Medicare is a federal health insurance program. In Texas, as in the rest of the country, it is designed to provide medical coverage for:
- people who are age 65 and over
- people with end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS)
- people under age 65 who have certain disabilities
Texans who meet any of these criteria are able to apply for every Medicare option available, including original Medicare, Medicare Advantage, and Medigap.
Medicare includes parts A, B, C, D, and Medigap. Here is an explanation for each of these elements of Medicare coverage in Texas and tips for finding the coverage that works for you.
Medicare is divided into specific parts that cover different services. Original Medicare is composed of Part A and Part B.
Medicare Part A is hospital coverage. In Texas as in the rest of the country, Part A is free for most people. This means that you do not have to pay a monthly premium to have coverage. In Texas, you are eligible for premium-free Medicare Part A if:
- you are age 65 or older and you or your spouse worked and have paid Medicare taxes for at least 40 quarters during your lifetime
- you are under age 65 and receive benefits from Social Security or from the Railroad Retirement Board, and have received those benefits for at least 24 consecutive months
- you have ESRD or ALS
Even people who do not meet any of these requirements can get Medicare Part A for a monthly out-of-pocket premium once they are 65 years old.
Medicare Part B is medical coverage. If you are eligible for Medicare Part A, you are also eligible for Medicare Part B. This part of Medicare is not premium free.
The cost of Medicare Part B in Texas is comparable to the rest of the country. That is because what you pay for Medicare Part B is determined by your or your spouse’s income history, not by your ZIP code or state.
Your Medicare Part B costs include an annual deductible and a monthly premium. Your monthly premium may be higher if you make more than a certain amount.
Medicare Part C (Medicare Advantage) is purchased through Medicare-approved private insurers. If you are eligible for Medicare, you are eligible for Medicare Advantage. You must, however, enroll in original Medicare before you can get a Medicare Advantage plan.
The premium and copay rates for Medicare Part C vary from insurer to insurer and from state to state.
Plans also vary in what they cover, as well as the service areas where they are available. A close friend who lives in a neighboring town may be eligible for a plan that does not cover your area and vice versa.
You can compare the cost of every Medicare Advantage plan offered in your county by using Medicare’s find a Medicare plan tool.
Some plans cover prescription drugs and others do not. Some Part C plans also cover services that original Medicare does not, such as vision and dental. There may be restrictions on the doctors you can see with a Medicare Advantage plan, so carefully reviewing the plan you are considering is important.
In Texas, your options for Medicare Advantage plans vary by your county and your ZIP code. They include:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Provider-Sponsored Organizations (PSOs)
- Private Fee-For-Service (PFFS) plans
- Special Needs Plans (SNPs)
Medicare Part D is prescription drug coverage. It is an optional part of Medicare that you may not think you need. However, if you do not enroll in Medicare Part D when you are eligible, and also do not have another source of creditable prescription coverage, you may incur a permanent late enrollment penalty when you do decide to buy Medicare Part D. This penalty will be in place for the entire length of your coverage.
You may enroll in Medicare Part D if you have original Medicare. If you have Medicare Advantage, your prescription drug coverage may already be included in your plan.
Medicare Part D is provided through Medicare-approved, private insurance companies. Like Part C plans, they vary in coverage and in price. Not all plans cover every medication you may need, so review each plan you are considering before you opt-in.
You can enroll for Medicare Part D during your initial enrollment period. If you are under age 65 and are getting Medicare because you have a disability, you can enroll in Part D during the 7-month period that begins 3 months before the 25th month of disability benefit payments, and ends 3 months after that date.
If you miss initial enrollment, you can enroll for Medicare Part D during general enrollment.
If you have creditable drug coverage through a group health plan that is ending, you must enroll in Medicare Part D within 63 days of losing your coverage.
Private insurance companies that are licensed by the Texas Department of Insurance are authorized to sell Medigap plans. These plans help to pay for the services that Medicare does not, such as copays, deductibles, and coinsurance.
You cannot have a Medigap plan if you are enrolled in a Medicare Advantage plan.
Medigap plans will only pay for services that Medicare considers medically necessary. Some plans pay for emergency medical treatment outside of the United States.
You can purchase Medigap during your 6-month open enrollment period. At that time, you can buy any Medigap policy that is sold in Texas, even if you have medical problems. Open enrollment for Medigap begins the month you turn 65 and enroll in Medicare Part B. If you miss open enrollment, you may not be able to purchase a Medigap policy for the same initial rate, or at all.
There are 10 standard Medigap plans which are designated by the letters A, B, C, D, F, G, K, L, M, and N. Each plan offers different benefits. You can access full information about these plans and what they cover on the Texas Department of Insurance website.
In Texas, a type of Medigap plan called Medicare Select is also available. Medicare Select plans require you to use specific hospitals and doctors. If you don’t like the Medicare Select plan you buy during open enrollment, you can change it to another Medigap plan within 12 months after purchase.
The enrollment periods and dates for Medicare Part C are the same in Texas as they are throughout the rest of the country.
- Initial enrollment period. This refers to the first time when you are eligible for Medicare. For people who are getting Medicare because they are approaching their 65th birthday, initial enrollment begins 3 months before your birthday and ends 3 months after it takes place, for a total of 7 months.
- 25th disability benefit. If you are under age 65 and are getting Medicare due to a disability, you can sign up for Part C during the 3-month period that occurs prior to receiving your 25th disability benefit through to the 3-month period that will occur after that date.
- General enrollment. Every year from January 1 through March 31, you may enroll in Medicare. If you miss initial enrollment and have to sign up during general enrollment, you may have to pay higher premiums.
- Open enrollment. Open enrollment for Medicare is an annual event that begins on October 15 and ends on December 7. During open enrollment, you can change plans, make changes to your existing plan, and add or drop services.
Help enrolling in Medicare in Texas
Enrolling in Medicare can be confusing. These organizations can help you navigate the process in Texas:
Medicare is a federal program that people in Texas are eligible for. There are many plans which you can choose between. Enrolling in Medicare on time can save you money. If you do not like a plan you enroll for, you can change it at specific times of the year.
This article was updated on October 8, 2020 to reflect 2021 Medicare information.
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