Medicare in Texas
Medicare is a United States federal health insurance program. In Texas, as in the rest of the country, it is designed to provide and reduce the cost of healthcare services for:
- People aged 65 or older.
- People younger than 65 with eligible disabilities.
- People with End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS).
If you’re a Texan who meets any of the above criteria, you can apply for Medicare. Continue reading to learn about Medicare options in Texas, enrollment periods, and how to find the coverage that supports your health and fits your budget.
Medicare Plan Options in Texas
Texans have both public and private Medicare plan options. The public option is called Original Medicare and includes Part A (hospital insurance) and Part B (medical insurance).
You can also apply through a private health plan approved by Medicare, which includes Medicare Part C (Medicare Advantage), Medicare Part D (Prescription Drug Coverage), and Medicare Supplement (Medigap).
Original Medicare: Part A & B
Original Medicare is the public option provided by the federal government and includes Medicare Part A (hospital insurance) and Part B (medical insurance).
Medicare Part A
Medicare Part A (hospital insurance) is part of Original Medicare and is usually premium-free. Plan A covers, but is not limited to, inpatient care in a hospital, skilled nursing facility care, short-term nursing home care, hospice care, and home health care. Private Medicare plans might have different rules, but your plan must give you at least the same coverage as Part A Original Medicare.
Medicare Part B
Medicare Part B (medical insurance) is part of Original Medicare. If you are eligible for Medicare Part A, then you can also enroll in Medicare Part B. However, Part B is not premium-free.
Your Medicare Part B costs include an annual deductible and a monthly or quarterly premium. If your income fluctuates or you make above a certain amount, your monthly premium may be higher.
Wondering what Part B will cost you? The premium in Texas is comparable to the rest of the country because it’s based on your or your spouse’s income history, not by your zip code or state.
Medicare Part B covers your basic medical needs, accounting for about 80% of costs, with the remaining 20% being your responsibility. Basic medical needs include doctor visits, lab tests, and medical equipment. You can also obtain second opinions about a medical issue.
Coverage for orthopedic, cardiology, radiology, and any other specialist from A to Z is covered under Part B. You can also receive screenings for common medical conditions and a complete annual wellness checkup. Flu shots, pneumococcal shots, and Hepatitis B shots are covered with no copay. Read more about Medicare Part B.
Medicare Part C (Medicare Advantage)
Approximately 41% of Texans are on a Medicare Advantage plan, also known as Medicare Part C. Medicare Advantage (MA) plans are an alternative to Original Medicare (Parts A & B). MA plans are offered by private insurance companies that have a contract with the Centers for Medicare & Medicaid Services (CMS).
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. Medicare Advantage plans are local—to the county level—and many options exist. In Texas, in 2021, 289 Medicare Advantage plans are available.
Twenty of these plans offer Medicare Advantage enrollees innovative benefits such as wellness and healthcare planning, reduced cost-sharing, and rewards and incentives programs.
What Medicare Advantage Plans Provide
A Medicare Advantage (MA) plan provides all of the benefits of Original Medicare, but with different cost-sharing. These plans have their own set deductibles, coinsurance, and copays within limits established by the federal government. Plus, they typically have additional coverage benefits for prescription drugs, wellness programs, and routine dental & vision.
Medicare Advantage plans limit the Medicare beneficiary’s out-of-pocket spending for services covered by Medicare Part A and Part B. Once your out-of-pocket costs reach their limit, including the deductible, your MA plan pays 100% of covered healthcare costs for the remainder of the year. In contrast, Original Medicare doesn’t have a maximum spending limit to cap your annual out-of-pocket costs.
Note that in addition to your Part B premium that’s paid to Medicare, an additional Medicare Advantage plan premium, if any, is paid directly to your plan.
Medicare Advantage plans that include prescription drug coverage are known as Medicare Advantage Prescription Drug (MA-PD) 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 offered prescription drug coverage (MA-PDs), and 89% of Medicare Advantage enrollees were in MA-PD plans.
In many cases, you’ll need to use health care providers who participate in the plan’s network and service area. Before you enroll, you may want to check with your providers and the plan you’re considering to make sure the providers you currently see or want to see in the future, are in the plan’s network. Connie Health can help you do this with our provider search tool.
Types of Medicare Advantage Plans
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.
With a MA HMO, you’ll likely choose a primary care physician who provides or coordinates your care through referral to other participating providers. Outside of emergencies, out-of-network providers’ services are not covered unless approved in advance by the MA plan.
With a MA PPO, your out-of-pocket costs are lower when you use hospitals, doctors, and other healthcare professionals in the PPO’s network versus non-participating healthcare providers.
To maintain your existing relationships with doctors, hospitals, or other care providers, check to see if your preferred healthcare providers are participating in the 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.
Medicare Part D (Medicare Prescription Drug Coverage)
When you sign up for Medicare Part A and B, you don’t automatically receive prescription drug benefits. If prescription drug coverage is needed, then Medicare Part D, also known as Medicare prescription drug coverage, fills that need.
Medicare Part D is a federal program designed to offer Medicare beneficiaries prescription drug coverage, whether you live in Texas or elsewhere. The plan is provided by private insurance companies that contract with the Centers for Medicare & Medicaid Services (CMS)—similar to Medicare Advantage plans.
Medicare Parts A and B work with Medicare Part D. However, if you have a Medicare Advantage plan, you’ll get this coverage through an MA-PD (Medicare Advantage Prescription Drug) plan. You cannot have both a Medicare Prescription Drug Plan and a stand-alone Medicare Part D Prescription Drug Plan.
As a Medicare beneficiary in Texas, you can enroll in a stand-alone Medicare Part D Prescription Drug Plan. The cost and availability will vary by county, and most plans require you to pay a monthly premium, annual deductible, and copayment or coinsurance. You may qualify for financial assistance for prescription drug costs through a program called Extra Help. In 2021, 29% of people with a stand-alone Medicare prescription drug plan receive Extra Help.
To ensure your Medicare plan covers your prescription drugs, contact Connie Health for a no-obligation Medicare plan review. Call (623) 223-8884. One of our local agents can see if you also qualify for Extra Help.
Avoid Medicare Part D Penalties
While Medicare Part D is an optional part of Medicare, if you don’t have another source of prescription coverage, you may incur a permanent late enrollment penalty when you do decide to buy Medicare Part D. If you have creditable coverage through group health coverage that is ending, you must enroll in Medicare Part D within 63 days of losing your coverage.
This penalty will be in place for the entire length of your coverage. If you’re enrolled in Part A & B, be sure that you also enroll in Part D during your initial enrollment period or general enrollment if you miss initial enrollment. This way, you can avoid those lifetime penalties.
Medicare Supplement (Medigap Plans)
Medigap, also known as Medicare Supplement plans, assists in paying for some of your out-of-pocket costs under Original Medicare, including cost-sharing expenses (copays, deductibles, and coinsurance). Some include emergencies during international travel.
Because Original Medicare (Parts A & B) does not include a cap on out-of-pocket costs, most enrollees have some form of supplemental coverage, and Medigap plans are one way to do this. Medigap plans can not be used with a Medicare Advantage plan.
Texas Medicare Supplement plans include plans F, G, K, L, M, and N. Each plan may provide different levels of coverage. The cost of these plans is determined by the carrier. Medicare Supplement plans may offer additional benefits like a gym membership, hearing, and dental discounts. Review your plan options with your local Medicare agent.
Medigap plans are provided by private insurance companies licensed by the Texas Department of Insurance and are authorized to sell Medigap plans. You can purchase a Medigap plan during your open enrollment period. If you miss open enrollment, you may not be able to buy a Medigap policy at the same initial rate or at all.
Enrollment Deadlines in Texas
There are four periods for enrolling, switching, or disenrolling in Medicare. Knowing when you need to enroll and when you can change can save you money. The best time to join a Medicare health or drug plan is when you first become Medicare eligible. Continue reading to learn about election and enrollment periods.
- Initial Coverage Election Period: Most Texans get Medicare Part A & B during this period when they become eligible for Medicare. It starts three months before you turn 65 and ends three months after you turn 65. If you’re not yet collecting Social Security benefits before your Initial Enrollment Period starts, you’ll need to sign up for Medicare online or contact Social Security.
To avoid the Medicare Part B late enrollment penalty, you should complete your Medicare enrollment application during your Initial Enrollment Period. The Part B penalty is a lifetime penalty and gets added to your monthly Part B premium. The longer you wait to sign up for Part B, the higher that monthly penalty becomes.
If you miss your Initial Enrollment Period, you may be able to enroll during the General Medicare Enrollment Period or a Special Election Period. Read below to learn more.
- General Medicare Enrollment Period: If you miss your Initial Enrollment Period (read above), you can sign up during Medicare’s General Enrollment Period between January 1 to March 31, annually, and your coverage will begin July 1st.
- Special Election Period (SEP): Once your Initial Enrollment Period ends, you’ll have the opportunity to sign up for Medicare during a Special Enrollment Period (SEP). You can sign up for Medicare Part A or B during a SEP if you change where you live, you lose your current coverage, you have a chance to get other coverage, your plan changes its contract with Medicare or other special circumstances.
- Fall Annual Enrollment Period (AEP): The AEP enrollment period is between October 15 to December 7, annually. During this time, you can join a Medicare Advantage plan, switch plans, or go back to Original Medicare (Parts A & B).
- Medicare Advantage Open Enrollment Period: Between January 1 to March 31, annually, you can disenroll from a Medicare Advantage plan and go back to Original Medicare. You can also switch from one Medicare Advantage plan to another. Or, if you drop a Medicare Advantage plan, you can join a Medicare prescription drug plan (Part D) to go alongside your Original Medicare plan (Parts A & B).
Learn more about Medicare
Visit our Medicare Resource Center which provides helpful articles on everything you need to know about Medicare.