Before you start

Texas residence
Income information for subsidy or financial assistance 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 does far more work than it would in Oregon or Arizona. Compare deductibles and out-of-pocket maximums between competing offers rather than only 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 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
Apply to Harris Health if you are uninsured and live in the county
Harris Health is the Harris County public hospital system — Ben Taub, LBJ and a network of community health centres — and its Financial Assistance Program gives eligible county residents access on a sliding scale, historically known as the Gold Card. It is not insurance, it does not travel outside the county, and it is heavily used, so apply before you need it rather than in an emergency.
In personWho: You
4
Register with a primary care physician while you are well
Your PCP gates specialist access on most plans. Confirm network status with the practice itself rather than the insurer's directory, which is frequently out of date. New patient appointments in this metro often run weeks out.
OnlineWho: You
5
Learn the urgent care versus emergency room distinction, and spot 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. The word 'emergency' on the sign is the whole tell.
In personWho: You
6
Plan for heat and for storm-season medication
Heat illness is a real presentation here from May to September, and multi-day power outages after storms threaten anything that needs refrigeration. If you or a family member depends on refrigerated medication, oxygen concentrators or dialysis, register with your provider's emergency programme and know where your nearest cooling centre is before the season starts.
In personWho: You

Documents you’ll need

Proof of Texas residence and Harris County residence for Harris Health
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

Harris Health eligibility turns on county residence, and the county line is not the city line.

Harris Health is funded by a dedicated Harris County property tax levy and serves county residents through Ben Taub, LBJ and its community clinics. Move a few miles into Fort Bend or Montgomery County — which enormous numbers of Houston commuters do — and you are outside it entirely, with a different and generally thinner safety net. For an uninsured household that boundary matters more than any city limit.

Source: Harris Health System — financial assistance

Texas's refusal to expand Medicaid creates a 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.

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

Being treated at a world-class hospital does not mean being billed like one.

The Texas Medical Center's reputation attracts people who assume access follows. It does not — MD Anderson, Houston Methodist and Texas Children's are private institutions with their own network agreements, and being in Houston gives you no automatic entitlement to them. Before choosing a plan, check whether the specific TMC institution you care about is in that plan's network, because several are not in the cheaper marketplace tiers.

Source: community-reported

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, are licensed as emergency departments, and charge emergency facility fees for minor complaints — producing four-figure bills that insurers process as emergency care. Read the sign carefully; 'emergency' in the name means emergency pricing.

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

Common mistakes to avoid

Accepting a Houston job offer without health insurance and assuming a marketplace plan will be cheap.
Assuming a Texas Medical Center hospital is in your plan's network without checking.
Moving to a suburb outside Harris County and losing access to Harris Health without realising.
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.

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