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Texas Health Insurance

Texas Medical Insurance Overview

People living in Texas are able to purchase health insurance coverage available through their workplace, through a private insurance provider for individual coverage or qualify for a program offered by the state. As of 2014, the amount of uninsured residents was quite high, but it has dropped 3 percent since 2013. It has been proven that the state’s residents choose to forgo the option of health insurance coverage altogether or they simply cannot afford it. Under the Affordable Care Act, legislators in the state hope that people residing in Texas will have easier access to health insurance and that it will improve the overall health of the state.

The ACA was designed as a means to provide affordable insurance rates to citizens nationwide and Texas hopes to benefit as the changes nationwide will be seen throughout the years to come. Under the healthcare reform legislation, it improves the accountability of insurance companies, brings awareness to various health problems and offers expanded coverage to people in this country who are not currently insured.

Texas’ Health Care Issues

The state of Texas’ overall health rank is 34 as compared to the rest of the states in the U.S., according to the ranking system provided by the United Health Foundation. Texas has its share of strong points and challenges, but there leaves a lot of room for the state’s health status to collectively improve.

Below is a brief breakdown of the state’s strengths and weaknesses:


  • Few poor mental health days
  • High rate of high school graduation
  • Low prevalence of smoking


  • High percentage of uninsured population
  • Low immunization coverage among children
  • Large disparity in health status by education level

Understanding Texas’ Uninsured Population

As of 2014, the state of Texas had 17% of the population without insurance coverage. It has seen a 3 percent drop since 2013 and that number is hoped to continue to fall as more Texans get covered.

The Henry J. Kaiser Family Foundation provides the following information, which provides some details on the uninsured population of the state of Texas:

  • As of 2014, 17% of the population of non-elderly people had no insurance
  • 9% of the total amount of uninsured people in Texas were under 18 years of age
  • 23% of the total population of uninsured residents were between 19 and 64 years of age

Group Health Plans

Large companies and organizations provide health coverage to employees and members through group health plans. In the state of Texas, 47% of the population is covered by an employer-sponsored health insurance plan, and the first place an employed individual should look in the search for health insurance is at the human resources office of their employer. Although a large portion of Texas employers do not offer group health insurance, most large companies that employ a lot of workers do offer insurance. An employed individual is, therefore, usually able to acquire insurance through his or her employer.

Signing Up

Through enrollment periods, employees can sign up for coverage under the company’s group health plan. However, if you miss the designated time frame, you will have to wait for the next enrollment period to obtain insurance coverage.

Prior to signing up for insurance coverage, keep the following factors in mind:

  • Dependents – Do you have to cover a spouse or dependents? This will likely drive up the costs of insurance under the plan.
  • Medical needs – Are you suffering from a chronic condition that requires a comprehensive insurance policy? You should keep this in mind so you can get coverage for anything medically necessary to your situation.
  • Cost – Is the group plan affordable to you? Many coverage options vary in cost and coverage offered, so check through the choices and see if one is affordable to your situation.

Pre-Existing Condition Exclusion Periods

Exclusionary periods apply in the event that you suffer from a pre-existing medical condition. In Texas, you can be excluded from coverage for a period of 12 months before you are able to use your insurance benefits.

In addition, the look-back period is six months for insurance companies to gather information on any pre-existing conditions of which you may suffer. If you are covering a dependent who is under the age of 19, pre-existing condition exclusion periods do not apply.

Waiting/Affiliation Periods

All enrollees into plans offered by HMOs are subject to waiting through a period of time called an affiliation period. Affiliation periods are typically no longer than two months, but can extend to three months if the enrollee obtains coverage late.

Individual Health Plans

For some, obtaining an individual insurance policy is the only choice available because of income guidelines. This type of plan is the best bet for self-employed people to obtain benefits for medically necessary services.

In the state of Texas, six percent of the population is covered under individual policies. These plans can be exorbitant in cost and offer little benefits with regard to coverage. However, it has been estimated that a healthy person of a young age can obtain such coverage for a monthly premium of $104.

Downsides of this type of insurance policy is that it is subject to medical underwriting and plan providers can deny you coverage if you have a pre-existing condition. In order to determine if you have a pre-existing condition, the insurance company can look back into your medical records for a period of five years. In addition, exclusion periods for pre-existing conditions can last up to two years if coverage is approved.

Continuation Coverage

In the event that you lose your insurance coverage under a group plan, you can obtain continuation coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA offers temporary benefits that can last for up to a year and a half.

Enrollment into this plan is strictly dependent on the size of the employer that previously offered the group benefits package. Once coverage expires, you may be able to seek continuation coverage or a conversion plan under HIPAA.

Texas Health Benefits Exchange

In 2012, former Texas Governor Rick Perry announced plans to forgo the pursuit of a state-managed benefits marketplace. Prior to that announcement, the Department of Insurance had partnered with the Health and Human Services Commission to explore the option of implemented a state-run exchange.

In 2010, the state of Texas received a federal grant of $1 million to work toward creating and implementing a state benefits exchange. However, the state has since returned 90 percent of the funds to the federal government.

In Texas, residents must use in order to compare the various options available and purchase an insurance policy.

State Insurance Programs

In Texas, many residents cannot afford health insurance benefits through group or individual plans. As such, they must turn to a state-funded option for assistance in receiving medically necessary services.

In order to receive coverage under one of the many plans offered by the state of Texas, your income level, age, gender and health status are all scrutinized to determine eligibility.

Below is a breakdown of each of the program options for state-sponsored coverage:

Texas Health Insurance Pool (The Pool)

The Pool was created to benefit persons suffering from a qualifying pre-existing condition who may find it difficult to otherwise obtain benefits in the private insurance market.

Pre-Existing Condition Insurance Plan (PCIP)

PCIP offers coverage to Texas residents and residents nationwide who have pre-existing medical conditions. Under PCIP, you can enjoy coverage, but premiums can cost anywhere between $133 and $572 every month.


The Medicaid program is a nationwide program that offers health insurance benefits to people who earn low incomes. In Texas, participants can receive coverage for pharmacy services, x-rays, doctor’s visits and lab tests. Your income level will be used to determine whether or not you are eligible for coverage under this program. Premiums are free in some cases, but others may warrant a nominal charge for services.

CHIP Perinatal

CHIP Perinatal is a program that benefits both women and children. Depending on your annual income and age, certain coverage options are available. Coverage is sometimes free, but can cost a minimal amount toward premiums.

Children’s Health Insurance Program (CHIP)

CHIP offers insurance coverage to kids who are uninsured as long as the households of which the children belong meet certain income guidelines. Participants in CHIP must be under the age of 18, uninsured for six months prior to enrollment and be part of a household that earns under 200 percent of the poverty level.

Children with Special Health Care Needs (CSHCN)

This plan is geared toward providing healthcare services to children who have special needs. There are no monthly premium requirements for participation in CSHCN.

Breast & Cervical Cancer Service (BCCS)

Utilizing the BCCS, women in Texas can obtain early detection screenings for breast and cervical cancers. Included services are pap tests, pelvic exams, mammograms and cervical dysplasia treatment.

Indian Health Services (IHS)

Those persons of Native American descent along with women pregnant by a qualifying Native American can obtain services for disease prevention, health screenings and x-rays under IHS.

Medicare and the Medicare Prescription Drug Program

The Medicare Program is a nationwide program that covers disabled individuals, persons suffering from Renal Disease and seniors who are over the age of 65.

In order to be eligible for coverage under one of the four parts of Medicare, a senior or their spouse must have worked in a job that was covered by Medicare for at least ten years or more.

VA Medical Benefits Package

Any veteran who has completed 24 consecutive months of service or has fulfilled their active duty requirement can be guaranteed coverage under this program. Insurance benefits are comprehensive in nature and are guaranteed as long as the veteran has been released from service with an honorable discharge.

Partnership for Prescription Assistance

Consumers in the U.S. can receive financial help with the costs of prescription medications through the Partnership for Prescription Assistance. The PPA connects consumers with 475 program options to obtain help with medication costs.

Women-Infants-Children (WIC)

WIC provides both pregnant women, new mothers and children with nutritional guidance, advice and offers immunization services.

National Association of Mental Illness (NAMI) Helpline

The NAMI Helpline helps people who are dealing with mental illness and their family members with counseling and advice. The Helpline is comprised of volunteers who aim to offer a great deal of resources to those affected by mental illness across the country.

The Health Insurance Portability and Accountability Act (HIPAA)

HIPAA was enacted to protect private medical data belonging to patients, but now offers protections to people with regard to health insurance providers.

Under HIPAA, insurance companies offering group health plans cannot deny coverage to participants suffering from pre-existing conditions. The law also regulates waiting and exclusionary periods along with the ability for consumers to receive continuation benefits after the exhaustion of COBRA coverage.