicare or Medicaid. You have 60 days from the time of the event to sign up for a new plan or make changes to your current plan.
• Marketplace plans: You can buy a health insurance plan through the Health Insurance Marketplace, through a broker, insurance agent, or directly from insurance companies. If you enroll through the marketplace, you can apply for a premium tax credit if your income is between 100% to 400% of the Federal Poverty Level. You may also be eligible for cost-sharing reductions (CSRs) if you select a silver marketplace plan.
• Coverage types: Most Texans get health coverage through an employer (47.6%) while the following two highest groups are Medicaid (15.9%) and Medicare (10.9%). Individual or short-term insurance plans account for 5.7% while military insurance accounts for 1.6%. Texas has the highest uninsured rate in the United States at 18.4%.

If you want to enroll in an ACA plan in Texas, you’ll need to visit Healthcare.gov. First, you must create an account for yourself and any family members. You’ll provide personal information, including your address, phone number, Social Security number, marital status, household income, and the number of people in your household. Once you’ve completed this step, Healthcare.gov will determine your eligibility for Medicare or a premium tax credit. You’ll then choose from available health plans and can compare as many as three at a time. There are currently 10 companies that offer health insurance coverage on the ACA marketplace in Texas:

• Blue Cross Blue Shield of Texas
• Celtic/Ambetter (Ambetter from Superior Health Plan)
• CHRISTUS
• Community Health Choice
• Friday Health Plan
• Molina
• Oscar
• Scott & White Health Plan
• Sendero
• SHA/FirstCare

Whether you’re selecting a plan on Healthcare.gov or buying a plan for yourself or multiple people, you should consider the following:

• Medical needs
• Preferred plan type
• Premium affordability
• Individual vs. family deductibles

Insurance for individuals in Texas

When selecting a plan, you can choose from several different options for the network of doctors you have access to and how you receive the health care.

• A health maintenance organization plan (HMO) is less expensive than other types of plans but has stricter rules about accessing health care. You can only use that plan’s in-network health providers, you’ll need to obtain referrals when you want to see a specialist, and you’ll be preassigned a primary care provider.
• A preferred provider organization (PPO) plan offers more flexibility, but you’ll pay a bit more for nationwide access to doctors and hospitals. A PPO has a higher monthly premium but allows you to use both in-network and out-of-network health care providers – in-network providers will have a far lower cost. If you have a chronic health condition, this is a good plan to investigate. Other benefits include no referrals to see a specialist, and you can choose any primary care provider.
• A point of service (POS) plan takes a little bit from an HMO and a little bit from a PPO. You can use an out-of-network provider, which is helpful if you have a chronic condition and have a preferred provider. You’ll still need to get a referral to see any specialist.

Insurance for families in Texas

When selecting health care for your family, the questions become more complex. You may be healthy, but if your spouse or one of your children has a chronic health problem, it’s a bit trickier to balance how much you can pay for your health insurance and how much coverage you’ll receive. If your family is healthy and you don’t make many trips to the doctor, consider a lower-cost premium with a deductible and max out-of-pocket you can afford in the event of a catastrophic medical issue. If a family member does have a chronic health issue, a plan with a higher monthly premium and a lower deductible might be a better option. Keep in mind that it’s possible to have separate policies for family members depending on their level of need for coverage.

The Texas health insurance marketplace offers plans that work on the metal tier system: Bronze, Silver, Gold, and Platinum. Every tier provides ACA-compliant coverage but differs in the percentage of coinsurance and deductibles, which dictate your out-of-pocket costs. Some have higher premiums; some have higher deductibles. Consider a balance of an affordable monthly premium offset against your out-of-pocket expenses when you visit the doctor or have a catastrophic event.

• Bronze plans are for people with few health concerns or limited financial resources. The plans offer low monthly premiums but a high deductible. There’s also a 40% coinsurance payment for a doctor’s visit or other medical services. The most affordable Bronze plan in 2022 in Texas costs $306 a month.
• You’ll pay a higher monthly premium for a Silver plan, but you’ll also have fewer out-of-pocket costs. The coinsurance fees drop to 30%. Silver plans offer cost-sharing reductions (CSRs). If you qualify for a CSR, you may pay less for a Silver plan than you would for a Bronze plan. The most affordable Silver plan in Texas costs $415 a month.
• gold or platinum plan. These plans offer the lowest deductibles and coinsurance payments (only 20% for gold and 10% for platinum). However, be prepared to pay heftier monthly premiums. The most affordable gold plan in Texas goes four $429 a month.

Texas offers Medicaid and CHIP for individuals and families with low income.

Medicaid in Texas

Texas Medicaid eligibility has financial and demographic requirements. Find out if you may qualify for Medicaid in Texas. To be eligible for Texas Medicaid:

• You must live in Texas
• You must be a U.S. citizen
• You must be a permanent resident or a legal alien in need of health care whose financial situation can be described as low income

You must belong to at least one of the following categories:

• Pregnant woman
• Responsible for a child or children aged 18 years or younger
• Blind
• Disabled or have a family member who is disabled
• Aged 65 or older

Income limits are $25,503 for an individual, $34,492 for a couple, and $43,481 for a family of three.

Children’s Medicaid and CHIP

Even if you don’t qualify for Medicaid, your children may receive coverage through CHIP. Services covered include regular checkups, dental service, immunizations, hospitalizations, X-rays and lab tests, vision and hearing, mental health care, access to specialists, and treatment of pre-existing conditions.

Income limits are $2,158 per month for an individual, $2,918 per month for a couple, and $3,679 per month for a family of three.

If you’re at least 65 or have a qualifying disability, you may be eligible to receive Medicare, the federal government’s health care program for seniors and the disabled.

• The basic program in Medicare is Original Medicare. It’s composed of two parts: Part A, which includes home care, skilled nursing care, hospice, and hospitalization, and Part B, which includes doctor’s visits, mental health care, durable health equipment, ambulance services. There are no out-of-pocket limits, and prescription drug coverage requires signing up for a Part D plan.
• Medicare Advantage Plans are private plans approved by Medicare that offer the same coverage as Original Medicare but with additional services. Medicare Advantage Plans offer vision, dental, and hearing, and many provide prescription drug coverage. These plans come in four basic types: HMOs, PPOs, Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs). As of 2022, there were 337 Medicare Advantage Plans in Texas. You can only select a Medicare Advantage Plan that’s available in your county in Texas.

A Medicare Supplement Insurance plan (Medigap) is a great way to deal with the extra costs associated with Original Medicare. It covers deductibles, copayments, and coinsurance. It can also provide coverage if you’re traveling outside the U.S. It doesn’t cover vision, hearing, or dental, nor does it cover any long-term care costs. Medigap doesn’t work with a Medicare Advantage Plan.

Eligibility

To qualify for Medicare, you must be at least 65 years old or have a qualifying disability. In most cases, a qualifying disability is a condition that makes you eligible for at least 24 months of payments from the Social Security Disability Insurance program or Railroad Retirement Board. You may be able to qualify sooner if you have end-stage renal disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Enrollment

If you start receiving your Social Security or Railroad Retirement Board benefits at least four months before you turn 65, you’ll be automatically enrolled in Medicare. Otherwise, you must fill out an application online or contact your local Social Security office. You can enroll in Medicare during the following periods:

• Initial enrollment: Your initial enrollment period starts three months before your 65th birthday and ends three months after your 65th birthday. If you’ve never had Medicare, you can enroll during this period. If you started receiving Medicare when you were younger, you can also make changes to your plan.
• General enrollment: Choose this enrollment period if you missed your initial enrollment period. The Medicare general enrollment period is January 1 to March 31. You can choose Original Medicare, Medicare Advantage, Medigap, or Part D.
• Medicare Advantage open enrollment: You can make changes to your Medicare Part C, also known as Medicare Advantage, from January 1 to March 31.
• Open enrollment: You can join, switch plans, or drop your coverage from October 15 to December 7 each year.
• Special enrollment periods: You may qualify for a special enrollment period if you lose your coverage or have changes to your eligibility outside the regular enrollment periods.

Medicare Resources

If you need help with Medicare, there are resources in Texas that can provide guidance.

The Texas Health Information, Counseling, and Advocacy Program provides resources for Medicare beneficiaries, their families, or their caregivers. You get free, unbiased, and confidential counseling about a wide range of Medicare issues and other health care options available.

Yes, you can purchase short-term health insurance in Texas. Plans can last for up to 364 days and can be renewed three times. Short-term health insurance is designed for people under 65 and in good health who are between jobs or waiting for the marketplace Open Enrollment Period. These plans are limited, don’t provide coverage for pre-existing conditions, and don’t cover pregnancy, mental health concerns, or prescription drugs. The plans are primarily designed to cover emergency health situations during a coverage gap and usually cap how much the insurance company will cover.

• Benefits.gov | Medicaid in Texas | Last accessed December 2021
• CMS.gov | 2021 Federal Health Insurance Exchange Weekly Enrollment Snapshot: Final Snapshot | Last accessed December 2021
• Healthcare.gov | Cost-Sharing Reduction | Last accessed December 2021
• HealthCare.gov | Dates and deadlines for 2021 health insurance | Last accessed December 2021
• HealthCare.gov | Deductible | Last accessed December 2021
• HealthCare.gov | Health Maintenance Organization (HMO) | Last accessed December 2021
• HealthCare.gov | Point of Service (POS) Plans | Last accessed December 2021
• HealthCare.gov | Preferred Provider Organization (PPO) | Last accessed December 2021
• Healthcare.gov | Premium Tax Credit | Last accessed December 2021
• HealthCare.gov | The ‘metal’ categories: Bronze, Silver, Gold & Platinum | Last accessed December 2021
• KFF | Health Insurance Coverage of the Total Population | Last accessed December 2021
• KFF |the Coverage Gap: on Insured Adults in States That Do Not Expand Medicaid | Last accessed December 2021
• Medicare.gov | Part A & Part B sign up periods | Last accessed December 2021
• National Academy for State Health Policy | Texas CHIP Fact Sheet | Last accessed December 2021
• Texas Health and Human Services | Texas: Medicaid and CHIP | Last accessed December 2021