Table of Contents:
- Medicare Advantage Plans in Texas: The Basics
- The Benefits Medicare Advantage Plans Provide
- Types of Medicare Advantage Plans in Texas: HMOs vs PPOs
- Getting Prescription Drug Coverage with Medicare Advantage in Texas
- How Much Do Medicare Advantage Plans Cost in Texas?
- When to Enroll in a Medicare Advantage Plan in Texas
Medicare Advantage Plans in Texas: The Basics
Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance companies that have a contract with the Centers for Medicare & Medicaid Services (CMS). According to the Kaiser Family Foundation, approximately 45% of Texans were enrolled in a Medicare Advantage plan in 2021. This is higher than the national average of 42%.
To qualify for a Medicare Advantage (MA) plan, you must be eligible for Part A and enrolled in Medicare Part B, and live in the service area of the plan you wish to enroll in. MA plans are local—to the county level—and many options exist.
In 2021, the 10 Texas counties with the highest Medicare Advantage enrollment are El Paso County (66%), Hidalgo County (64%), San Patricio County (59%), Starr County (58%), Nueces County (58%), Cameron County (58%), Willacy County (57%), Kleberg County (57%), Zavala County (56%), and Jim Wells County (56%).
Within Texas, in 2021, 289 Medicare Advantage plans are available, compared to 231 plans in 2020. This means there was a 25% increase in MA plan options—and many more plans for you to potentially choose from.
Twenty of these plans offer Medicare Advantage enrollees innovative benefits such as wellness and healthcare planning, reduced cost-sharing, and rewards and incentives programs. These are benefits that Original Medicare does not offer.
The Benefits Medicare Advantage Plans Provide
Looking for a way to reduce your Medicare costs? A Medicare Advantage plan is an option. A Medicare Advantage plan provides all of the benefits of Original Medicare coverage offered in Texas, but often at a lower cost. And 100% of people with Medicare Part A and B have access to a Medicare Advantage plan.
Lower Monthly Premiums
Many Medicare Advantage plans have a $0 monthly premium. If you enroll in an MA plan that does charge a premium, you’ll pay the MA plan premium in addition to the monthly Part B premium. The bonus of Medicare Advantage? Most plans include prescription drug coverage. Read more about how much Medicare Advantage plans cost in Texas.
Lower Out-of-Pocket Costs
Medicare Advantage plans also limit the Medicare beneficiary’s out-of-pocket costs for services covered by Medicare Part A and Part B. MA plans set their own deductibles, coinsurance, and copays within limits established by the federal government.
Once you reach your out-of-pocket maximum, including the deductible, your Medicare Advantage plan pays 100% of covered healthcare expenses for the remainder of the year. Unlike an MA plan, Original Medicare doesn’t have a maximum spending limit and there is no cap on your annual out-of-pocket costs.
If you’d like to keep Original Medicare (Part A & B), but want more predictable, albeit higher, monthly premiums, a Medicare Supplement plan (Medigap Plans), is an alternative to Medicare Advantage.
Not sure which is best for you? Have a local Medicare agent guide you to the optimal health insurance plan for your health needs and budget. Call (623) 223-8884.
Types of Medicare Advantage Plans in Texas: HMOs vs PPOs
The most common Medicare Advantage plans are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). HMOs and PPOs have networks of participating hospitals, doctors, and other healthcare professionals.
How are Medicare Advantage HMOs and PPOs similar?
- Both are available through private insurance companies that contract with Medicare.
- They typically use provider networks.
- There’s usually prescription drug coverage included, and the plans may have preferred pharmacy networks.
- Both plan types require that you have Medicare Part A and Part B, and live within the plan’s service area.
With a Medicare Advantage HMO, your costs are generally lower than a PPO. You’ll need to choose a primary care physician who provides or coordinates your care through referrals to other participating in-network providers. If you want to see a specialist with an HMO, you’ll need to receive a referral from your primary care physician. Outside of emergencies, out-of-network providers’ services are not covered unless approved in advance by the Medicare Advantage HMO plan.
With a Medicare Advantage PPO, you’ll have more flexibility, but with slightly higher costs. For example, monthly premiums will generally be higher than an HMO. While you can see doctors outside the Medicare Advantage PPO plan network, you’ll also likely pay higher coinsurance or copayments for that care. And you’ll need to provide information about the medical care and prescription drugs you’ve received. This means you’ll need to keep excellent records and take a more active role in the coordination of your care.
To maintain your existing relationships with doctors, hospitals, or other care providers, check to see if your preferred healthcare providers are participating in a Medicare Advantage plan’s network.
Do you need help ensuring that you pick a plan that includes the doctors you value and the prescriptions you need? Call Connie Health to find a Medicare plan that maintains your doctors and hospital relationships: (623) 223-8884.
Getting Prescription Drug Coverage with Medicare Advantage in Texas
Medicare Advantage plans that include prescription drug coverage are known as Medicare Advantage Prescription Drug (MAPD) plans. These plans provide the convenience of having all your Medicare medical and prescription drug benefits through one plan. In 2020, 90% of Medicare Advantage plans nationwide offered prescription drug coverage (MAPDs), and 89% of all Medicare Advantage enrollees were in MAPD plans.
How Much Do Medicare Advantage Plans Cost in Texas?
$0 is the lowest monthly premium for a Medicare Advantage plan. And 100 percent of people with Medicare Part A and B have access to a Medicare Advantage plan with a $0 monthly premium. The average monthly Medicare Advantage plan premium in 2021, for those who have a premium, is $11.42.
For Medicare Advantage Prescription Drug (MAPD) plans nationwide, the premiums vary by plan type. The Kaiser Family Foundation found that in 2020, premiums ranged from $20 per month for HMOs to $32 per month for local PPOs and $47 per month for regional PPOs. Nearly 61% of Medicare Advantage beneficiaries enrolled in an HMO, 33% were in local PPOs, and only 5% were in regional PPO plans.
The Medicare Advantage and MAPD premiums are paid directly to the plan provider. They are paid separately from the Part B premium paid to Medicare, which is usually paid by a monthly withdrawal from your Social Security benefit.
When to Enroll in a Medicare Advantage Plan in Texas
Want to enroll, switch, or unenroll in a Medicare Advantage plan? Knowing when you should— and can—may save you money. The best time to join a Medicare health or drug plan is during your Initial Enrollment Period. But continue reading to learn about the other times you can make a change.
Initial Enrollment Period: Your Initial Enrollment Period is three months before you turn 65 plus the month you turn 65, and ends three months after you turn 65. You have a seven-month window. And that’s when most Texans enroll in Medicare Part A & B. If you’re not yet collecting Social Security benefits before your Initial Enrollment Period begins, you’ll need to sign up for Medicare online or contact Social Security.
Note: If you don’t enroll in Medicare Part B during your Initial Enrollment Period you could face a lifetime penalty late enrollment penalty. This amount is added to your monthly Part B premium for your lifetime. And the longer you wait to sign up for Part B, the larger the monthly penalty becomes.
Should you miss your Initial Enrollment Period, you may be eligible to enroll 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 can make changes during the Medicare Advantage Open Enrollment Period. Keep reading to learn more.
Annual Election Period (AEP): Want to join a Medicare Advantage plan? The AEP enrollment period, annually, between October 15 and December 7 is your time to do the following:
- Switch from Original Medicare (with or without a Medicare Prescription Drug Plan) to a MA plan.
- Switch from a MA plan back to Original Medicare—with or without a Medicare prescription drug plan.
- Switch from one MA plan to another MA plan.
- Switch from a MA plan that doesn’t offer drug coverage to a MA plan that offers drug coverage—or vice versa.
- Join a Medicare prescription drug plan. Switch from one Medicare prescription drug plan to another prescription drug plan.
- Drop your Medicare prescription drug coverage entirely.
Medicare Advantage Open Enrollment Period: Annually, between January 1 through March 31, you have options to change your Medicare Advantage plan. Here are some of those options:
- If you’re enrolled in a Medicare Advantage (MA) plan—with or without prescription drug coverage—switch to another MA plan with or without prescription drug coverage.
- Disenroll from your MA plan and enroll in Original Medicare. If you choose this route, you’ll be able to also join a Medicare prescription drug plan.
- Did you enroll in a MA plan during your Initial Enrollment Period? You can change to another MA plan or go back to Original Medicare—both with or without a prescription drug plan—within the first three months you have Medicare.
During the Medicare Advantage Open Enrollment Period, you cannot switch from Original Medicare to a MA plan, join a Medicare prescription drug plan if you’re in Original Medicare, or switch your Medicare Prescription Drug plan to another if you’re in Original Medicare.
Medicare Advantage Special Election Period (MA SEP): If you move, lose your current coverage, have the chance to get other coverage, your plan changes its contract with Medicare or other special circumstances—you qualify for a Medicare Advantage Special Election Period. During this SEP you can sign up for or make Medicare Advantage or Medicare Advantage Prescription Drug plan changes.