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Healthcare Advisor

Dr. Noor Ali is a licensed medical doctor and surgeon with an established national health insurance consulting practice serving clients in 34+ states.

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.

What to know about insurance in Texas

  • 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 October 1 to November 15. 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.
  • Open Enrollment extension: The federal government extended the 2021 Open Enrollment Period to August 15 due to the COVID-19 pandemic. You can enroll in a marketplace plan until this date without a qualifying life event.
  • 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 (46.7%), 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 America at 18.4%.

How do I enroll in Texas’s health insurance marketplace?

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

How do I enroll in Texas’s individual and families insurance?

Whether you’re selecting a plan on Healthcare.gov or buying a plan from a broker or insurance agent, you’ll need to ask yourself some essential questions. First, you need to determine your level of health.

  • If you are generally in good health, consider a plan with a balance of an affordable premium and a deductible that you can meet in the low chance of a worst-case catastrophic event.
  • If you have a chronic health condition, consider a plan with a lower deductible that you will likely meet earlier in the year so the plan can cover more of your medical expenses.

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 will be pre-assigned 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 Plan (POS) 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. However, 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. However, 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 is possible to have separate policies for family members depending on their level of need for coverage.

How much does health insurance cost in Texas?

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.

Average premiums in Texas 2018 2019 2020 2021
Most affordable bronze plan $309 $313 $295 $301
Most affordable silver plan $419 $422 $418 $420
Most affordable gold plan $461 $496 $471 $429

  • 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 2021 in Texas costs $301 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 $420 a month.
  • If you have a chronic health issue and make numerous visits to the doctor or need regular prescriptions, your best bet is a 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.

What kind of low-income health insurance is available in Texas?

Texas offers Medicaid and the Children’s Health Insurance Program (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 US citizen, or
  • 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
  • 65 or older

Income limits are $25,503 for an individual, $34,492 for a couple, and $43,481 for a family of three. Resource limits are $4,000 for an individual and $6,000 for a couple.

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.

What are Texas’s Medicare options for seniors and people with disabilities?

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 (home care, skilled nursing care, hospice, and hospitalization) and Part B (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 Plans, and Special Needs Plans. As of 2019, there were 137 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 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 United States. However, it doesn’t cover vision, hearing, or dental, nor does it cover any long-term care costs. A Medicare Supplement Insurance Plan doesn’t work with a Medicare Advantage Plan.

Eligibility and Enrollment
Eligibility
  • You must be a U.S. citizen or a permanent resident for the past five years
  • You must be at least 65 or have a qualifying disability such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
Enrollment
  • Your Initial Enrollment starts three months before your 65th birthday, the month you turn 65, and the three months following your birthday.
  • Open Enrollment takes place between October 15 and December 7. During Open Enrollment, you can move from Original Medicare to a Medicare Advantage Plan, return to Original Medicare from a Medicare Advantage Plan or switch between Medicare Advantage Plans.
  • If you move to a different county in Texas and have a Medicaid Advantage Plan, you’ll use a Special Enrollment Period to select a new plan.

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.

Are there short-term health insurance plans available in Texas?

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, do not 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. Nine companies in Texas provide short-term health care:

  • AdvantHealth
  • Aspen
  • Companion Life
  • Everest Reinsurance
  • Independence American Insurance Company
  • National General
  • Standard Security Life Insurance Company
  • United Healthcare (Golden Rule)

Texas Insurance FAQs

Does Texas require health insurance?

Federal law requires all U.S. citizens to carry health insurance, but there is no longer a tax penalty for not having insurance.

Do I have to use the Health Insurance Marketplace in Texas?

No. You can buy a plan off-exchange from several providers in Texas or purchase short-term insurance. You will need to use the marketplace if you want a premium tax credit or want to apply for Medicare.

What types of alternative health insurance plans (like cost-sharing plans) are available in Texas?

The most popular form of cost-sharing plan is a faith-based program. These plans share costs between members and are relatively inexpensive. You typically don’t need to be a member of a particular denomination to sign up for a plan. However, many of these plans do not cover pre-existing conditions or other essential health benefits guaranteed under ACA plans. Before you sign up for a cost-share program, make sure it provides coverage in the areas you need. Most cost-sharing plans are not legally obligated to pay out claims as the programs are not health insurance.

Do I need health insurance if I have HSA/FSA?

In most cases, yes. It’s almost impossible to save enough money under an HSA or FSA plan to pay for a significant medical expense or unexpected catastrophic events. HSA and FSA plans can help pay for out-of-pocket costs like deductibles, copays, and coinsurance.

Do I need short-term disability coverage in Texas if I have health insurance?

Yes, depending upon the nature of your job. Short-term disability coverage covers regular household expenses like your mortgage, utilities, or groceries when you’re injured. Health insurance will not cover these costs. If there is a risk of injury with your job, you should consider a short-term disability plan.

Do I need long-term disability coverage in Texas if I have health insurance?

Yes. Long-term disability covers the same costs as short-term disability. Health insurance will not pay for these costs. If you work in a potentially dangerous job where an injury is possible, like construction or roofing, a long-term disability plan is a good idea.

What does CHIP in Texas cover?

CHIP provides health care to children from families in Texas with low or no income. 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.

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