Who is Eligible For Group Health Insurance in Texas?

A stethoscope resting on a medical chart with a red heart.

Group Health Insurance in Texas

Obtaining insurance coverage in a business setting is a more complex process than buying insurance as an individual. Most decently sized businesses choose group health insurance benefits for their employees. The question is, however, what are the qualifications for both individuals and businesses for group health insurance in Texas?
Let’s briefly examine how group coverage works and how companies and individuals are affected by the requirements for eligibility.

A Basic Overview of Group Coverage

There are other groups that may be included in group insurance coverage, but for this article we’re strictly referring to a business with employees. Group medical coverage is a single policy issued to a group of individuals (or employees) and their dependents. On the flip side of the coin is individual medical coverage, which is a single policy provided to single person or family.
There are specific rules and regulations that group health insurance in Texas coverage must adhere to. This is primarily because of the calculated risk associated with specific coverage. For individual coverage, unlike group health insurance, premiums are based on the market and the general cost of coverage throughout the market you live in.
However, for small business group health insurance in Texas, the insurer dictates the premium price based on risk factors throughout the entire group. The Affordable Care Act requires businesses to provide health insurance to their employees or risk a $100 a day per employee fine.

Eligibility for Companies

Regardless of their health status, individual employees are guaranteed group coverage by their employee if they choose to purchase it. Both small and large companies are required to offer coverage. Businesses with more than 50 full-time employees, or full-time equivalent, fall under the Employer Shared Responsibility Payment. Small businesses with fewer than 50 full time or full-time equivalent employees, are not required to pay no penalty for not offering health insurance.
However, regardless of the size of the company, all employers are required to provide specific information about coverage options available on the marketplace.

Plan Requirements

Employers also have to adhere to strict group health insurance requirements. These include:
• Plans with No More than a 90 Day Wait Period
• Employers must provide a Summary of Benefits and Coverage (SBC) to employees
• Dependent Coverage Extension
These rules and regulations vary depending on the group health insurance plan. For more information about the requirements, Minimum Essential Coverage, and more, talk to our experienced PCI team.

Eligibility for Individuals

For individuals, group health coverage extends to any employee who works 30 or more hours per week on average. Coverage also extends to their dependents, including children, spouses and anyone they may be required to take care of physically or financially. Employers are required to share their coverage options with employees upon hiring. Additionally, dependent children may be covered until age 26. However, they’re employer must not offer health care coverage for the rule to apply.
Employees cannot be denied coverage for pre-existing conditions or because of previous medical conditions. Employees must be enrolled to ensure coverage for all of their dependents. If an employee does not enroll, dependents do not have coverage through the employer.


Group health insurance is one of the primary benefits of the Affordable Care Act. It is designed to provide coverage to all employees who fall under the full-time law. However, understanding how eligibility works and what coverage options are available, is critical to pursuing the best possible coverage available. Employers too need to fully understand the requirements for their group health insurance before committing to single plan.
For more information about group health insurance in Texas, contact the Primary Care Insurance Solutions team. We’d be happy to help.

Frequently Asked Questions

What is the difference between group medical coverage and individual medical coverage?

Group medical coverage is a single policy issued to a group of individuals, usually employees and their dependents, within a business setting. On the other hand, individual medical coverage is a policy provided to a single person or family.

How are premiums determined for small business group health insurance in Texas?

For small business group health insurance in Texas, the insurer sets the premium price based on risk factors across the entire group, as opposed to individual coverage where premiums are based on the market and general cost of coverage in the specific region.

What are the group health insurance requirements for employers in Texas?

Employers in Texas need to adhere to several requirements, including offering plans with no more than a 90-day wait period, providing a Summary of Benefits and Coverage (SBC) to employees, and ensuring dependent coverage extension. The exact rules can vary depending on the specific group health insurance plan.

Who is eligible for group health coverage as an individual in Texas?

Individuals eligible for group health coverage are those who work an average of 30 or more hours per week. This coverage also extends to their dependents, such as children, spouses, and anyone they might be obligated to support physically or financially. Additionally, dependent children can be covered until the age of 26 under specific conditions.

Related Posts