Choosing health insurance in Texas feels overwhelming to most people. Premiums, deductibles, networks, co-pays, out-of-pocket maximums — what do they all mean, and which plan is the best deal for you? This guide cuts through the confusion with 8 clear steps.
Step 1: Know Your Coverage Options
ACA Marketplace: for individuals and families without affordable employer coverage. Open Enrollment runs November 1 to January 15. Many Texans qualify for income-based tax credits that lower premiums; check yours at HealthSherpa.
Employer-Sponsored Insurance — If your job offers health benefits, this is usually your best starting point. Always compare cost, network, and benefits before assuming it is automatically the best deal.
Medicare — For Texans 65 and older or those with qualifying disabilities. Includes Original Medicare (Parts A and B), Supplement plans, Advantage plans (Part C), and Part D drug coverage.
Medicaid/CHIP — For very low-income Texans and children. Apply at YourTexasBenefits.com.
Short-Term Plans — Temporary coverage for gaps. Lower premiums but no pre-existing condition coverage.
ICHRA — If your employer offers an ICHRA, they give you tax-free money to buy your own marketplace plan.
Step 2: Figure Out Your Subsidy Eligibility
If you are on the ACA Marketplace, tax credits are often the biggest factor in your decision. They are based on your income and household size, and for some people they bring the premium very low, even to $0.
Check your exact subsidy at HealthSherpa — enter your zip code, household size, and income to see your real premium after subsidies.
Step 3: Understand the Five Key Numbers
- Premium — Your monthly payment whether you use insurance or not
- Deductible — The amount YOU pay before insurance kicks in
- Co-pay — A flat fee for specific services (e.g., $30 for a doctor visit)
- Co-insurance — Your percentage share after the deductible (e.g., 80/20 means plan pays 80%, you pay 20%)
- Out-of-Pocket Maximum — The most you will pay in a year; after this, the plan pays 100%
The critical calculation: Add your annual premium to your maximum possible out-of-pocket. That is your worst-case annual cost. Compare THAT number — not just the premium — across plans.
Step 4: Choose the Right Metal Tier
| Tier | Plan Pays | You Pay | Best For |
|---|---|---|---|
| Bronze | 60% | 40% | Healthy, low medical use, emergency-only protection |
| Silver | 70% | 30% | Most people — also unlocks Cost-Sharing Reductions |
| Gold | 80% | 20% | Regular medical needs, ongoing prescriptions |
| Platinum | 90% | 10% | High medical usage, predictable care needs |
Silver plan tip: if your income is up to 250% of the federal poverty level, you may qualify for Cost-Sharing Reductions (CSR). You only get them on a Silver plan. CSR lowers your deductible and copays, so a Silver plan can work more like a Gold plan.
Step 5: Check Your Network
A plan’s network is the list of doctors and hospitals that accept it at in-network rates. Going out-of-network can cost 2-5x more. Before enrolling, verify your primary care doctor, preferred hospital, and any specialists you see regularly are all in-network.
Network types: HMO (in-network only, referrals required, lowest premiums) | PPO (any provider, no referrals, higher premiums, most flexibility) | EPO (in-network only, no referrals) | POS (hybrid: referrals needed, some out-of-network coverage).
Step 6: Check Your Prescriptions
Each plan has a formulary — a drug coverage list organized into tiers with different co-pays. Before enrolling, list every prescription you take regularly and verify each is covered on the plans you are considering. This single step can shift your plan decision significantly.
Step 7: Budget for Dental, Vision, and Hearing
ACA plans include dental and vision for children, but usually not for adults. If you want adult dental or vision, budget for a separate plan. Many can be bought any time of year.
Step 8: Work With a Licensed Agent — It’s Free
Working with a licensed health insurance agent costs you nothing. Agents are paid by the insurance carriers, not by you. A good agent calculates your exact subsidy eligibility, compares 10-20 plans side-by-side, verifies your doctors are in-network, checks your prescriptions across plan formularies, and explains the real total cost — not just the premium.
At Brilliant Insurance, David Gustafson does all of this for Texans at zero cost to you.
Book a Free Health Insurance Review: Schedule Now | Call: (972) 750-3031 | TX License #2116912 | Serving all of Texas
Talk to a licensed agent
Brilliant Insurance is an independent agency in Plano, Texas. David Gustafson is a licensed agent (Texas License #2116912, NPN 18037219) and can compare options from many carriers for you, at no cost to you.
Book a free 30-minute call or call (972) 750-3031.
This article is general information, not advice for your situation. Plans, prices and availability vary by carrier, age, health and location. Coverage is subject to the policy’s terms, limitations and exclusions.
