Texas health insurance marketplace guide 2023

Texas has one of the highest exchange enrollments in the country, trailing only Florida. During the open enrollment period for 2023 coverage, more than 2.4 million people enrolled in private qualified health plans (QHPs) through the Texas exchange. This was by far a record high, eclipsing the previous record high of 1.8 million enrollees the year before. 

According to US Census Bureau data, Texas had the highest uninsured rate in the country in 2013, at 22.1%, and it has continued to have the highest uninsured rate in the nation ever since. Although 18.4% of Texans were still uninsured as of 2019, a substantial number of Texas residents have obtained health coverage since the ACA was implemented.

However, the number of people gaining coverage would be far higher if Texas were to accept federal funding to expand Medicaid under the ACA. Among adults with income up to 138% of the poverty level (ie, the population that would be Medicaid-eligible if Texas were to expand Medicaid), Texas still has the highest uninsured rate in the country; 45% of the state’s lowest-income residents are without health coverage. 

The open enrollment period for individual/family health coverage runs from November 1 to January 15 in Texas. 

Outside of that annual open enrollment window, you’ll need a special enrollment period to enroll or make a change to your coverage. In most cases, you’ll need a qualifying life event in order to qualify for a special enrollment period. But some special enrollment periods (such as the enrollment opportunity for Native Americans, or for people earning under 150% of the poverty level) aren’t tied to a specific life event.

If you want more information about health insurance enrollment opportunities, you can read more in our guide to open enrollment and guide to special enrollment periods, both of which are comprehensive resources.

For 2023, three new insurers joined the Texas individual/family market: Cigna, Imperial Insurance Companies, and Ascension Personalized Care. But Friday and Bright both left the Texas market at the end of 2022 (the Texas Department of Insurance asked Friday to stop offering plans and the company has since been placed into receivership and ordered to liquidate; Bright opted to exit the individual market in every state where they had offered coverage in 2022). So Texas has 15 insurers offering exchange plans for 2023, up from 14 in 2022.

The following insurers offer plans in the Texas exchange for 2023, with plan availability varying from one location to another:

• Aetna CVS Health (expanded into 18 additional counties for 2023)
• Ascension Personalized Care (new for 2023)
• Blue Cross Blue Shield of Texas
• Celtic/Ambetter (Ambetter from Superior Health Plan)
• CHRISTUS
• Cigna (new for 2023)
• Imperial Insurance Companies (new for 2023)
• Moda Health Plan
• Molina
• Oscar
• Sendero 
• SHA/FirstCare
• Community Health Choice
• Scott & White Health Plan
• UnitedHealthcare of Texas

The exchange in Texas had 15 carriers offering plans in Texas for 2015, up from 12 in 2014.  Only Michigan and Ohio had more carriers in their exchanges, with 16 each. By 2018, the number of participating insurers had dropped to eight, but it had rebounded to 14 as of 2022.

UnitedHealthcare, Aetna, Cigna, Allegian Health Plan, and Scott & White Health Plan all exited the Texas marketplace at the end of 2016. So by 2017, only ten insurers were offering plans in the Texas exchange, and most of them only offered coverage in a fraction of the state’s 254 counties. In the majority of the counties, there were one, two, or three carriers offering plans. And there were no PPO plans available in the exchange by 2017; insurers had opted to switch to more economical HMOs and EPOs as a cost-saving measure.

At the end of 2017, Humana and Prominence left the Texas marketplace (and the entire individual market). But both insurers had only offered plans in a tiny fraction of the counties in Texas, so their exits did not affect most of the state.

By 2021, insurers had started to return to the Texas exchange. Friday Health Plan joined the exchange, and Scott & White Health Plan rejoined the exchange, after previously exiting at the end of 2016. This brought the total number of participating insurers to ten. Molina expanded its coverage area into five counties that previously only had plans available from Blue Cross Blue Shield of Texas and/or Ambetter.

And for 2022, there was an influx of insurers: United Healthcare rejoined the exchange, along with Aetna/CVS. In addition, Moda Health Plan and Bright Health Care also joined the exchange, bringing the total number of exchange insurers to 14.

For 2023, Friday and Bright exited the Texas exchange, while Ascension Personalized Care, Imperial Insurance Companies, and Cigna joined, bringing insurer participation to 15. 

According to the federal rate review website, the following average rate changes were implemented by insurers in Texas for 2023, applicable to full-price premiums (keeping in mind that very few enrollees pay full price, as most are eligible for premium subsidies; caveats described in more detail below):

• Aetna/CVS: 6.92% decrease
• Celtic/Ambetter (Superior Health Plan): 10.7% increase
• Blue Cross Blue Shield of Texas: 3.42% increase
• CHRISTUS: 7.61% increase 
• Community First Insurance Plans: 3.14% decrease
• Community Health Choice: 10.19% increase
• Moda: 5.57% increase
• Molina: 17.67% increase
• Oscar: 10.9% increase
• Sendero: 1.8% decrease
• SHA/FirstCare: 4.3% increase (As of 2019, Scott & White Health Plans acquired FirstCare)
• Baylor Scott & White Health Plan: 1.7% increase
• UnitedHealthcare: 13.46% increase
• Ascension Personalized Care: New for 2023, so no rate change
• Cigna: New for 2023, so no rate change
• Imperial Insurance Companies: New for 2023, so no rate change

Bright had proposed an 11% rate increase and Friday had proposed a 30% rate increase, but both insurers ultimately opted to leave the market so their rates were not applicable for 2023.

According to ACA Signups, the weighted average rate increase (after accounting for Bright and Friday leaving the market) amounted to about 4.9% for 2023.

As of 2022 (for health plans effective in 2023), Texas conducts its own rate review. In previous years, the federal government did the rate review, as Texas was one of only three states that didn’t have its own effective rate review program. That changed as of 2022, so the Texas Department of Insurance now conducts the rate review for ACA-compliant health plans.

Whenever we talk about average rate increases — from a single insurer or as a statewide average — it’s important to keep in mind that the actual rate changes that individual enrollees see from one year to the next can be very different from the average. There are several reasons for this:

• The proposed and approved rate changes only apply to full-price plans, and very few enrollees pay full price for plans that are purchased through the exchange (during the open enrollment period for 2023 coverage, more than 95% of Texas exchange enrollees were eligible for premium subsidies). For subsidized enrollees, the year-over-year net rate change depends on how their own plan’s rates are changing, as well as how their subsidy is changing (which depends on the cost of the benchmark plan and the enrollee’s projected income for the coming year).
• Overall average rate changes don’t account for the fact that premiums increase with age. Even if a health plan has an overall rate change of 0% for several years in a row, individual enrollees within that plan will continue to pay more each year (assuming they don’t get a subsidy), simply because higher rates apply to older enrollees and we all continue to get older.
• A weighted average lumps all the plans together in order to paint a general picture. But different insurers offer plans in each region of the state, and each insurer’s rate change is different. So the specific rate change that applies to a given enrollee can vary quite a bit from the average.

For perspective, here’s a look at how rates have changed in the Texas exchange over the years:

2015: Twelve carriers offered a total of 95 different health plans in the Texas exchange in 2014. This increased to 15 in 2015, and a Commonwealth Fund analysis found an average rate increase of 5% in the Texas exchange for 2015.  For silver plans, it was just 2%. Rate increases tended to be lower in urban areas of Texas.

2016: Average premiums in the individual market in Texas increased by 15.8% for 2016, although there was considerable variation from one insurer to another. Rates decreased for five carriers, and increased by between 5% and 34% for the remaining carriers. Statewide, the average benchmark plan was 5.1% more expensive in 2016, which means subsidies were higher, but only modestly so.

2017: For 2017, average premiums in the individual market in Texas rose by about 34%. Although premium subsidies grow to keep pace with premiums, they’re based on the cost of the benchmark plan (second-lowest-cost silver plan) in each area. HHS reported that for a 27-year-old enrollee, the average second-lowest-cost silver plan in the Texas exchange was 18 percent more expensive in 2017 than it had been in 2016 (that’s a little lower than the 2017 national average increase of 22% for second-lowest-cost silver plans). So although subsidies did increase in 2017 in Texas, the increase may have been smaller than the premium increase that some enrollees experienced, leaving them with higher net premiums.

2018: In most cases, Texas insurers filed rates in the spring/early summer 2017 that assumed federal funding for cost-sharing reductions (CSR) would continue in 2018. But by the time CSR funding was officially eliminated by the Trump Administration in October 2017, all of the Texas insurers had filed rates that were based on the assumption that CSR funding would not continue. Texas did not instruct insurers on how to add the extra cost to their premiums, so they had to option of spreading it across the premiums for all plans, adding it to all silver plan rates, or adding it to only on-exchange silver plan rates. In some cases, the Texas filings make it clear that the cost of CSR was only being added to silver plans, and at least one insurer (CHRISTUS) filed an additional revised rate structure to ensure that the cost of CSR would only be added to on-exchange silver plans. Sendero’s rate filing indicated that they would market an off-exchange-only silver plan in addition to their exchange plans (off-exchange-only plans do not have to include the cost of CSR in their rates).

There was some uncertainty in terms of exactly how large the approved rate increase was for 2018. But the average premium (before any subsidies were applied) in the Texas exchange was $404/month in 2017, and it grew sharply, to $543/month, in 2018.

2019: At ACA Signups, Charles Gaba calculated an average rate increase of 2.25% for 2019, including a few insurers that only offer plans outside the exchange. As was the case for 2018, the Texas Department of Insurance did not instruct insurers on how to add the cost of cost-sharing reductions (CSR) to premiums for 2019. The CSR approach was instead left to each insurer’s discretion. Adding the cost of CSR only to silver plan premiums (in many cases, only to on-exchange silver plan premiums) is the most popular approach across the country, but insurers also had the option to add the cost of CSR to all plans.

2020: Eight insurers offered plans in the Texas marketplace for 2020. Gaba calculated a weighted average rate decrease of 1.4% for 2020, including the insurers that only offer plans outside the exchange.

2021: Ten insurers offered plans in the Texas marketplace for 2021. Gaba calculated a weighted average rate increase of 7.4%, although as always, the average doesn’t tell the whole story.

2022: Across all of the existing carriers, the average rate change was somewhere in the range of a 1.5% to 5% increase, although some of the enrollment numbers are unavailable, making it impossible to determine a fully weighted average. Nationwide, the average rate change for 2022 amounted to an increase of about 3.5%, making the Texas rate changes very much in line with the national average.

In June 2021, Texas enacted House Bill 3924. The legislation, which took effect in September 2021, allows Texas Farm Bureau to sell medically underwritten health plans that are not considered health insurance. This means that the plans are exempt from state and federal health insurance regulations.

The Texas Farm Bureau made these plans available as of mid-2022.

Since the plans are not subject to insurance rules, they are not required to cover essential health benefits, cap out-of-pocket costs, or provide guaranteed-issue coverage. H.B.3924 specifies that the plans cannot exclude a pre-existing condition for more than six months after a person enrolls. But the plans are allowed to charge applicants higher premiums based on their medical history, or reject the application altogether.

People who aren’t eligible to enroll in the Farm Bureau plans due to their medical history will still be able to sign up for ACA-compliant health insurance (through the Texas exchange or directly through an insurance company) during open enrollment or a special enrollment period. But consumer advocates worry that if healthy enrollees shift over to the Farm Bureau plans, they will leave the ACA-compliant risk pool with less healthy membership and thus higher premiums for everyone.

It’s worth noting, however, that the American Rescue Plan’s temporary elimination of the “subsidy cliff” means that most people are now eligible for premium subsidies in the exchange, at least through the end of 2025 (and Congress might extend that again). There are no subsidies available for Farm Bureau plans, so they’re really only an attractive alternative for healthy people who would otherwise have to pay full price for an ACA-compliant plan. And since more people are now eligible for premium subsidies in the exchange, there are fewer people who are likely to enroll in Farm Bureau plans instead.

Indiana, Iowa, Kansas, South Dakota, and Tennessee have similar laws on their books, allowing medically underwritten, non-insurance, Farm Bureau plans to be sold (Nebraska also has Farm Bureau health plans available, but they can only be purchased by people actively involved in agriculture, and they do not use medical underwriting).

The legislation, which passed in the Texas Senate by a vote of 29 to 2 and unanimously in the House, is robust. But it only applies to the 16% of Texas residents — those who have state-regulated private plans (self-insured plans, which are used by most very large businesses, are not state-regulated). This is why the federal No Surprises Act was so important, as it protects people who don’t have state-regulated health insurance.

The Texas law prohibits the out-of-network provider from billing the patient for amounts in excess of the patient’s regular cost-sharing responsibilities (ie, copays, deductible, coinsurance), and instead requires the provider and the patient’s insurance to enter into mediation or arbitration, overseen by state regulations, to come to a payment agreement, without the patient being stuck in the middle of the financial dispute.

The Texas Department of Insurance was tasked with developing the rules related to the mediation and arbitration process; updates on that process are available here. The Department announced in November 2019 that FAIR Health had been selected as the benchmarking database that will be used in arbitration cases.

The process of rulemaking for the implementation of SB1264 was complicated. Controversy arose when the Texas Medical Board proposed having all out-of-network providers give patients consent forms (the law intended for those forms to only be used when a patient knowingly wants to use an out-of-network provider). Consumer advocates were concerned that the Board’s proposal would essentially result in patients having to deal with confusing paperwork and potentially signing away their balance billing protections. But the Board withdrew that proposal in early December.

Texas also enacted SB1037 in 2019, ensuring that when a surprise balance bill is sent to collections, it won’t show up on the person’s credit report. As long as the person had health insurance at the time of the treatment and the bill is for out-of-network emergency care or out-of-network providers who treated the patient at an in-network facility, the unpaid bill won’t affect the person’s credit report.

SB1742, also enacted in 2019, requires health plan provider directories to make it clear whether specialists practicing at in-network facilities are also in-network. In addition, the legislation imposes new rules related to prior authorization, including a readily available list of services that are subject to prior authorization requirements, and information about the insurer’s total volume of prior authorization requirements and denials.

Here’s a look at how enrollment has changed over the years in the Texas marketplace (in terms of the number of people signing up for private plans through the exchange during the open enrollment window):

• 2014: 733,757 people enrolled (Open enrollment for 2014 coverage lasted six months — October 2013 through March 2014 — plus an extension at the end that continued into April.
• 2015: 1,205,174 people enrolled.
• 2016: 1,306,208 people enrolled. Prior to 2022, this had been the record-high enrollment year for the Texas marketplace. The Texas Hospital Association mounted a significant marketing campaign to get people enrolled in health insurance through the exchange for 2016, and their efforts seemed to pay off. Across all 38 states that used Healthcare.gov, eight of the ten local areas with the fastest-growing enrollment numbers in the final week of the 2016 enrollment period were in Texas: Corpus Christi, Harlingen, Laredo, El Paso, Odessa-Midland, San Antonio, Abilene-Sweetwater, and Lubbock.
• 2017: 1,227,290 people enrolled. The Trump administration’s decision to suspend HealthCare.gov’s marketing campaign in the final days of open enrollment likely played a role in the enrollment declines, as did uncertainty about the future of the ACA combined with fairly substantial rate increases — offset by subsidies for those who were subsidy-eligible, but not for those who had to pay full-price for their plans.
• 2018: 1,126,838 people enrolled. The enrollment drop was similar to the national trend across states that use HealthCare.gov, where average enrollment declined by 5% in 2018. The Trump administration reduced funding for HealthCare.gov’s marketing and enrollment assistance, and premiums in the individual market increased significantly again.
• 2019: 1,087,240 people enrolled. The individual mandate penalty was eliminated, and access to short-term plans was expanded. Both of these changes likely resulted in fewer people enrolled in ACA-compliant plans.
• 2020: 1,116,293 people enrolled. Most states that use HealthCare.gov saw another enrollment decline in 2020, but enrollment grew in Texas.
• 2021: 1,291,972 people enrolled. And nearly 417,000 additional people enrolled during the COVID-related special enrollment period in 2021 (more than triple the normal enrollment rate during the same timeframe, when a qualifying event would normally be necessary in order to sign up for coverage).
• 2022: 1,840,947 people enrolled, far surpassing any previous years. Open enrollment was longer than it had been for the last few years, and the American Rescue Plan’s subsidy enhancements made coverage more affordable. The Biden administration also substantially increased the funding for marketplace outreach and enrollment assistance.
• 2023: 2,410,810 people enrolled