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Texas Health Insurance
Health insurance plays a pivotal role in securing the financial and physical well-being of your family. Purchasing suitable health insurance coverage for your family is expensive and requires a thorough appraisal of all future risks and its impact on your finances. More than 47 million Americans are uninsured, majority of whom are the working families. The unaffordable health insurance costs render these families, especially children, vulnerable to the financial disasters arising from the absence of proper health coverage. For those families who are not covered under their employers’ group plan, there are low-cost state sponsored health insurance programs.
According to the United Health foundation’s 2008 Health Rankings, Texas is the 46th healthiest state to live in. The state plunged nine spots from its 37st position in 2007 and 2006 consecutively. The major challenges faced by the health care system of the state include poor public health funding, high rate of uninsured population, limited access to primary care, high percentage of children under 18 in poverty, and high prevalence of smoking. The state of Texas, having the population of more than twenty three million people, boasts of both private-market and public health insurance alternatives. The private-market health insurance comprises of numerous types of health plans including family, Medicare supplemental, short-term, student, group and dental. Additionally, the state and federal government sponsored programs provide low-priced health coverage to the uninsurable residents of Texas who meet specific eligibility requirements such as age and income.
The Texas Department of Insurance is in charge for regulating all types of insurance sold in the state of Texas including health insurance policies offered by private-market health insurers or public health coverage programs. However, approximately 24.9% of the population remains uninsured, which is the biggest health issue for the state lawmakers. According to the Censor Bureau’s 2007 and 2008 Current Population Survey, approximately 31.6% uninsured Texas residents come under the above 200% FPL category.
Choosing a health plan is not as easy as it used to be before. Therefore, it is advisable to consult with a licensed health insurance agent/broker to avail the appropriate health insurance alternatives.
Individual/Family Health Insurance
Below is the guidelines for applying for and obtaining individual health insurance in the state of Texas. These regulations apply to all insurance companies offering individual or family health insurance in Texas:
| Medical Underwriting | Yes |
Pre-Existing Condition Exclusion Period | 24 months |
Look Back Period | 60 months |
Look Back Standard | Prudent person |
Mandatory Benefits | Cancer screening for women including screening of breast and cervical cancer, mastectomy stay of 48 hours, reconstructive surgery after mastectomy, osteoporosis screening, direct access to OB/GYNs, infertility treatment |
Market Rate Restrictions | None |
Guaranteed Issue Options | None |
Small Group Health Insurance
Below is the guidelines for small group health insurance in the state of Texas. These regulations apply to all insurance companies offering small group health insurance in Texas:
| Small Group Size | 2-50 |
Employee Qualifications | 30 hours per week, non-seasonal |
Guaranteed Issue | Yes |
Premium Rating Factors | Rate Bands |
Rate Adjustment Factors | 25% |
Look-Back Period | 6 months |
Pre-existing condition exclusionary period | 12 months |
Mandatory Benefits | Same as individual |
State Cobra Variations for Small Groups
Below are the COBRA guidelines for small groups in the state of Texas. For employer groups of more than 20 employees, refer to the federal COBRA guidelines:
| Mini-Cobra Option | Yes |
Eligible Group Sizes | 2-19 |
Extension of Benefits Period - Standard | 6 months |
Extension of Benefits Period - Disabled | 6 months |
Maximum Premium Increase | 102% |
State Legislation Reference | Texas Continuation Law |
Additional Notes | For qualified Texas residents that have been covered under federal COBRA, they may be entitled to an additional 6 months of coverage under mini-Cobra after the termination of their 18 months of federal COBRA. |
State Sponsored Health Insurance Programs
There are several state sponsored health insurance programs in the State of Texas to assist those without insurance in obtaining adequate coverage.
High-Risk Pools
Some states offer special state sponsored health insurance plans for qualified persons that are not eligible for individual health insurance due to pre-existing medical conditions. The guidelines for enrollment in these programs vary by state. The high-risk pool in the State of Texas is summarized in the chart below:
| Plan Name | Texas Health Insurance Risk Pool |
Website | |
Phone Number | 888-398-3927 |
HIPPA Eligibility Required? | Yes |
Available Carriers | BlueCross and BlueShield of Texas |
Pre-Existing Condition Waiting Period | 12 months |
Enrollment Periods | Currently Open to New Enrollment |
Premium Limits | No more than 200% of standard rate |
Lifetime Maximum Benefit | $ 2 million |
Special Notes | To qualify, you must have health benefit plan coverage for at least 18 months preceding application for coverage to the Health Pool, with no gap in coverage greater than 63 days; you must not be eligible for Medicare, employer-sponsored health coverage, including a self-insured health benefit plan, or continuation of coverage under state or federal law. |
Children’s Health Insurance Program
Through shared funding from the federal government, the State of Texas provides health insurance for uninsured children that meet certain eligibility guidelines. A summary of this program is outlined in the chart below:
| Program Name | Children’s Health Insurance Program |
Website | |
Phone Number | 877-543-7669 |
Apply Online | Yes |
Age Limits | Under 18 |
Insurance Carrier | Varies based on community of residence |
Length of Coverage | 12 months |
Residency Requirements | Texas resident, U.S. citizen, qualified immigrant |
Other Eligibility Requirements | Children enrolling in CHIP for the first time after being covered by private health insurance will have a 90-day waiting period before the benefits can be used. |
Pre-Existing Condition Exclusions | None |
Cost | CHIP enrollment fees and co-payments are based on the family’s income. Enrollment fees are $50 or less per family for each 12 month term of eligibility and most co-payments for doctor visits and prescription drugs range from $3 to $10. |
Medicaid
Medicaid is a state program partially funded through the federal government. Qualification guidelines, as well as the types of people that are eligible, will vary by state. The chart below provides a summary of the Medicaid programs in the State of Texas:
| Governing Agency | Texas Health and Human Services Commission |
Website | |
Phone Number | 800-252-8263 |
Residency Requirements | Texas resident, U.S. citizen, some legal immigrants |
Federal Poverty Line Income Limits | At or below 100% FPL |
Additional Resources
Texas Health Care Options Matrix™ Guide
Provided by the Foundation for Health Coverage Education, the guide is a quick reference guide prepared by the non-profit Foundation for Health Coverage Education that outlines Texas’ public and private health care choices for individuals and groups with various demographic profiles.
Family Health Insurance Guide by HealthInsuranceFinders.com
The guide created by HealthInsuranceFinders.com provides useful information regarding health insurance coverage such as individual/family health insurance, group health insurance, separate child health insurance and state-sponsored programs that are available for low to middle income families.
Texas: At-A-Glance
Provides exclusive health data of the Texas state. Statehealthfacts.org, a project of the Henry J. Kaiser Family Foundation, is designed to provide free, up-to-date, and easy-to-use health data on all 50 states.
