If you live in Texas and are looking for Medicare Advantage coverage, you may have many 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 another way to receive your Original Medicare, Part A and Part B, benefits. What differs will be the specific 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 have a contract with the federal program. If you have Medicare Advantage, you are still in Medicare, and you will still get all of the same benefits that you would in Original Medicare (except hospice care, which is still covered by Medicare Part A). Some plans offer other benefits not included in Original Medicare, such as health and wellness programs, routine vision and dental benefits, or prescription drug benefits. You will need to continue to pay your Part B premium if you have Medicare Advantage.
Many Medicare Advantage plans offer prescription drug coverage; these are known as Medicare Advantage Prescription Drug (MA-PD) plans. You can’t have both a Medicare Advantage plan and a stand-alone Medicare prescription drug plan.
You can enroll in a Medicare Advantage plan if you have both Medicare Part A and Part B, live in the service area of the plan you wish to join, 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 Medicare Advantage. 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.
- Annual Election Period (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 Disenrollment Period (MADP): This enrollment period runs from January 1 to February 14 every year. During this time, you can disenroll from Medicare Advantage and go back to Original Medicare.
- Special Election Period (SEP): If you qualify for a Special Election Period (for example, if you move out of your plan’s service area or you lose your current coverage), you can make changes to your Medicare Advantage coverage outside of the regular enrollment periods.
Types of Medicare Advantage plans in Texas
There are multiple 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 a primary care doctor and need a referral to see a specialist. This type 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. Note that a private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.
- Special Needs Plans (SNPs): Members can only join 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 can use to pay your medical costs.
- Medicare Advantage Prescription Drug (MA-DP): This type of plan, sometimes called an MA-PD plan, includes prescription drug coverage. With a Medicare Advantage plan that includes drug coverage, you get all of your Medicare coverage in one plan. (If you have a Medicare Advantage plan that doesn’t include this coverage, you cannot add a stand-alone Medicare Part D prescription drug plan. If you drop your Medicare Advantage plan and return to Original Medicare, you would have to buy a Part D plan if you want Medicare prescription drug coverage.)
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 huge differences in cost and any additional benefits they 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.
Ultimately, the county and zip code you reside in determine which plans are available to you. It’s especially important to shop around if you’re looking for a Medicare Advantage plan that includes drug coverage. Out-of-pocket costs can vary widely for Medicare Advantage plans and will depend on the drugs you take, whether the plan covers them, and which cost tier the drugs fall under. Remember to consider costs like copayments, deductibles, and out-of-pocket maximums, in addition to the plan premium.