Medicare Advantage Plans in Texas

• Mark the deadlines: Open enrollment for Medicare Advantage plans is October 15 to December 31. If you are enrolling in Medicare for the first time, you have three months before your 65th birthday and three months after to get on the plan.
• Look for plans in your county: Medicare Advantage plans in Texas can vary by county. Approved insurance companies offering these plans must fulfill Medicare Part A and Part B (Original Medicare) and offer other benefits, depending on the plan and insurance company.
• Compare Texas Medicare Advantage Plans: The federal Medicare Plan Finder can help you identify and compare Medicare Advantage plans in Texas. All you have to do is type in your ZIP code to find local plan providers.
• Get help in Texas: The Texas Health Information, Counseling, and Advocacy Program can help you enroll and learn about your Medicare Advantage plan options. It’s a partnership between Texas Health and Human Services, Texas Legal Services Center, and the Area Agencies on Aging. Also, the Texas State Health Insurance Assistance Program (SHIP) can help you compare plans and costs if you call 800-252-9240.

You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.

With 221 Medicare Advantage Plans available in Texas, you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:

• Monthly premium: This is how much you pay for coverage monthly, regardless of the care you receive. You may need to pay your plan’s premium in addition to the Medicare Part B premium, although some plans have $0 premiums or help pay for your Part B premium.
• Plan network: You may need to use doctors and providers who are within a plan’s network. Before choosing a Medicare Advantage Plan, think about the doctors and facilities (including pharmacies) you prefer to use, then check if the plan offers coverage at those locations. Some plans may provide out-of-network coverage, but this usually comes at a higher cost.
• Deductible: Your deductible is the amount you must pay before your insurance plan starts helping cover the costs. Medicare Advantage Plans set their deductibles, and these may change only once per year on January 1.
• Copayments and coinsurance: Copayments or coinsurance are how much you pay for each service or doctor’s visit, such as $20 per doctor visit. Each Medicare Advantage Plan sets its copayment or coinsurance amount that can differ from what you would pay through Original Medicare.
• Out-of-pocket maximum: Each Medicare Advantage Plan sets a yearly limit on the maximum amount you’d be responsible for paying for services covered by Medicare. Once you reach this limit, you won’t have to pay anything for the services you receive covered by Part A and Part B in that year.
• Additional coverage: Most Medicare Advantage Plans also provide prescription drug coverage and often include additional benefits that Original Medicare won’t cover, such as vision, dental, and hearing. Plans may provide even more benefits, like discounted gym membership or transportation to doctor’s visits. Medicare Advantage Plans can also tailor their benefits to the specific needs of particular chronically ill beneficiaries.

There are several types of Medicare Advantage plans in Texas, including

• Health Maintenance Organization (HMO) plans
• Preferred Provider Organization (PPO) plans
• Private Fee-for-Service (PFFS) plans

There are 221 different Medicare Advantage plans available in Texas, with two of them rated 3.5 or higher by the National Committee for Quality Assurance (NCQA).

Understanding Medicare Advantage Plan Types:

• HMO: Health Maintenance Organization plans generally provide coverage only at in-network providers except in medical emergencies. You usually need to have a primary care physician who can give you a referral to see specialists. Most HMO plans include prescription drug coverage.

• HMO-POS: HMO-POS plans are HMO plans with a Point of Service benefit for out-of-network providers. In these plans, you may be able to use out-of-network providers for certain services but may pay more for your care if you do.

• PPO: Preferred Provider Organization plans have a network of healthcare providers and facilities where your care will cost less. You can use out-of-network providers as well, but your care will cost more. You usually do not need a primary care doctor to get referrals to see specialists or receive treatment. Most PPO plans include prescription drug coverage.

• PFFS: Private Fee-for-Service plans allow you to use any Medicare-approved provider. Some PFFS plans have networks of providers where you can receive lower-cost care. You don’t need referrals to see specialists in PFFS plans, but prescription drugs are not always covered.

• SNPs: Special Needs Plans are for beneficiaries with specific diseases or characteristics. These plans tailor benefits and providers to the special needs of the group they serve. You are generally limited to the network of providers the plan offers and need a primary care doctor and get referrals to specialists. All SNP plans include prescription drug coverage.

Enrollment and Eligibility for Medicare Advantage Plans in Texas

You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:

• You’ve received Social Security Disability Insurance or Railroad Board Disability Annuity for 24 months
• You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease
• You have End-Stage Renal Disease

When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.

• Your IEP begins three months before the month you turn 65 and extends for three months after the month you turn 65. During this period, you can enroll in a Medicare Advantage Plan. If you join before the month you turn 65, your coverage will begin the first day of the month you turn 65. If you enroll in the three months after turning 65, your coverage will begin the first day of the month after you enroll.
• If you miss your IEP, you can sign up for Medicare during the General Enrollment Period from January 1 to March 31.
• After you enroll in Medicare, you can enroll in or make changes to your Medicare Advantage Plan coverage during the Medicare OEP from October 15 and December 7 of each year. During this time, you can change from Original Medicare to Medicare Advantage, switch to a different Medicare Advantage Plan, or change from Medicare Advantage back to Original Medicare.

Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.

There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.

Medicare Enrollment Periods

Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which Texas Medicare Advantage Plan to use.

Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.

Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.

• Medicare Prescription Drug Coverage / Texas Department of Insurance | Last accessed December 2021
• Medicare Program General Information / Centers for Medicare & Medicaid  | Last accessed December 2021
• Medicare | What’s Medicare Supplement Insurance (Medigap)? | Last accessed December 2021
• Texas Health Information, Counseling, and Advocacy Program (HICAP) | Last accessed December 2021