6.3 Texas State Health Programs
Key Takeaways
- Texas did NOT expand Medicaid under the ACA
- Texas uses the federal HealthCare.gov marketplace
- Texas Medicaid covers certain categories including children, pregnant women, and disabled
- CHIP provides coverage for children in families above Medicaid limits
- The Texas Life and Health Insurance Guaranty Association protects policyholders
Texas has specific state health programs, though options are more limited than in Medicaid expansion states.
Texas Medicaid
Texas Medicaid covers specific categories of individuals:
Eligibility Categories
| Category | Income Limit |
|---|---|
| Children (0-5) | Up to 198% FPL |
| Children (6-18) | Up to 133% FPL |
| Pregnant Women | Up to 198% FPL |
| Parents | Very limited (approximately 14% FPL) |
| Aged/Disabled | SSI-related eligibility |
| Adults | Generally NOT covered |
No Medicaid Expansion
Unlike many states, Texas did NOT expand Medicaid:
- No coverage for adults up to 138% FPL
- Creates "coverage gap" for some adults
- Adults above Medicaid limits but below marketplace subsidies affected
Exam Tip: Texas is a NON-EXPANSION state. Know that most low-income adults do not qualify for Medicaid in Texas.
Federal Marketplace in Texas
Texas uses the federally facilitated marketplace:
Marketplace Features
| Feature | Description |
|---|---|
| Platform | HealthCare.gov |
| Open Enrollment | November 1 - January 15 |
| Premium Tax Credits | Based on income |
| Plan Tiers | Bronze, Silver, Gold, Platinum |
Special Enrollment Periods
Qualify for special enrollment with:
- Loss of other coverage
- Marriage or divorce
- Birth or adoption
- Move to new coverage area
Children's Health Insurance Program (CHIP)
Texas CHIP covers children in families above Medicaid limits:
CHIP Eligibility
| Factor | Requirement |
|---|---|
| Age | Under 19 years old |
| Income | Above Medicaid, up to approximately 201% FPL |
| Residency | Texas resident |
| Citizenship | U.S. citizen or qualified immigrant |
CHIP Benefits
- Comprehensive health coverage
- Dental services
- Vision services
- Mental health services
- Low-cost premiums (income-based)
Texas Life and Health Insurance Guaranty Association
Protects policyholders when insurers become insolvent:
Coverage Limits
| Coverage Type | Maximum Limit |
|---|---|
| Life Insurance Death Benefit | $300,000 |
| Cash Surrender Value | $100,000 |
| Health Insurance | $500,000 |
| Annuity Present Value | $250,000 |
| Disability Income | $300,000 |
Important Rules
| Rule | Description |
|---|---|
| Advertising | Cannot use as selling point |
| Eligibility | Texas residents with covered policies |
| Funding | Assessments on member insurers |
| Coverage | Policies from licensed Texas insurers |
What Is NOT Covered
- Policies from unlicensed insurers
- Self-funded employer plans
- Variable product investment portions
- Government programs
- HMOs (separate guaranty)
Exam Tip: Producers CANNOT use Guaranty Association coverage as a selling point. This is a frequently tested rule.
Did Texas expand Medicaid under the Affordable Care Act?
What platform does Texas use for its health insurance marketplace?
What is the maximum life insurance death benefit coverage under Texas's Guaranty Association?
Can Texas producers use the Guaranty Association as a selling point?
Texas CHIP covers children in families with income up to approximately:
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