Before you start

Texas residence
Income information for subsidy eligibility
An SSN or ITIN for the marketplace application
A qualifying life event, if enrolling outside the annual open-enrolment window

Step-by-step

1
Enrol in your employer's plan within the new-hire window
Typically 30 days from your start date, and missing it can mean waiting for the next open enrolment. In a non-expansion state this is the most important form you will fill in during your first month. Compare the deductible and out-of-pocket maximum, not just the premium.
Via employerWho: YouFirst 30 days of employment
2
Without an employer plan, use HealthCare.gov
Texas runs no state exchange, so the federal marketplace is where individual plans are bought. Open enrolment runs on a fixed annual calendar; outside it you need a qualifying life event such as moving state, losing coverage, marriage or a birth. There is no state-run alternative if you miss it.
OnlineWho: You
3
Check Texas Medicaid and CHIP eligibility, but do not assume
Texas has not expanded Medicaid to low-income adults. Children's coverage through CHIP and Medicaid is considerably broader than adult coverage, so a family can find the children eligible and the parents not. Apply through YourTexasBenefits and check each household member separately.
OnlineWho: You
4
Register with the county system if you have no cover
University Health is Bexar County's public hospital system and operates a county financial assistance programme for eligible low-income residents, alongside federally qualified health centres that charge on a sliding scale. This is the practical safety net in a state without Medicaid expansion. Register before you need it, not in an emergency.
In personWho: You
5
Register with a primary care physician in month one
Do it while you are well. An established relationship is what gets you referrals and urgent slots later, and confirming the practice is in your network before the first visit avoids an out-of-network bill for a routine appointment.
In personWho: YouMonth 1
6
Learn the urgent care versus emergency room distinction
An emergency room visit for something a clinic could treat can cost thousands even when insured. Urgent care handles fractures, stitches and infections far more cheaply. Freestanding emergency rooms in Texas look like urgent care from the car park and bill like hospitals — read the sign carefully.
In personWho: You
7
Plan for heat, allergy and air quality
Summer heat here is a genuine medical risk rather than a discomfort, and cedar fever — an intense allergy season from Ashe juniper pollen from roughly December to February — catches almost every newcomer off guard in their first winter. Bexar County has also been designated in non-attainment for ozone, which is the reason the emissions programme is arriving.
In personWho: You

Documents you’ll need

Proof of Texas residence
Income documentation for subsidies
SSN or ITIN
Immigration documents for marketplace eligibility categories
Evidence of losing prior coverage, if using a special enrolment period

Things most newcomers don’t know

Texas has no Medicaid expansion, which is the single biggest difference from the other US cities here.

In Maryland, Michigan, Ohio, Nevada and California an adult earning below the subsidy floor is covered. In Texas they are frequently covered by nothing at all. That makes an employer health plan a material part of a job offer rather than a benefit line, and makes a gap between jobs genuinely risky. Weigh it when comparing a Texas salary to one elsewhere.

Source: Texas Health and Human Services / HealthCare.gov

The county hospital system is the safety net, and it works — if you register.

University Health is Bexar County's public system, funded partly by county property tax, and operates a financial assistance programme for eligible residents. Combined with the sliding-scale community clinics it is a genuine second layer that many non-expansion metros lack. It requires an application and proof of income; doing that while healthy is far easier than doing it from an emergency department.

Source: University Health / Bexar County

Cedar fever will surprise you in your first winter.

Ashe juniper pollen peaks in central Texas from roughly December to February and produces symptoms severe enough that people assume they have flu. It is one of the highest pollen counts recorded anywhere. Newcomers with no history of allergy frequently develop it after a season or two here.

Source: community-reported

A freestanding emergency room is not an urgent care clinic.

Texas has an unusually large number of freestanding emergency departments in suburban retail parks. They are licensed as emergency facilities and bill accordingly, and people walk into them for stitches thinking they are a clinic. Check whether the sign says 'emergency' before you walk in — the price difference is an order of magnitude.

Source: Texas Department of Insurance

Common mistakes to avoid

Assuming Medicaid will catch you if income is low. In Texas, for an adult, it usually will not.
Missing HealthCare.gov open enrolment and finding Texas has no state fallback.
Missing the 30-day new-hire enrolment window at a new employer.
Walking into a freestanding emergency room for something urgent care handles.
Waiting until you are ill to apply for county assistance or register at a sliding-scale clinic.

Some of this may be out of date. Spotted something inaccurate? Help us keep it right for the next newcomer.

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