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Medicare in Texas

October 6, 2016

If you live in Texas and have Original Medicare (Part A and Part B), you may have several Medicare plan options, depending on where you live.

Medicare beneficiaries can get health coverage in two ways: through Original Medicare or through a private health plan approved by Medicare, such as Medicare Advantage.

Original Medicare for Texas beneficiaries

Original Medicare is the federally-administered Medicare program that includes Part A (hospital insurance) and Part B (medical insurance). Part A generally covers inpatient hospital care, skilled nursing facility (SNF) care, hospice care, and limited home health care. Part B may cover outpatient services like doctor visits, preventive services, and durable medical equipment.

Original Medicare includes only limited prescription drug coverage. Medicare Part A typically covers prescription drugs you receive as part of your treatment as a hospital inpatient. Medicare Part B, on the other hand, may cover certain medications administered to you as an outpatient, such as by injection or infusion; prescriptions you take at home aren’t covered in most cases.

Most people are eligible for Medicare at age 65, or before age 65 if they qualify for Medicare through disability. Many people are automatically enrolled into Medicare.

If you’re not automatically enrolled, you can apply for the Medicare program through Social Security:

You can sign up during the following enrollment periods:

  • Initial Enrollment Period, which begins three months before you turn 65, includes your birthday month and three months after your birthday month, lasts seven months. If you receive Social Security or Railroad Retirement Board disability benefits, your Initial Enrollment Period generally starts three months before your 25th month of receiving disability benefits and lasts for seven months.
  • General Enrollment Period, which takes place every year from January 1 to March 31. You may have to pay a late-enrollment penalty for Part A and/or Part B if you didn’t sign up when you were first eligible.
  • Special Enrollment Period, if you’re covered under an employer group plan that is ending. You may not have to pay a late-enrollment penalty for Part B if you have other creditable health coverage, such as through an employer. If you’re serving as a volunteer in another country, you may also be eligible for a Special Enrollment Period for Part A and Part B.

Original Medicare generally works the same way for everyone, regardless of which state you live in. This means that Medicare beneficiaries in Texas will have the same benefits, enrollment periods, and cost-sharing as beneficiaries in other states.

 Medicare plan options in Texas

Certain types of Medicare coverage are available through private insurance companies that contract with Medicare to provide benefits. These plan options include Medicare Advantage plans and  stand-alone Medicare Prescription Drug Plans. You might be able to enroll in Medicare Supplement insurance. All of these are briefly described below.

Medicare Advantage plans

Beneficiaries in Texas (as in other states) may also be able to choose to get their Medicare Part A and Part B benefits through a Medicare Advantage plan. Medicare Advantage plans cover the same Part A and Part B benefits as Original Medicare, except for hospice care, which Part A continues to cover. Medicare Advantage plans often include additional benefits, such as routine vision or dental services, or prescription drug coverage.

You must enroll in Medicare Part A and Part B to be eligible to join a Medicare Advantage plan, and live in the service area of the plan you wish to enroll in. You might not be eligible for Medicare Advantage if you have end-stage renal disease (ESRD).

If you have a Medicare Advantage plan that includes drug coverage, this is known as a Medicare Advantage Prescription Drug (MA-PD) plan. Medicare Advantage Prescription Drug plans offer your health and prescription drug benefits under a single plan. When you’re enrolled in any kind of Medicare Advantage plan, you’re still in the Medicare program, and need to keep paying your Medicare Part B premium along with any premium your plan may charge.

Medicare Part D

Medicare prescription drug coverage (Part D) is optional. You can get this coverage in either of two ways. If you have Original Medicare, Part A and Part B, you can sign up for a stand-alone Medicare Part D Prescription Drug Plan. If you have Medicare Advantage, you’d get this coverage through an MA-PD plan (not all Medicare Advantage plans offer drug coverage). You cannot have both a Medicare Advantage Prescription Drug plan and a stand-alone Medicare Part D Prescription Drug Plan.

 Medicare Supplement (Medigap) plans

Medicare Supplement (Medigap) plans help pay for some of your out-of-pocket costs under Original Medicare, including cost-sharing expenses and emergency overseas travel coverage. Plan benefits are standardized across 10 plan types (labeled letters A through N), and each plan includes different benefits and level of coverage. In 47 states, including North Carolina, Medigap plans offer the same standardized benefits for plans of the same letter type.

Medicare Supplement plans can only be used to help with Original Medicare costs, and you’ll need to stay enrolled in Medicare Part A and Part B for your hospital and medical coverage. In addition, keep in mind that prescription drug coverage isn’t included in these plans, so if you want help with your medication costs, you should enroll in a stand-alone Medicare Prescription Drug Plan.

Medicare Supplement plans only work with Original Medicare. You cannot use Medigap benefits to pay for costs in Medicare Advantage.

Texas resources for Medicare beneficiaries

For more information on Medicare and health services in Texas, please refer to the following resources from Medicare.gov:

Learn more about how Medicare plans work in Texas including:

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