Eligibility for Medicare in Texas
Medicare is designed to provide and reduce the cost of healthcare services in the United States. It is a federal health insurance program.
As of 2020, there were approximately 4.3 million Texans enrolled in Medicare. You’re not alone. If you meet the eligibility criteria, you’ll be joining the ranks of the 14% of Texans who are Medicare beneficiaries.
In Texas, as in the rest of the country, you’re eligible for Medicare if you meet the following criteria:
- You’re aged 65 or older.
- You’re younger than 65 with eligible disabilities by the Social Security Administration.
- You have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
If you’re a Texan and meet the criteria above, you can apply for Medicare. As of 2019, 86% of Medicare beneficiaries were eligible due to age, while 14% were eligible due to a Social Security Administration-approved disability.
Becoming eligible for Medicare is a significant milestone. Continue reading to learn about your Medicare options in Texas, plus how and when to apply.
Public and Private Medicare Plan Options in Texas
In Texas, you have access to both public and private Medicare plan options. Your public option is called Original Medicare and includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Original Medicare doesn’t cover 100% of costs and most people have a private health plan, like Medicare Part C or Medicare Supplement. Read more below.
You also have the option of applying through a private health plan approved by the Centers for Medicare and Medicaid Services (CMS). Private options include Medicare Part C (Medicare Advantage), Medicare Part D (Prescription Drug Coverage), and Medicare Supplement (Medigap).
The Public Plan Option: Original Medicare in Texas
Medicare Part A in Texas
Medicare Part A (hospital insurance) is part of Original Medicare. It covers inpatient care, skilled nursing facility care, short-term nursing home care, hospice care, and home health care. If you choose to enroll in a Medicare Advantage (Medicare Part C) or other Medicare plan, there might be different rules. But the plan you choose must provide at least the same coverage as Part A Original Medicare.
Did you or your spouse earn 40 credits or work and pay FICA taxes for at least ten years? If you meet these criteria and meet the Medicare eligibility requirements, you’ll likely qualify for Medicare Part A that’s premium-free. If not, you will probably pay a monthly or quarterly premium.
Read more about the inpatient, skilled nursing facility, short-term nursing home care, hospice, and home health care that Medicare Part A provides in What is Medicare Part A and What Does it Cover?
Medicare Part B in Texas
Medicare Part B (medical insurance) is part of Original Medicare. Medicare Part B covers your basic medical needs, such as doctor visits, lab tests, and medical equipment. Coverage includes orthopedic, cardiology, radiology, and any other specialist services. You can also get screenings for medical conditions, shots, and an annual wellness checkup without a copay, among other services.
If you are eligible to enroll in Medicare Part A, you can also enroll in Part B. However, Part B is not premium-free and doesn’t cover 100% of costs. Instead, Part B covers 80% of costs, with the remaining 20% being your responsibility.
Your Medicare Part B costs include an annual deductible, cost-sharing, and a monthly or quarterly premium. Your monthly premium is based upon your income, so if your income fluctuates or if you make above a certain threshold, your monthly premium may be higher.
Should You Enroll in Medicare Part B?
Because you must pay a premium for Part B coverage, you can turn it down or delay enrollment. If you make a choice not to sign up for Medicare Part B and then decide to later on, your medical coverage could be delayed, and you may have to pay a higher monthly premium for as long as you have Medicare Part B.
That premium could go up 10 percent for each 12-month period you were eligible for Part B and chose not to sign up—unless you qualify for a Special Enrollment Period (SEP).
When and How to Apply for Medicare Part A & B in Texas
Are you 65 or turning 65? Your Initial Enrollment Period begins three months before your 65th birthday, includes the month you turn age 65, and ends three months after your birthday. You have a seven-month window to enroll in Medicare.
Should you not enroll in Medicare Part A & B during your Initial Enrollment Period, the two other chances you have is the Open Enrollment Period from January 1st through March 31st. Your coverage would begin on July 1st of the year you enroll. Or a Special Enrollment Period, if you’re eligible.
Already Receiving Social Security Benefits
Suppose you’re already receiving Social Security or Railroad Retirement Board (RRB) benefits. In that case, you’ll be automatically enrolled in Medicare Part A & B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A & B will begin on the first day of the prior month.
Not Yet Retired
Do you have private health insurance through your or your spouse’s employer? You can choose to have that private insurance and Part A until you retire and receive Social Security benefits. If you aren’t receiving benefits from the Social Security Administration (SSA) or RRB at least four months before turning 65, you’ll need to sign up with SSA to get Medicare Part A and Part B.
Under 65 and Have A Disability
You will automatically receive Medicare Part A and Part B after receiving disability benefits from the Social Security Administration for 24 months or certain disability benefits from the RRB for 24 months. You should receive your red, white, and blue Medicare card in the mail three months before your 25th month of disability (your 22nd month of disability).
I Have End-Stage Renal Disease
You can choose whether to enroll in Medicare or not. You can enroll in Part A and Part B if you’re eligible for Medicare because of End-Stage Renal Disease (ESRD). You can choose whether or not to sign up for Part B. However, you’ll need Part A and Part B to cover certain services under Medicare, including dialysis and kidney transplant services.
I Have Amyotrophic Lateral Sclerosis
If you have Amyotrophic Lateral Sclerosis (ALS), you’ll automatically get Medicare Part A and Part B the month your disability benefits begin. You’ll receive your red, white, and blue Medicare card the month that your disability benefits begin.
Apply for Part A & B Medicare in Texas
You can sign up for Medicare Part A and Part B through the Social Security Administration. Speak with a local Medicare agent if you need help applying or have questions. Call (623) 223-8884 or schedule an appointment online.
Here are the five ways to apply:
- Apply online at Social Security Medicare Benefits.
- Visit your local Social Security office. Find your field office.
- Call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778).
- If you worked for a railroad, call the RRB at 1-877-772-5772.
- If you’ve already signed up for Part A and want Part B, complete an Application for Enrollment in Part B (CMS-40B). Get this form and instructions in Spanish.
The Private Medicare Options: Part C, Part D, and Medigap
Medicare Advantage in Texas
Medicare Advantage (MA), also known as Medicare Part C, is an alternative to Original Medicare (Part A & B). Approximately 41% of Texans are on an MA plan.
To qualify for an MA plan, you must enroll in Medicare Part A & B and live in the service area of the plan you wish to enroll in. MA plans are very local, down to the county level, and you have many options available. In Texas, in 2021, 289 Medicare Advantage plans are available.
Read more about the benefits, types of plans and costs in Medicare Advantage Plans in Texas.
When and How to Apply for Advantage in Texas
The best time to enroll in a Medicare Advantage plan is during your Initial Enrollment Period (the seven-month window around when you turn 65). Should you miss your Initial Enrollment Period, you may be eligible to enroll in a Medicare Advantage plan during the Annual Election Period or the Medicare Advantage Special Election Period (MA SEP). If an election was made during the Annual Enrollment Period, you could make changes during the Medicare Advantage Open Enrollment Period.
Medicare Part D in Texas
Medicare Part D, also known as Medicare prescription drug coverage, is a federal program that offers Medicare beneficiaries prescription drug coverage whether you live in Texas or elsewhere. You must be enrolled in Medicare Part A and/or Part B and live in the Part D plan’s service area to qualify.
If you choose to enroll in Medicare Part A & B, you’ll likely need Medicare Part D coverage because it fills the requirement of having creditable coverage. However, if you enroll in a Medicare Advantage plan, you’ll have creditable coverage through a Medicare Advantage Prescription Drug (MA-PD) plan. You cannot have both an MA-PD and Medicare Part D.
Yes, you must have prescription drug coverage at all times. In fact, if your creditable coverage through your group health plan ends, you must enroll in Part D within 63 days of losing that coverage. Or you could incur a permanent late enrollment penalty when you do decide to enroll in Medicare Part D. And that penalty will be in place for the entire length of your Medicare coverage.
Extra Help for Prescription Drug Coverage
You may qualify for financial assistance for prescription drug costs through a program called Extra Help. The Social Security Administration (SSA) and the Centers for Medicare & Medicaid Services (CMS) work together to provide the benefit. In 2021, 29% of Texans with a stand-alone Medicare prescription drug plan receive Extra Help, also known as low-income subsidy or LIS.
You must have limited income and resources to qualify for Extra Help. For example, in 2021, your income must be less than $19,380 if single and $26,100 if married. And you should have resources less than $14,610 if single and $29,160 if married.
If you meet these guidelines, you’ll have low or no deductible, low or no premiums, no coverage gap, and will pay much less for your prescriptions. To see if you qualify for Extra Help, contact Connie Health. One of our local agents can help you apply. Call (623) 223-8884.
When and How to Apply for Medicare Part D in Texas
Suppose you’re enrolling in Medicare Part D for the first time. In that case, you’ll typically do it during your Medicare Part D Initial Enrollment Period, which is usually the same as your Medicare IEP, the Annual Enrollment Period (October 15th through December 7th annually), or a Special Enrollment Period (SEP), if you qualify.
You may qualify for a SEP to enroll in Part D if you had creditable coverage, have job-based drug coverage through you or your spouse’s employer, or are eligible for Extra Help.
Medicare Supplement in Texas
Medicare Supplement plans, also known as Medigap plans, are used with Original Medicare and are not stand-alone plans. Because Original Medicare does not have a cap on out-of-pocket costs, these plans can assist you in paying for some or all of the expenses you would otherwise have to pay for under Part A & B Original Medicare.
Many Medicare enrollees have some sort of supplemental coverage. In fact, in Texas, according to AHIP analysis, there were 911,802 Texas Medicare beneficiaries (36% of fee-for-service enrolled) with Medicare Supplement coverage in 2019.
Read more about the ten types of Medicare Supplement plans available in Texas, plus additional details about eligibility and enrollment in Medicare Supplement Plans in Texas.
When and How to Apply for Medicare Supplement in Texas
The best time to enroll in a Medicare Supplement plan in Texas is during your Medigap Open Enrollment Period. That occurs the first month you are enrolled in Medicare Part B, and you’re older than 65.
The Medigap Open Enrollment Period lasts six months, and the period only happens once. It cannot be changed or repeated. Should you miss this period, you might be able to purchase a Medigap policy, but it will likely cost more due to past or present health problems.
Your Medigap Open Enrollment Period is the best time to enroll because insurance carriers must sell you any plan that they offer regardless of your pre-existing medical conditions. After this period, most carriers apply the pre-existing clause to newly issued plans. And there’s no guarantee that an insurance company will sell a plan to you—unless you meet specific medical underwriting requirements or situations.
Learn more about Medicare
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