Health insurance is a contract in which a health insurance company agrees to pay for some or all of an insured’s medical expenses in exchange for a premium. Insurance policies follow the principle of cost-sharing. That is, you pay some of the cost of your healthcare, while the rest of the expenses are covered by the insurance company. You normally must meet a deductible and make copayments and coinsurance in addition to the monthly premiums.
Over 18% of Texas residents (≈ 5 million people) under the age of 65 are uninsured.
There are two types of health insurance in Texas: private and public insurance. Private insurance includes plans obtained as an individual or group directly from an insurer or the marketplace. Public insurance is provided through government programs like Medicare, Medicaid, and Children’s Health Insurance Program (CHIP).
The two most notable types of private health insurance in Texas are:
Health insurance policies protect the insured from unexpected and frequently costly medical bills that arise from emergencies. Hospital and medical expenses, loss of income from disability, and long-term care expenses are the three main types of losses and benefits covered by most insurance policies. Some of the plans may also provide preventive services. Preventive services usually include screening tests and medical checkups.
A health insurance policy may be limited or comprehensive. A limited health insurance policy only covers particular accidents or diseases, while a comprehensive policy covers all accidents or illnesses that are not specifically excluded.
The average unsubsidized cost of ACA health insurance in Texas in 2023 was $440-$450. The average cost of short-term health insurance in Texas is around $100-$200 per month, per person, but the coverage can be possibly obtained for as low as $50.
Here are the most common insurance companies offering health insurance coverage in Texas:
|Most Commonly Purchased Health Insurance Providers in Texas|
|(in alphabetical order)||Also Offers Short Term Health Insurance|
|AmBetter (Superior Healthplan Network)||NO|
|Blue Cross BlueShield of Texas||NO|
|UnitedHealthcare (Golden Rule)||YES|
Here are the most common insurance companies offering dental insurance in Texas:
|Common Dental Insurance Providers in Texas|
|Blue Cross BlueShield of Texas|
|Dental Health Services|
Here are the most common insurance companies offering dental insurance in Texas:
|Common Dental Insurance Providers in Texas|
|Blue Cross BlueShield of Texas|
|Dental Health Services|
Speak with a licensed agent to choose the insurer based on your needs.
The Texas Department of Insurance (TDI) regulates health insurance and its price in Texas. It regulates health insurance according to the Texas Insurance Code and all federal laws and regulations relating to health insurance. The main federal laws that guide health insurance in Texas include:
Under Texas state law, state residents are not required to get health insurance, and currently approximately one out of five Texas residents have no reliable health insurance coverage.
The primary purpose of health insurance in Texas is to provide a person and their family with healthcare when they fall sick or get injured. ACA-compliant insurance also covers preventive health services, which involve screenings and counseling sessions on medical issues like blood pressure, cancer, cholesterol, depression, etc. Insurance companies provide health coverage for individuals and groups. Group health insurance is usually obtained through employment or membership of an association, union, or church.
Health insurance premiums in Texas are paid by the insured person and/or the sponsoring organization every month. The cost of premiums is determined primarily based on:
Whether gender and health factors, including medical history or disability, are considered - depends on the type of Texas health insurance plan. If the plan falls under the Affordable Care Act (ACA), aka Obamacare in Texas, these factors are not considered. However, such factors are considered in non-ACA plans (such as Texas Short Term health insurance), and may constitute grounds for denial of health insurance coverage. To sum up: ACA-compliant insurers do not discriminate and treat everyone equally, while non-ACA compliant Texas insurers may deny coverage based on the conditions chosen by the insurer.
In health insurance for individuals in Texas, monthly premiums are fixed for one year. The cost usually increases upon the next year's renewal, as a result of the insured's age and (usually) higher health care costs. By federal law, insurance companies have to justify increasing the policy rate by more than 10%.
For Texas group health insurance plans, the insurance company determines the premiums based on the whole group as a single entity. An employer may decide to pay all or part of the employees' premiums. However, if an employee seeks to include their family members in the health plan, the employer is not required to contribute to those premiums.
All health insurance policies in Texas usually require the insured to cover part of the health coverage costs through cost-sharing. The insured must normally satisfy a deductible, pay copayments, and coinsurance in addition to premiums. No copayments or coinsurance need be made for the remainder of the plan year once the limit has been reached. Premiums, on the other hand, must be paid monthly, regardless of the use of the policy. If the premium is not paid within the health insurance grace period (31 days past the due date), your health insurance coverage will be canceled.
Health insurance coverages differ based on the selected plan. The coverage standards for plans obtained through work and those obtained directly from an insurance company or through an online quote may vary. Even among workplace plans, the rules differ depending on whether you work for a small or large company.
All ACA-compliant individual market and small-employer plans are required by federal law to include ten types of healthcare services known as Essential Health Benefits (EHBs). Texas also mandates that some plans include specific health benefits.
Health insurance in Texas can be obtained through any of the following means:
To get individual health plan or family health insurance coverage in Texas - speak with a state-licensed health insurance agent who has access to multiple insurers offering coverage in your county.
Individual health insurance is the type that an individual purchases for themself, not as part of a group or association - using plans available on the individual market. When you purchase an individual health insurance in Texas, you sign a contract between you and the insurer, in which you agree to pay a set monthly premium fee for the coverage up to the limits pre-set by the plan.
Premium is a fee you pay to your insurance company periodically - usually monthly - to keep the coverage active. When you start using insurance, you also have to make out-of-pocket payments in the form of deductibles, copays, or coinsurance. A deductible is the total amount you pay until your health insurance provider begins to cover healthcare costs according to the terms of the plan. The moment you meet your deductible, your insurer begins to cover an agreed percentage or amount of your healthcare expenses. The other percentage or amount will be covered by you in the form of copays or coinsurance, respectively. Your coinsurance and copay are usually listed on your insurance ID card.
The insured’s total expenses on health care are calculated by adding the total cost of the monthly premium payments for a year plus the Maximum out of Pocket (MOOP) annual amount of the plan - which the insured must pay out of pocket if they were actively using the plan. MOOP includes the deductible and copayment.
If you get sick and end up in a hospital for multiple days, the costs for the stay and the treatment will add up fast. In 2020 a typical average day in a hospital in Texas was estimated at nearly $3,000, and the costs continue to grow. Until you meet the MOOP of the plan you are expected to participate in the cost sharing.
Health insurance providers usually have agreements and work with health professionals and institutions. These people are considered "in-network" professionals and institutions. Whenever you receive services or supplies from them, you get them at a discounted cost, which was pre-negotiated as part of your insurance. This agreement helps you save on medical expenses by the virtue of simply having an active insurance policy, without filing a claim. Your insurer maintains a list of such in-network providers. If you use an out-of-network provider, you do not get a pre-negotiated discount.
The world of insurance changes, so every year you should speak to your Texas health insurance agent, to check if there are better and more affordable health insurance products on the market that fit your needs and budget better. A proactive agent does this assessment for their current clients at least once a year.
Individual health insurance may be purchased from the Texas health marketplace, through an agent, or directly from an insurer. Health insurance companies and health maintenance organizations (HMOs) sell major medical health insurance plans. These plans are also called comprehensive coverage or Qualified Health Plans (QHP). There are four main types of qualified health plans in Texas:
Texas marketplace health insurance providers sell health plans only during an open enrollment period. Under some exemptions (also known as qualifying events), you may be able to qualify for coverage outside of enrollment period. This is called a Special Enrollment Period. An example of a qualifying event is a loss of a job, divorce, change in family size, or involuntary loss of coverage. If this applies to you, you may be able to enroll outside of the open enrollment period. You may also be eligible if you have been the victim of misrepresentation or fraud by an agent or insurer.
You can buy other types of health insurance, like short-term, accident, or critical illness, and supplemental, at any time of the year.
Discuss your health insurance needs with a licensed Texas health insurance agent. An agent can recommend the best health insurance based on your needs and get you health insurance quotes from multiple competing insurers.
Alternative health plans allow Texans the flexibility to get health coverage without paying the non-subsidized high premium cost of ACA insurance. The most commonly purchased alternative health insurance plan is Texas Short Term Health Insurance, accompanied by a matching Hospital Indemnity plan that provides a hospital cash benefit to take care of the typically high deductible of the short-term insurance.
Alternative health plans offer coverage for important health matters and serve as a good way to save money, particularly for healthy people. They can be a suitable alternative for people who are healthy, who do not need health services or prescriptions on a regular basis, and do not have major pre-existing conditions. Alternative health plans are frequently beneficial for those who require urgent coverage or need a health plan that would kick-in in case of an emergency or accident medical expense.
It is important to understand that the cost savings of alternative health plans in Texas come with a host of drawbacks that the prospective insured should be aware of, prior to buying the plan. Alternative health plans do not provide traditional major (ACA in Texas - compliant) medical coverage.
Alternative health insurance plans in Texas are frequently not regulated by the state and usually do not have to comply with the Texas Department of Insurance rules and regulations. Because of this, Texas residents covered by alternative health plans are usually not counted in the published "insured" statistic.
Texas alternative health plans include:
TIP: Always discuss your insurance needs with a Texas-licensed health insurance agent who has a selection of options from different health insurance companies. Ask your agent for at least 3 options, compare all coverages side by side, and don't forget to always read the exclusions first.
Texas is one of the few states that allows the sale of Short Term major medical insurance to offer affordable health coverage. A short term health insurance in Texas may not cover all or some of the essential health benefits. Usually, short-term health insurance does not cover pre-existing conditions and does not qualify as minimum essential coverage, the way ACA insurance does. In some cases of multi-year short-term Texas plans, a select set of pre-existing conditions may be covered after a year or more of continuous coverage.
Short term plans are usually issued for 12 months or less; however Texas short-term health insurance can sometimes be renewed for up to three annual terms (for a maximum of 36 months).
Short term health insurance enrollment in Texas can be done year-round, without restrictions, which makes it a useful choice for those who ended up without ACA health coverage and cannot get it until the open enrollment season starts in the fall.
TX short term health insurance often provides fewer benefits and lower coverages than traditional medical plans. When a short-term insurance expires, it does not auto-renew. You must apply and purchase a new one. If you develop certain health conditions during the policy, you might not be able to get another short-term policy from this insurer at the expiration of the existing coverage. To purchase a traditional (ACA Texas health) plan which cannot discriminate for pre-existing conditions, you may have to wait until open enrollment (usually November through December).
Speak with an insurance agent who specializes in Texas short term health insurance coverage in your county.
What are limited benefit plans? There are several kinds of limited benefit plans, which only pay for some health coverage costs. Limited benefit plans are also referred to as a limited medical plan, and are usually used as supplemental to each other and to major health insurance plans. Discuss your health coverage needs with a Texas-licensed health insurance professional, to find out how limited benefits health plans can supplement your insurance and possibly save you money on Texas healthcare.
Texas subscription healthcare plans are sometimes called direct care or concierge care plans. Basically, members pay a subscription fee (monthly or annually) to use a doctor or service, which is part of the plan. Additional charges may apply for each visit, lab work, or other services. If you require care that is not covered by your subscription plan, you may be responsible for the entire cost.
Members of Texas discount health insurance plans pay a monthly fee in exchange for lower prices on certain health care services. Discount plans usually cover vision, hearing, or pharmaceutical services. These are not standard health plans, and they do not provide a discount for insurance.
IMPORTANT: If you are looking for health insurance deals in Texas, speak with a state-licensed health insurance agent who can help you save by assessing your health insurance needs and matching them with the most optimal plan to fit those needs, at the best possible cost available in your county.
Health plans offered by associations generally vary. Some are set up by member-based associations, while others are set up by employers. Association plans in Texas are not always subject to state and federal regulations, and they may not cover as many services as big medical plans. If you must join an association to purchase a plan, carefully consider the membership dues, the plan's coverage, and its customer reviews.
If you have an existing Texas health insurance policy and you get an opportunity to get cheaper coverage through an association health plan - speak with a trusted health insurance agent to compare the coverages first.
Direct primary care (DPC) plan is a way for Texas residents to have an affordable doctor without insurance. DPC, also known as the Doctors Direct Healthcare, is an agreement between a patient and a doctor in which the patient pays the doctor a monthly, quarterly, or annual fee in return for comprehensive primary and urgent care medical services.
The objectives of telehealth and telemedicine are to offer Texas residents more flexibility with appointments. Telehealth is the option to speak with a medical professional through virtual visits - from the comfort of your home, in a remote setting. Lots of Texas health insurance plans, including the ones subsidized by the government, commonly offer a telehealth model as one of its basic benefits.
While telehealth is the access to a broader system of remote health care, telemedicine typically refers to the access to remote clinical services only, but sometimes the terms are used interchangeably. The benefit of telemedicine is that you save time, save money, and do note get exposed to other sick people at the doctor’s office.
Discuss your Texas telehealth and telemedicine options with a qualified health insurance agent.
Group health insurance in Texas may be obtained through employment or membership of an association. The majority of Americans get health insurance through their jobs, but not all employers offer group insurance.
Group health insurance plans generally provide coverage at a lower premium compared to the plans purchased on the individual health insurance marketplace. Additionally, the employer pays at least 50% of the total premium, leaving a smaller and more manageable payment to the employee. Group insurance premiums may be raised because of changes in medical costs, employee age, and employee tobacco use. However, it cannot change because of an employee’s health. All group health insurance plans in Texas are compliant with the federal Affordable Care Act (ACA) rules and regulations.
There are different requirements for group insurance in Texas, depending on the size of the employer. The group insurance market is separated into two categories: small and large.
Under Texas insurance law, a small group is a business or association with two to 50 people, irrespective of the number of working hours. Small group plans must cover a minimum set of federal essential health benefits (EHB). Health insurance companies usually consider the employer’s geographic location, and employees’ ages and tobacco use to determine the premium to charge.
Large groups are groups of at least 51 people. Large employer group health plans in Texas are exempt from covering federal EHBs and can base premiums on an employer group’s health status and claims experience. Except for consumer choice plans, which can remove some state-mandated benefits, large employer plans must cover certain benefits specified by Texas state law.
Multiple employers can obtain health insurance as a group through association health plans. Some arrangements are not mandated to conform with all federal and state small employer plan regulations because there may be more than 50 employees participating.
Employers should be aware that the association is the policyholder when choosing an association health plan. That implies that the employer has no say in benefits, administration, whether the policy is terminated, renewed, or changed by the insurance company. Employers should review contracts to ensure that they understand the terms and conditions.
Always speak with a state-licensed insurance professional, to see what group insurance option suits your needs the best and why.
Commercial health insurance in Texas is any health insurance not obtained from a government program, like Medicare, Medicaid, or CHIP. It is administered and provided by private companies. Commercial medical insurance may be bought privately or provided by an employer. Commercial healthcare insurance is available as a fee-for-service plan or as part of a managed care plan.
Commercial health insurance is one of the types of insurance a business may purchase, to provide business insurance coverage for the business and its staff. To the insured, there is no major difference between commercial health insurance and private health insurance.
Commercial health insurance pays medical expenses and disability income. Group health insurance, disability income insurance and workers' compensation insurance are the three most common examples of commercial health insurance.
Texas disability insurance, also known as paycheck insurance, is designed to make periodic payments to the insured, when the insured cannot work because of an injury or illness. The benefit for disability is decided based on the insured's past earnings. The definition of disability in disability income insurance varies. It can be the disability to carry out the duties of the insured's occupation or any occupation. An "any occupation" definition will only pay benefits if the insured cannot perform any of the duties of the occupation for which they are qualified due to education, training, or experience. The more broad term "own occupation" delivers a better advantage to the insured. It pays benefits when the insured cannot carry out tasks of their own occupation because of sickness or accident.
Texas disability insurance is typically purchased as Guaranteed Renewable and/or Non-Cancellable:
The average cost of disability insurance in Texas is 1 to 3 percent of annual income.
Texas disability insurance comes as individual or group insurance. They differ in the following ways:
Discuss paycheck insurance disability coverage with a Texas state-licensed health insurance agent who has access to multiple disability insurance companies offering coverage near you.
Workers' compensation insurance (Texas Workmen’s Compensation) covers work-related injuries or illnesses of Texas employees by paying for medical care and treatment. It may also pay a part of their lost income. When a Texas employee dies as a result of a work-related injury or illness, Workers' Comp pays burial expenses and benefits to their family. Workers' compensation insurance exists because most employees' health plans do not include payment of work-related injuries and illnesses. Workers' compensation insurance is not a requirement in Texas.
What is workers’ compensation benefits? Texas workers comp includes 3 main benefits:
Generally, Texas workers' compensation does not pay benefits to employees when:
The Texas Department of Insurance's Division of Workers' Compensation (TDI DWC) is in charge of Texas workman compensation. A Texas employer that does not provide workers' compensation insurance may lose legal protection against most lawsuits, which may be launched by the injured employees. If the employer who did not get Workers' Comp coverage is sued, they cannot argue the following in court:
If the employer does not offer workers compensation coverage, they usually must:
How to File a Work Comp Claim in Texas?
Injured Texas employees must report the injury to the employer, who then takes care of their end with the insurance company. Filing workers compensation claim in Texas begins by submitting the Notice of Injury Letter (CS-41) and the Employee’s Claim for Compensations for a Work-Related Injury or Occupational Disease (DWC Form-041). To get help with filing a workers’ compensation claim in Texas, call DWC at (800) 252-7031, option 1.
How Do I Get Workers Comp Insurance?
To buy workers compensation insurance, speak with a qualified state-licensed insurance agent with access to multiple insurers offering Texas workers compensation benefits. Alternatively, you can purchase workers comp from the Texas Mutual Insurance Company, which was setup by the Texas legislature as the work-related injury insurer of the last resort.
Texas seniors may find it difficult to keep up with rising healthcare costs as our income declines. In 2022, nearly 4 million (over 13% of total population) Texas residents were aged 65 or older. The Texas health insurance market offers a wide array of healthcare coverage options for seniors. They include Medicare, Medicaid, private insurance plans, Medigap, Medicare Advantage, and long-term care insurance.
Medicare is a federal health insurance program for persons over 65 years old who have worked full time for at least ten years. In Texas Medicare plans can be purchased in 2 ways: as Original Medicare and as Medicare Advantage.
Medicare program is divided into four parts:
Part A (Hospital insurance) covers hospitalization, inpatient care in a skilled nursing facility, hospice care, and home health care. It is financed through a portion of the payroll tax (FICA) during the person's employment and is usually given free of charge to most seniors who receive social security benefits.
Part B (Medical insurance) covers medical services in or out of the hospital, including doctor's visits, lab tests, clinical trials, mental health care, preventive care, and surgeries. It is financed from monthly premiums paid by the insured and from the general revenues of the federal government. Part B is the part for which everyone must pay a standard premium based on the geographic location and the county.
Part A and Part B combined are referred to as the Original Medicare. Original Medicare typically covers 80% of most medical costs and does not include prescription drug coverage. In 2023 the average cost of Original Medicare in Texas is $164.90.
Part C (Medicare Advantage Plan) - Medicare Advantage plans are sold by private Medicare-approved health insurance companies and typically come with drug coverage. These plans include:
Except for hospice care and some care in eligible clinical research studies, Medicare Advantage plans must cover all of the services offered by Original Medicare. These plans may have lower out-of-pocket expenses than Original Medicare. Extra coverage may be available, including vision, hearing, dental, and other health and wellness programs, as well as prescription drugs.
Unlike Original Medicare, Medicare Advantage in Texas is not accepted by all doctors and hospitals that provide services for the recipients of Medicare. Seek the advice of a licensed health insurance agent to make sure that your doctor is covered.
When you buy Medicare Advantage coverage, you typically pay the standard Part B premium plus the cost of the MA plan. In 2023, Medicare Advantage plans in Texas could add an average of $0 - $213 on top of the $164.90 average for Plan B, resulting in an estimated monthly premium of $164.90 - $379.90.
Part D (prescription drugs) - Also known as Pharmacy Benefits, Part D covers prescription drug costs of Original Medicare (Parts A+B). It is an optional coverage provided through private prescription drug plans (PDPs) that contract with Medicare.
The choice of medicare drug plans in Texas vary based on the type of Medicare you are receiving:
Medicare Part D typically adds $6.60 - $108 to the monthly cost of Original Medicare in Texas, resulting in the total monthly cost of $171.50 - $272.90.
Explore your Medicare coverage options. Speak with a Texas-licensed health insurance agent specializing in Medicare insurance coverage to assess your Medicare needs and help you get the best plan for you.
Medigap is a supplement for Medicare. While Original Medicare in Texas covers most healthcare needs, a few noticeable gaps in coverage are not covered unless you get Medicare Supplement Insurance, also called "Medigap." Medigap supplemental benefits cover deductibles, copayments, or coinsurance that Original Medicare does not cover. Private insurance companies sell Texas Medigap policies, which are used after Medicare pays its part of the approved amount for covered healthcare expenses.
Medigap, which supplements for Medicare, is not the same thing as the Medicare Advantage Plan. Medigap only complements the benefits provided by an original Medicare plan (Parts A and B - combined).
Medigap policies do not cover long-term care, dental or vision coverage, eyeglasses, hearing aids, or private duty nursing care. Prescription drugs are not covered by Medigap plans purchased after 2006. Unlike Medicare Advantage, which typically includes prescription drug coverage, if you are using Medigap to supplement Original Medicare, you may still need to purchase Part D to cover drugs.
Other things to keep in mind concerning Medigap:
In 2023, Medigap policy can cost Texas seniors an additional $28 - $2,400 per month.
Purchased with Original Medicare only, the total monthly cost of Texas Medigap and Medicare could be $193 - $2,600/mo.
With drug coverage (Part D), that is an additional $6.60 - $108 per month, for a $203 - $2,700 total average per month.
With such a drastic range of prices based on the level of coverages, it is imperative to consult a licensed health insurance agent to help you compare the policies based on your actual and anticipated needs. As a general rule the more expensive the plan, the more it covers and less you need to pay out of pocket. The older you get the more coverage you may need.
Medicaid is a health insurance program funded by both state and federal government, which allows qualifying Texas residents to get free medical insurance. In Texas, the Texas Health and Human Services Department (THHS) runs the state's Medicaid program. Medicaid provides health insurance coverage for persons whose income and resources cannot meet the cost of necessary medical care.
To qualify for Medicaid’s free healthcare for low income Texas residents, one must meet income and other eligibility requirements, (being over 65 years is one of them). Once it is confirmed that you are eligible, the Texas Medicaid plans program provides coverage for the following services for elderly persons:
Texas residents who qualify for Medicaid plans and Medicare at the same time are considered "dual eligible" and can participate in the one Medicare-Medicaid plan (MMP).
How to Get Medicaid in Texas? Start the application on the Your Texas Benefits website. Once approved, the application will also guide you through the process of how to apply for a medicaid card.
In Texas, long-term care insurance provides coverage for persons who can no longer live an independent lifestyle and require living assistance at home or in a nursing home facility. This might be as a result of an illness, disability, or Alzheimer's disease.
There are many ways to access long-term care in Texas:
To get long-term care insurance, check the list of companies in Texas that sell long-term care insurance and reach out to a health insurance agent to help you sort through the possible options. After purchasing long term care insurance in Texas, the insured has 30 days to review the policy and make sure that the benefits meet their needs. If the purchased long term care insurance policy does not offer what was expected, the insured can cancel it within the 30-day free look period for long term care and receive the paid premium in full.
Discuss best companies for long-term care insurance with a Texas-licensed health insurance agent who has access to multiple long-term care insurance providers.
Additional or stand-alone options are health care plans that cover anything that basic medical coverage does not cover. These are also called supplemental health insurance. They provide additional medical coverage and contribute to other costs not covered by primary insurance plans like copayments and deductibles. Supplemental health insurance in Texas helps with medical and out-of-pocket expenses. It can be purchased as a supplement to major health insurance coverage or as a standalone plan. Some examples include dental insurance, vision insurance, and hearing (and hearing-aid) insurance.
Another additional option is travel health insurance. It can be obtained as part of a comprehensive travel insurance coverage or a stand-alone plan. International travel health insurance provides health insurance coverage for people traveling out of the country.
When shopping for a Marketplace health insurance plan in Texas, you have the following rights:
Below are general tips that you should take note of when shopping for health insurance in Texas:
Complete and accurately fill out your application. An insurance provider may cancel your coverage or refuse to pay your claims if you intentionally mislead or leave something out.
To get complete details about health insurance options in Texas, discuss your health insurance needs with a state-licensed health insurance agent today.