Health Care Coverage for Texas Children
( En Español)
Health care coverage helps ensure that your child can get needed medical treatments if he or she gets sick. It also allows your child to get regular checkups to stay healthy. Beginning in 2014, most Americans - including children - must have health insurance that meets minimum federal coverage standards. If you don't get health coverage for your children, you might have to pay a tax penalty.
Most people cover their children by adding them to the insurance they get at work. Health plans that you get at work, as well as most state and government health plans, meet the federal requirement to have health insurance.
In most cases, if your plan provides coverage for dependents, you can keep your children on the plan until they turn 26. Your children don't have to live at home, be enrolled in school, or be claimed as a dependent on your tax return to stay on your plan. If your child is married, your child's spouse and dependents can't be added to your plan. They'll have to get separate coverage.
Texas law allows grandparents to keep their dependent grandchildren on their policies until the grandchild turns 25.
If you don't have insurance through your employer, or if you are unable to add your children to it, consider these other options to insure your children:
- individual coverage from an insurance company or health maintenance organization (HMO)
- coverage through Children's Medicaid
- coverage through the Children's Health Insurance Program (CHIP).
This publication describes the options for getting health care coverage for your child. Visit TexasHealthOptions.com to learn more about health insurance and the types of plans available. TexasHealthOptions.com is an online resource of health care coverage information and is a free service of the Texas Department of Insurance.
You can buy health insurance for your child or your entire family directly from insurance companies and agents. This coverage is called individual coverage because it covers individuals, not members of a group.
You can also buy individual coverage through the federally operated online insurance marketplace at HealthCare.gov, or by calling the marketplace toll-free at 1-800-318-2596.
Comprehensive or major medical individual health insurance plans are required to cover a minimum set of essential health benefits, including pediatric oral and vision services. Insurance companies can't deny coverage to anyone because of health factors, including a preexisting condition or disability.
For lists of insurance companies and HMOs that sell health policies in Texas, call the TDI Consumer Help Line at 1-800-252-3439 or 512-463-6515 in Austin, or visit our website at www.tdi.texas.gov.
If you buy insurance through the federal marketplace, you might be able qualify for a subsidy to help pay for coverage if your employer doesn't offer insurance and your income is between 100 percent and 400 percent of the federal poverty level. In 2013, this would mean a gross annual income between $11,490 and $45,960 for an individual, and between $23,550 and $94,200 for a family of four.
If your income is less than 100 percent of the federal poverty level, you probably won't be eligible for a subsidy. However, you won't have to pay the tax penalty if you don't have health insurance.
For more information about the insurance marketplaces, visit HealthCare.gov or call 1-800-318-2596.
Children's Medicaid and CHIP
You might be able to get coverage through Children's Medicaid or CHIP. Both programs provide health coverage through age 18. Children's Medicaid and CHIP cover
- regular checkups and doctor visits
- prescription drugs and vaccines
- dentist visits, cleanings, and fillings
- eye exams and glasses
- hospital care and services
- mental health care
- treatment of special health needs
- medical supplies, X-rays, and lab tests.
To qualify for Children's Medicaid or CHIP, a child must be
- a Texas resident
- a U.S. citizen or permanent resident (parents' citizenship or immigration status doesn't affect a child's eligibility and is not reported on the application form)
- under age 19
- living in a family that meets the income requirements.
For more information or to apply for Children's Medicaid or CHIP, call the Texas Health and Human Services Commission (HHSC) at 1-877-KIDS-NOW (543-7669) or visit its website at chipmedicaid.org/. You use the same application to apply for both programs.
Children's Medicaid is a state and federal assistance program that provides free health care coverage for eligible low-income Texans. A family's home and personal property aren't included when determining assets, but all or part of the value of a vehicle may be included. Children's Medicaid defines family as any adults - parents, grandparents, relatives, legal guardians, or adult siblings - who are living and caring for uninsured children.
HHSC determines Medicaid eligibility for most children. Children in families that get Temporary Assistance for Needy Families (TANF) automatically qualify. HHSC usually reviews a family's financial situation every six months to determine whether participating children are still eligible.
CHIP is a federal and state health coverage program for families who earn too much money to qualify for Medicaid but can't afford private health care coverage. Private insurance companies and HMOs sell CHIP coverage statewide.
Participating families usually pay a fee that covers all of the family's children in the plan. The fee is based on income and is $50 or less per family every 12 months. Most families also have copayments ranging from $3 to $10 for doctor visits, prescription drugs, and emergency care.
There is a 90-day waiting period for children who were insured in the 90 days before applying for CHIP for the first time. There are several exceptions, including one for children who lost coverage because a parent was laid off, the parent's plan stopped covering dependents, or the parent's marital status changed. After enrolling, families must renew CHIP coverage every year.
CHIP also provides a CHIP perinatal program for Texas residents who are pregnant, uninsured, and not eligible for Medicaid. Coverage starts before your child is born and covers your child for one year. Benefits include 20 prenatal visits; hospitalization that results in delivery; and regular checkups, vaccines, and prescriptions for the baby.
Ask someone at your child's school if the school has an affordable health plan for its students. Schools might also be able to tell you about other ways to get health care coverage, such as any partnerships with local health care providers to provide free or low-cost services.
If none of these options work for you and your family, you and your children might be eligible for indigent health care. For information on indigent care options in your county, contact your county courthouse.
Tax Penalty and Exemptions
If you don't get coverage for your children, and aren't exempt, you'll have to pay a tax penalty. You pay the penalty when you file your federal income taxes.
In 2014, the tax penalty for adults will be $95 or 1 percent of income above the tax filing threshold, whichever is more. In 2015, the penalty increases to $325 or 2 percent of income above the threshold. And in 2016, the penalty will be $695 or 2.5 percent of income above the threshold. For years after 2016, the penalty will be determined based on inflation. The penalty for children is 50 percent of the penalty for adults. There is a family maximum each year.
Some people are exempt from the requirement to have health insurance or pay a tax penalty. You might be exempt if you:
- are a member of a recognized religious sect in existence since 1950 with a conscientious opposition to the acceptance of medical care
- are a member of a health care sharing ministry
- are in the United States illegally
- are in prison
- are a member of a federally recognized American Indian tribe
- had a gap in coverage of fewer than three months
- get a hardship exemption certification from the marketplace.
You're also exempt if the only coverage you can find would cost more than 8 percent of your household's income or if your household income is below the tax-filing threshold. In 2013, the tax-filing threshold is $20,000 for a family.
For More Information or Assistance
For answers to general insurance questions, for information about filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line at 1-800-252-3439 or 512-463-6515 in Austin between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website at www.tdi.texas.gov.
For printed copies of consumer publications, call the 24-hour Publications Order Line at 1-800-599-SHOP (7467) or 512-305-7211 in Austin.
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal's 24-hour Arson Hotline at 1-877-4FIRE45 (434-7345).
The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.
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Last updated: 09/08/2014