Texas Health Insurance (TX)

With the 2010 passage of the Patient Protection and Affordable Care Act, all states are in the process of examining their insurance regulations with an eye toward federal compliance. A major change already in effect is the prohibition against excluding children from coverage on the basis of a pre-existing condition. Also, children may now remain on their parents’ health insurance up to age 26, regardless of educational or marital status.

Currently, adults with pre-existing conditions can access coverage via temporary high risk pools, an arrangement that will be replaced on January 1, 2014 by the federally mandated health insurance exchanges.

General Insurance Regulations

Insurers issuing policies in Texas are required to include a provision of guaranteed renewability. Currently, pre-existing condition exclusions may be put in place for up to two years, with a five-year look-back period. Health status can be used to determine both eligibility for coverage and rate level. Applicants cannot, however, be denied insurance if there has been no gap in their coverage and no policy can be cancelled due to health status.

Health Care Exchanges

There has been no significant activity in Texas toward the creation of a health care exchange, due in large part to the opposition voiced by Governor Rick Perry about setting up an exchange prior to the Supreme Court’s review of the Affordable Care Act scheduled for March 2012. If Texas does not establish an exchange by the January 2013 deadline, the U.S. Department of Health and Human Services will take charge of the process.

Pre-Existing Condition Insurance

The U.S. Department of Health and Human Services administers the state’s Pre-Existing Condition Insurance Plan, which offers both primary and specialty care as well as hospitalization and prescription drug coverage. Monthly premiums range from $133 to $572 depending on age and option, with deductibles of $1000 to $3000. (There may be a separate drug deductible.) Out-of-pocket expenses are capped at $7000 per year.


Medicaid eligibility is determined by income as a percentage of the Federal Poverty Level. Infants under the age of one year qualify at 185% FPL, children 1-5 at 133%, and 6-19 at 100%.

Pregnant women can access Medicaid coverage at 185% FPL, parents at 14%, and disabled Social Security recipients at 74%.


Approximately 11 percent of the residents of Texas are Medicare beneficiaries, with more than 2,829,000 accessing some form of drug coverage. On average, $8000 is spent per Medicare enrollee each year.

The Health Information Counseling and Advocacy Program (HICAP), which is funded by the Texas Department of Aging and Disability Services, offers counseling and educational services to all Medicare recipients.