What Are Medicare Advantage Plans in Texas?

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital insurance) and Part B (medical insurance), and most also include Part D (prescription drug coverage). Many plans provide added benefits such as dental, vision, hearing, telehealth, and fitness programs.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, although those with disabilities or qualifying conditions like ALS or ESRD may qualify earlier.

Enrollment opportunities include:

• Initial Enrollment
• General Enrollment
• Special Enrollment

Delays in enrollment or ineligibility for premium-free Part A may result in penalties.

What Types of Medicare Advantage Plans Are Available in Texas?

Texas offers several Medicare Advantage (MA) plan options:

• Health Maintenance Organizations (HMOs): Require you to use a network of providers and get referrals for specialists.
• Preferred Provider Organizations (PPOs): Offer broader provider flexibility but higher out-of-network costs; referrals are usually not required.
• Private Fee-for-Service (PFFS): You can see any Medicare-approved provider who agrees to the plan terms; some plans include provider networks.
• Special Needs Plans (SNPs):
  • C-SNPs: For individuals with chronic conditions such as diabetes or cancer.
  • I-SNPs: Designed for people in nursing homes or who require in-home care.
  • Dual Eligible Special Needs Plans (D-SNPs): Serve people with both Medicare and Medicaid and often include enhanced benefits.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with a medical savings account that the insurer funds.

What Are Your Prescription Drug Options with Medicare Advantage?

Most MA plans include Part D drug coverage. If your plan doesn’t include drug coverage, you may:

• Enroll in a standalone Part D plan (only allowed with some plan types).
• Pay a late enrollment penalty if you go without creditable prescription coverage.

To ensure coverage for your current medications, check each plan’s formulary before enrolling.

How Do You Choose a Medicare Advantage Plan?

Understanding Medicare Advantage costs is essential when comparing plans. Key considerations include:

• Premiums: Many plans offer $0 monthly premiums, though other out-of-pocket costs may be higher.
• Deductibles, Coinsurance & Copays: Assess what you’ll owe for doctor visits, prescriptions, or hospital care.
• Out-of-Pocket Maximums: This cap protects you from excessive costs for covered services.
• Extra Benefits: Many plans include dental, vision, hearing aids, telehealth services, over-the-counter allowances, and gym memberships.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during the following specific enrollment periods:

• Initial Enrollment: Starts 3 months before and ends 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop a Medicare Advantage plan.
• General Enrollment (Jan 1–Mar 31): For those enrolling in Part B for the first time.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Apply if you:
  • Move outside your plan’s area
  • Lose coverage through Medicaid or an employer
  • Your current plan ends
  • Qualify for an SNP due to a chronic condition

What If You Want to Change Your Medicare Advantage Plan?

You can change your Medicare Advantage plan during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

You’ll be automatically disenrolled from your old plan when your new coverage begins.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in Texas?

Texas offers a variety of helpful programs:

• Texas Health Information, Counseling, and Advocacy Program (HICAP): Free counseling for Medicare beneficiaries.
• Texas SMP Program: Teaches beneficiaries how to identify and avoid Medicare fraud.
• Texas Department of Insurance: Provides consumer support and handles complaints.
• Texas Medicaid Program: Assists low-income residents with healthcare costs. Visit hhs.texas.gov or call 1-877-541-7905. Learn more about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, or Medigap, are sold by private insurers and help pay out-of-pocket costs associated with Original Medicare, including deductibles, coinsurance, and copayments.

• You must be enrolled in Parts A and B to purchase a Medigap plan.
• The best time to enroll is during the six-month Medigap Open Enrollment Period, which begins when you start Part B.
• After this period, medical underwriting may be required.
• Medigap plans don’t include drug coverage—you’ll need a separate Part D plan.
• There are 10 standardized Medigap plans. Medicare Supplement Plan G had the highest enrollment in 2023, and Plans G and N are growing fastest.
• Plan F is not available to newly eligible Medicare members after January 1, 2020.
• All Medigap plans offer nationwide coverage with predictable out-of-pocket costs and no network limitations.

Learn more about Medicare Supplement plans in Texas.

Next Steps

If a Medicare Advantage plan in Texas fits your needs, start by comparing plans in your area. Look at premium costs, provider networks, extra benefits, and out-of-pocket expenses. Once you’ve found a plan, enroll during the proper enrollment window to begin coverage.