Before you start

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

Step-by-step

1
Treat employer coverage as part of the offer, not a perk
Enrol within the new-hire window, typically 30 days from your start date. In a state without Medicaid expansion the employer plan carries far more weight than it would in Oregon or Arizona. Compare the deductible and the out-of-pocket maximum between competing offers, not just the premium or the salary.
Via employerWho: YouFirst 30 days of employment
2
Without an employer plan, enrol through HealthCare.gov
Texas does not run its own exchange, so the federal marketplace is the route. Open enrolment starts on 1 November each year. Outside it you need a qualifying life event such as moving to Texas, losing coverage, marriage or a new child.
OnlineWho: You
3
Run your real expected income through the subsidy estimator
Marketplace subsidies phase in above a floor set by the federal poverty level. In expansion states Medicaid catches people below that floor; in Texas it largely does not. Guessing your income wrong in either direction has consequences at reconciliation, so use the estimator rather than a rule of thumb.
OnlineWho: You
4
Register with a primary care physician before you are ill
Your PCP gates specialist access in most plans. Confirm network status with the practice itself rather than the insurer's directory, which is frequently out of date, and do it while you are healthy — new patient appointments in Dallas often run weeks out.
OnlineWho: You
5
Learn the urgent care versus emergency room distinction, and watch for free-standing ERs
An emergency room visit for something a clinic could treat costs thousands even with insurance. Texas has an unusual density of free-standing emergency rooms in suburban retail settings that look like urgent-care clinics and bill at hospital emergency rates. Read the signage: 'emergency' in the name means emergency pricing.
In personWho: You
6
If you are uninsured, apply to Parkland's financial assistance programme
Parkland Health is the Dallas County hospital district, funded partly by county property tax, and it runs a sliding-scale financial assistance programme for county residents plus a network of community clinics. It is not insurance and it does not travel with you, but it is a real safety net and newcomers rarely know it exists.
In personWho: You

Documents you’ll need

Proof of Texas residence
Income documentation for subsidy or financial assistance eligibility
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's refusal to expand Medicaid creates a real, structural coverage gap.

In expansion states Medicaid covers adults up to 138% of the federal poverty level and marketplace subsidies take over above that. Texas did not expand, so adult Medicaid is limited largely to very low-income parents, people with disabilities and pregnancy coverage. The result is a band of working people who qualify for neither — and the highest uninsured rate in the United States, by a wide margin.

Source: HealthCare.gov — Medicaid expansion and the coverage gap

Parkland is a county hospital district, and residence in Dallas County is what qualifies you.

Parkland is funded partly by a dedicated Dallas County property tax levy and provides charity and sliding-scale care to county residents through its hospital and community clinics. Live one street over the line in Collin or Denton County and you are outside it. For an uninsured newcomer that county boundary is a more consequential line than any city limit.

Source: Parkland Health — financial assistance

Free-standing emergency rooms look like clinics and bill like hospitals.

Texas has an unusual density of free-standing ERs in strip malls and suburban retail parks. They resemble urgent-care clinics and are licensed as emergency departments, which means emergency facility fees for a minor complaint and four-figure bills that insurers process as emergency care. The word 'emergency' on the sign is the tell, and it is the whole tell.

Source: Texas Department of Insurance — free-standing emergency rooms

The deductible is what actually shocks people from national health systems.

US plans commonly require you to pay the first several thousand dollars of care each year before the insurer contributes anything. Someone arriving from the UK, Canada or India reads 'I have insurance' as 'I am covered', then receives a $2,800 bill for a scan. Read the deductible and the annual out-of-pocket maximum before you look at the premium.

Source: community-reported

Common mistakes to avoid

Accepting a Dallas job offer without health insurance and assuming a marketplace plan will be cheap.
Missing the 30-day new-hire enrolment window.
Walking into a free-standing emergency room thinking it is an urgent-care clinic.
Choosing a plan on premium alone and meeting a five-figure out-of-pocket maximum.
Assuming Medicaid is a fallback — in Texas, for a working-age adult without children, it usually is not.

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