The Texas health insurance answer hub.

Health insurance is a contract where you pay a monthly premium and, in exchange, the insurance company pays a share of your covered medical costs. Without it, a single hospital stay or surgery can cost tens or hundreds of thousands of dollars. Coverage also gives you access to negotiated network rates that are dramatically lower than what an uninsured person is billed.

The premium is what you pay every month to keep the plan active. The deductible is what you pay out of pocket for covered services before the plan starts sharing costs. A copay is a flat fee for a specific service (like $30 for an office visit). Coinsurance is a percentage you pay after the deductible (like 20%). The out-of-pocket maximum is the most you'll pay in a plan year for covered in-network care — after that, the plan pays 100%.

HMO plans limit you to an in-network group of providers and usually require a primary care doctor and referrals for specialists. PPO plans let you see any provider, in or out of network, but you pay more out of network. EPO plans work like a PPO but only cover in-network care (except emergencies). POS plans blend HMO and PPO — you pick a primary care doctor but can go out of network at higher cost.

A network is the group of doctors, hospitals, labs, and pharmacies that have contracted with a plan to accept negotiated rates. In-network care is far cheaper than out-of-network care and, on some plan types, out-of-network care isn't covered at all. Always verify your doctors and hospitals are in-network before choosing a plan.

On the ACA Marketplace, plans are grouped by how they split costs. Bronze plans have the lowest premiums but the highest deductibles (the plan covers roughly 60% of costs). Silver covers about 70%, Gold about 80%, and Platinum about 90%. If you qualify for cost-sharing reductions, they only apply to Silver plans.

Under the Affordable Care Act, every individual and small-group plan must cover 10 categories: outpatient care, emergency services, hospitalization, pregnancy and newborn care, mental health and substance use treatment, prescription drugs, rehabilitative services, lab services, preventive/wellness care and chronic disease management, and pediatric services including dental and vision.

On ACA-compliant plans, most recommended preventive services — annual physicals, many screenings, most vaccines, well-child visits, and many contraceptives — are covered at no cost when you use an in-network provider, even before you meet your deductible.

The Marketplace (HealthCare.gov in Texas) is the federal exchange where individuals and families can shop for private health insurance, compare plans side by side, and apply for premium tax credits and cost-sharing reductions that can substantially lower monthly costs.

You can use either. A licensed broker like Tyler is paid by the carriers, not by you, so the cost is the same — but a broker can compare plans across many carriers, verify your doctors are in-network, and help you claim the correct subsidy.

For plan years starting in 2026, ACA Open Enrollment on HealthCare.gov runs November 1 through January 15 in Texas. Enroll by December 15 for coverage that starts January 1. Outside that window, you generally need a qualifying life event to enroll.

Premium tax credits lower your monthly premium based on your household income and family size relative to the federal poverty level. You can apply the credit directly to your monthly bill (advance premium tax credit) or claim it when you file taxes. Report income changes during the year so your credit stays accurate and you don't owe money back at tax time.

Cost-sharing reductions (CSRs) lower your deductible, copays, coinsurance, and out-of-pocket maximum. They're only available if you choose a Silver plan and your household income falls within the qualifying range. For eligible households, a Silver CSR plan is usually a better deal than a Bronze plan.

Yes, but you typically can't get a premium tax credit if the employer plan is considered 'affordable' by IRS standards and meets minimum coverage. If the employer plan is unaffordable for you (or your family), you may still qualify for subsidies on the Marketplace.

Report the change to the Marketplace as soon as possible. Your premium tax credit will be recalculated. If income rose and you got too much subsidy, you may owe some back at tax time; if income dropped, you may get a bigger refund.

There is no federal individual mandate penalty. Texas does not impose a state-level penalty either. However, going without coverage exposes you to the full cost of any medical event and you generally can't enroll mid-year without a qualifying life event.

Most people become eligible at age 65. Your Initial Enrollment Period is a seven-month window: the three months before your 65th birthday month, your birthday month, and the three months after. People under 65 can also qualify after 24 months of Social Security Disability Insurance, or with ALS or end-stage renal disease.

Not always. If you're still working and have qualifying employer coverage from a company with 20+ employees, you can usually delay Part B without a penalty. If you have coverage from a smaller employer, retiree coverage, COBRA, or a Marketplace plan, you generally should enroll at 65 to avoid lifelong late-enrollment penalties.

Original Medicare (Parts A and B) is run by the federal government, lets you see any provider that accepts Medicare, and pairs with a separate Medigap policy and a Part D drug plan. Medicare Advantage (Part C) is a private, all-in-one alternative that bundles A, B, usually D, and often extras like dental and vision — but you must use the plan's network and follow its rules.

Original Medicare generally does not cover routine dental, routine vision, hearing aids, most long-term nursing home care, cosmetic procedures, or care outside the United States. Many Medicare Advantage plans add some of these; standalone dental, vision, and hearing plans can fill the gaps.

Medigap is a private policy that pays for many of the out-of-pocket costs Original Medicare leaves you with, like coinsurance and deductibles. You keep Original Medicare and can see any Medicare-accepting provider nationwide. You cannot use a Medigap policy with a Medicare Advantage plan.

Medicare Annual Enrollment runs October 15 through December 7 each year. The Medicare Advantage Open Enrollment Period runs January 1 through March 31 and lets people already in Advantage switch plans once or return to Original Medicare. Some Special Enrollment Periods apply after events like moving or losing other coverage.

If you don't sign up for Part B when first eligible without qualifying coverage, your Part B premium can go up 10% for each full 12-month period you delayed — for the rest of your life. Part D has a smaller monthly penalty that also lasts as long as you have Part D. These penalties are real and preventable with planning.

List every medication you take with dosage. Then compare plans by whether each drug is on the formulary, what tier it's in, what your preferred pharmacy charges, and the annual total cost — not just the premium. This is one of the highest-impact decisions in Medicare shopping and it's worth reviewing every year.

Many Advantage plans have a $0 monthly plan premium, but you still pay your Part B premium and you'll pay copays and coinsurance when you use services. 'Free' means no extra premium above Part B — not free care.

Texas uses the federal Marketplace at HealthCare.gov. Texas has not expanded Medicaid, which affects who qualifies for subsidies at lower income levels.

No. Texas has not adopted ACA Medicaid expansion. Adults without dependent children generally cannot qualify for traditional Texas Medicaid based on income alone. This creates a 'coverage gap' for some low-income Texans who earn too much for Medicaid but historically too little for Marketplace subsidies — though enhanced federal subsidies have helped close much of that gap for people who apply on HealthCare.gov.

Texas Medicaid primarily covers low-income children, pregnant women, parents with dependent children (at very low income limits), seniors, and people with certain disabilities. Apply through YourTexasBenefits.com or 2-1-1 Texas. Children who don't qualify for Medicaid may qualify for CHIP.

The Children's Health Insurance Program covers children up to age 19 in Texas families that earn too much for Medicaid but still need affordable coverage. It includes doctor visits, prescriptions, dental, vision, and hospital care with low or no monthly fees. Apply at YourTexasBenefits.com.

The Texas Department of Insurance (TDI) licenses agents like Tyler, regulates carriers doing business in Texas, and helps consumers with complaints and disputes. If you have a problem with a carrier that you can't resolve directly, you can file a complaint at tdi.texas.gov.

Yes, short-term limited-duration plans are sold in Texas within federal limits. They can be cheaper, but they are not ACA-compliant — they can exclude pre-existing conditions, cap benefits, and skip essential health benefits like maternity or mental health care. Read the fine print carefully or ask a broker before choosing one.

Availability varies by county, but Texans commonly see plans from Blue Cross Blue Shield of Texas, Ambetter/Superior, Oscar, UnitedHealthcare, Aetna CVS Health, Molina, and Community Health Choice, among others. Networks and formularies differ significantly between carriers — comparing them is where a broker adds a lot of value.

You can enroll directly at HealthCare.gov, work with a licensed independent broker (there's no cost to you), or find a certified Navigator or Enrollment Assister through HealthCare.gov's 'Find Local Help' tool.

In Texas, you can generally offer a small-group plan with as few as 2 eligible employees (or in some cases 1, depending on the carrier). Employers with fewer than 50 full-time equivalent employees are not required to offer coverage under federal law, but many do so to recruit and retain talent.

Contribution rules vary by carrier, but most Texas small-group carriers require the employer to pay at least 50% of the employee-only premium. Employers typically contribute less (or nothing) toward dependent premiums, though they can choose to pay more.

A level-funded plan looks like a traditional insured plan from the employer's perspective — a set monthly payment — but is structured as a self-funded arrangement with stop-loss insurance. Healthier groups can sometimes get a refund of unused claim dollars at year-end. They can be a fit for smaller, healthier employers.

An Individual Coverage HRA lets employers reimburse employees tax-free for individual health insurance premiums (like ACA Marketplace plans) instead of offering a traditional group plan. It gives employees more choice and gives employers predictable costs — but it disqualifies affected employees from premium tax credits.

Employers with fewer than 25 full-time equivalent employees, average wages below an IRS-set limit, and who pay at least 50% of premiums for a SHOP-eligible plan may qualify for a federal tax credit of up to 50% of their contribution (35% for tax-exempt employers). Ask your tax advisor if you qualify.

Yes. Many small employers 'stack' voluntary benefits — dental, vision, term life, disability, accident, and hospital indemnity — either paid by the employer or offered on an employee-paid basis at group rates.

Most adult medical plans (including Original Medicare) don't cover routine dental cleanings, fillings, glasses, or contacts. Standalone dental and vision plans are inexpensive and often pay for themselves in a single year of routine care.

Supplemental plans pay cash benefits directly to you when specific events happen — an accident, a hospital stay, a cancer diagnosis, or a critical illness like a heart attack or stroke. The money is yours to use for deductibles, copays, groceries, or lost income — the payments are on top of your regular health insurance.

It can be, especially if you have an active family, play sports, or have a high-deductible plan. A single ER visit can leave you owing thousands before your deductible is met; an accident policy can pay a lump sum to help cover that gap.

It pays a lump-sum cash benefit if you're diagnosed with a covered serious illness like cancer, heart attack, or stroke. It's separate from — and pays on top of — your health insurance.

It pays a set daily or per-admission cash benefit when you're admitted to the hospital, regardless of what your medical plan pays. It's frequently paired with high-deductible plans to soften the cost of a hospital stay.

Term life covers you for a set number of years (commonly 10, 20, or 30) and pays out only if you die during that term. It's the cheapest way to get a large death benefit. Permanent life insurance (whole life, universal life) lasts your whole life as long as premiums are paid and builds a cash value over time — but costs several times more per dollar of coverage.

A common starting point is 10 to 12 times your annual income, plus enough to pay off your mortgage, cover future education for children, and clear any other major debts. The right number depends on your family's specific situation.

Not always. Many term policies today are available with no-exam underwriting for healthy applicants, using electronic health records and questionnaires. Traditional underwriting (with a paramedical exam) is still common for larger policies.

Usually not by itself. Group life at work is a nice benefit, but coverage is often just 1–2 times your salary, and it typically ends when you leave the job. An individual policy stays with you regardless of where you work.

A time (usually 60 days) after a qualifying life event when you can enroll in or change a Marketplace plan without waiting for Open Enrollment.

Common ones include losing other health coverage, getting married, having or adopting a child, moving to a new area, becoming a U.S. citizen, income changes that affect eligibility, and — in some cases — gaining membership in a federally recognized tribe.

You typically have three: continue your employer plan through COBRA (usually expensive because you pay the full premium plus an admin fee), enroll in a Marketplace plan under a Special Enrollment Period (often with subsidies that make it far cheaper than COBRA), or apply for Medicaid/CHIP if your household qualifies.

A federal law that lets you keep your employer's group health plan for up to 18 months (sometimes longer) after leaving a job, but you pay the entire premium yourself plus up to a 2% administrative fee. For most people who qualify for Marketplace subsidies, an individual plan is significantly cheaper than COBRA.

Turning 26 triggers a Special Enrollment Period. You have 60 days before and 60 days after losing coverage to enroll in a Marketplace plan, join an employer plan if offered, or explore other options like a student plan.

Birth of a child is a qualifying life event. On the Marketplace you have 60 days from the birth to enroll the baby, and coverage is retroactive to the date of birth. On employer plans, follow the enrollment process in the employee handbook — usually a 30- or 60-day window.

In most cases, an in-network provider files the claim for you. Call your insurance company directly to walk through their process for any out-of-network or reimbursement claims — the number is on the back of your insurance card.

An EOB is a statement your insurance company sends after processing a claim. It shows what the provider charged, what the plan's negotiated rate was, what the plan paid, and what you owe. It is not a bill — the provider will send you a separate bill for your share.

Common reasons include: the service wasn't covered, prior authorization wasn't obtained, the provider was out of network, coding errors on the claim, or the claim was filed late. Denied claims can almost always be appealed — start by calling your insurance company for the specific denial reason.

First, do an internal appeal directly with your insurance company using the process on the denial letter. If that fails, you have the right to an external review by an independent third party. In Texas, the Texas Department of Insurance can help walk you through the appeal and IRO (Independent Review Organization) process.

A federal law that protects you from most surprise out-of-network bills for emergency care and for non-emergency care from out-of-network providers at in-network hospitals or ambulatory surgical centers. It also gives uninsured and self-pay patients the right to a good-faith cost estimate before scheduled care.

Ask the provider for an itemized bill and check it for errors. Ask about financial assistance or charity care — nonprofit hospitals must offer it. Ask for a cash-pay discount and request a payment plan. If you have insurance and think the bill is wrong, check it against your EOB before paying.

Premiums reflect age, tobacco use, geography, plan design, and the medical costs of everyone in the risk pool. On the Marketplace, higher-income households pay more because subsidies phase down. A broker can help you compare plans that keep total annual cost — not just premium — down.

A High Deductible Health Plan has a higher deductible than most plans (set annually by the IRS) in exchange for a lower monthly premium. If you're generally healthy and want to pair coverage with a tax-advantaged HSA, an HDHP can save money. If you have ongoing prescriptions or expect regular care, a lower-deductible plan often costs less overall.

You can spend HSA dollars tax-free on qualified medical, dental, and vision expenses. After age 65 you can also use HSA funds for non-medical expenses without penalty (though you'd pay income tax on those, like a traditional IRA). Non-qualified withdrawals before 65 are taxed and hit with a 20% penalty.

A formulary is the plan's list of covered prescription drugs, grouped into tiers. A drug in a higher tier costs you more. Two plans with identical premiums can charge wildly different amounts for the same prescription — always check the formulary before enrolling.

Use in-network preferred pharmacies, ask about generics or therapeutic alternatives, use manufacturer copay cards where allowed, check GoodRx or similar tools if the cash price is lower than your copay, and see if the manufacturer has a Patient Assistance Program.

No — and you shouldn't just auto-renew without looking. Networks, formularies, premiums, and available subsidies change every year. A 15-minute check during Open Enrollment can save hundreds or thousands of dollars.

Nothing. Licensed independent brokers are paid by the insurance carriers — not by you. Your premium is the same whether you enroll on your own, through HealthCare.gov, or with a broker.

A good broker won't. Commission is typically similar across major carriers, and long-term client relationships matter more than a one-time sale. Ask any broker to walk you through why they're recommending a specific plan.

Names, dates of birth, and tobacco status for everyone who needs coverage, your ZIP code, an estimate of household income for the plan year, a list of any regular prescriptions, and the names of any doctors or hospitals you want to keep.

Yes. Ongoing service is part of the relationship — questions about ID cards, claim disputes, changing doctors, adding a new baby, or reshopping at renewal time. Call anytime; there's no separate fee.

Yes. Tyler Stansell is a licensed Texas health insurance agent and works with individuals, families, Medicare-eligible adults, and small businesses across Texas.