If you live in Texas and are looking for Medicare Advantage coverage, you may have options depending on which plans are available in your area.
How Medicare Advantage works in Texas
Generally, Medicare Advantage works the same way in Texas as it does in other states: as an alternative way to receive your Original Medicare, Part A and Part B, benefits. What differs will be the specific Medicare-approved insurance companies and plans available, which will depend on your location and zip code.
Medicare Advantage plans provide Part A and Part B benefits through private insurance companies that have a contract with the federal program. If you are enrolled in a Medicare Advantage plan, you will still get all of the same benefits that you would if enrolled in Original Medicare (except for hospice care, which is still covered by Medicare Part A). Some plans offer additional benefits not included in Original Medicare, such as health and wellness programs, and routine vision and dental benefits. Many Medicare Advantage plan include prescription drug coverage (Medicare Advantage Prescription Drug plans). You will need to continue to pay your Part B premium if you enroll in a Medicare Advantage plan.
Many Medicare Advantage plans offer prescription drug coverage; these are known as Medicare Advantage Prescription Drug plans. You can’t have both a Medicare Advantage plan and a stand-alone Medicare Part D Prescription Drug Plan.
You may enroll in a Medicare Advantage plan if you have both Medicare Part A and Part B, live in the local area of the plan you wish to enroll in, and do not have end-stage renal disease (ESRD). You can enroll, switch plans, and disenroll during the following periods:
- Initial Coverage Election Period: If you have delayed enrollment in Medicare Part B, this is the enrollment period when a person is first eligible to enroll in a Medicare Advantage plan. It starts three months before your Part B effective date and ends on whichever date falls later, the last day of your Initial Enrollment Period or the last day of the month before you’re enrolled in Part B.
- Fall Open Enrollment Period (also called Annual Election Period, or AEP): This enrollment period runs from October 15 to December 7 every year. During this time, you can join Medicare Advantage, switch plans, or go back to Original Medicare.
- Medicare Advantage Open Enrollment Period: This enrollment period runs from January 1 to March 31 every year. During this time, you can disenroll from Medicare Advantage and go back to Original Medicare. You can also switch from one Medicare Advantage plan to another. If you drop a Medicare Advantage plan, you’ll be able to join a Medicare prescription drug plan to go alongside your Original Medicare.
- Special Election Period (SEP): If you qualify for a Special Election Period (for example, if you move out of your plan’s local area or you lose your current coverage), you may be able to make changes to your Medicare Advantage plan coverage outside of the regular enrollment periods.
Types of Medicare Advantage plans in Texas
There are different types of Medicare Advantage plans. As a Medicare beneficiary living in Texas, availability will depend on your county and, in some cases, whether you meet certain eligibility criteria:
- Health Maintenance Organization (HMO): Members usually have to choose a primary care doctor and may need a referral to see a specialist. This type of plan generally requires you to use providers within the plan’s network.
- Preferred Provider Organization (PPO)*: Usually, members don’t need a referral to see specialists and can use both in-network and out-of-network providers. However, visits with providers that are in-network generally cost less.
- Health Maintenance Organization Point-of-Service (HMO-POS): Some HMO plans have a point-of-service option that allows members to see out-of-network providers for a higher cost. This provides provider flexibility similar to a PPO plan, but you generally still have to choose a primary care physician.
- Private Fee-for-Service (PFFS): Members aren’t restricted to using providers in the plan’s network, but you might have to check before each visit to make sure the provider accepts the plan’s payment terms, to make sure the service is covered. Providers who do not contract with the plan are not required to see you except in an emergency.
- Special Needs Plans (SNPs): Members may enroll if they meet certain eligibility criteria, such as having a chronic health condition, living in an institution, or receiving Medicaid benefits.
- Medicare Medical Savings Account (MSA): These Medicare Advantage plans set up a medical savings account you may use to pay your medical costs.
- Medicare Advantage Prescription Drug plan: This type of Medicare Advantage plan includes prescription drug coverage. With a Medicare Advantage plan that includes prescription drug coverage, you receive all of your Original Medicare benefits in one plan (except for hospice care, which Medicare Part A still provides). Medicare Advantage is an alternative way to receive your Original Medicare benefits and many Medicare Advantage plans include prescription drug coverage (Medicare Advantage Prescription Drug plans).
Comparing Medicare Advantage plans available in Texas
When you’re choosing a Medicare Advantage plan in Texas, it’s important to consider all of your options and research what’s available. Although all Medicare Advantage plans are required to provide at least the same amount of coverage as Original Medicare, there can be differences in cost and any additional benefits they may offer. Some plans may even offer premiums as low as $0, although you must continue to pay your Part B premium for any Medicare Advantage plan you join, along with any copayments, coinsurance, and deductibles.
Ultimately, the county and zip code you reside in determine which plans are available to you. It may be important to shop around if you’re looking for a Medicare Advantage plan that includes prescription drug coverage. Out-of-pocket costs may vary for Medicare Advantage plans and may depend on the prescription drugs you take, whether the plan covers them, and which cost tier the prescription drugs fall under. Remember to consider costs like copayments, deductibles, and out-of-pocket maximums, in addition to the plan premium.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.