What Are Medicare Advantage Plans in Texas?

Texas Medicare Advantage Plans Give You Added Coverage

Once Texans reach age 65, they can enroll in Medicare, which consists of Part A (hospital insurance) and B (medical insurance). This is also known as Original Medicare. However, Original Medicare doesn’t put a cap on out-of-pocket costs and doesn’t cover prescription drugs.

You can increase your Original Medicare coverage with Medicare Advantage, or Medicare Part C. Medicare Advantage (MA) plans are run by private insurance companies. Still, they must provide the same basic coverage as Medicare Part A and B. Most Medicare Advantage plans add more comprehensive coverage, including prescription drugs, so you don’t need a separate Part D plan.

What Types of Medicare Advantage Plans Are Available?

Medicare Advantage plans are private insurance, so you can choose from different plan types and providers. Most plans use a network of doctors and healthcare facilities to provide services at discounted costs. Plans include:

• Health Maintenance Organization (HMO): This plan requires you to use an in-network medical facility, except in certain emergencies. You’ll also need to designate a primary care physician (PCP) for your regular medical care.
• Preferred Provider Organization (PPO): You’ll be able to choose any doctor on a PPO plan, but you’ll usually have lower out-of-pocket costs by staying in-network. You won’t need to choose a PCP.
• Special Needs Plans (SNP): SNPs are designed to cover chronic health conditions or illnesses.¹
  • Chronic Condition SNP (C-SNP): You qualify if you have diabetes, cancer, or certain other conditions.
  • Institutional SNP (I-SNP): This is available if you live in a nursing home or similar facility or require in-home nursing care.
  • Dual-Eligible SNP (D-SNP): You qualify if you have both Medicare and Medicaid.
• Private Fee-for-Service (PFFS): This plan decides how much it will pay doctors or other medical providers for services. It also decides how much you’ll need to pay. You don’t need to pick a PCP.²
• Medicare Medical Savings Accounts (MSA): These plans use a special high-deductible insurance plan combined with a medical savings account (MSA). You use the MSA to help pay for out-of-pocket expenses.

What You Need to Know

Medicare Advantage plans provide the same basic coverage as Original Medicare.

Most Medicare Advantage plans include prescription drug coverage and benefits like dental and vision coverage.

You can switch Medicare Advantage plans during the Medicare Annual Election Period or Medicare Advantage Open Enrollment.

What Are Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans cover prescription drugs, which is different from Original Medicare.

As you look for an MA plan, check the plan’s drug formulary, or list of drugs covered by the plan. That way you’ll know if your current medications are covered.

How Do You Choose Medicare Advantage Plans?

You need to know a Medicare Advantage plan’s costs and benefits to decide whether it’s right for you. You should consider:³

• Premiums: This is the monthly cost of your health plan, in addition to your Medicare Part B premium ($144.60 for most people in 2020). Some MA plans don’t have a monthly premium, but zero-premium plans might require higher costs elsewhere.
• Other Costs
  • Deductibles: This is how much you’ll pay before your plan begins to pay for medical expenses.
  • Coinsurance: The percentage of the cost of a service that you’ll need to pay.
  • Copays: A fixed fee for specific medical services.
  • Out-Of-Pocket Maximum: The capped amount you’ll have to pay out-of-pocket per year for care.
• Plan Benefits
  • Vision: Provides coverage for services such as eye exams or frames.
  • Dental: Provides coverage for services including checkups and teeth cleaning.
  • Telehealth: This includes coverage for remote health care, such as a phone consultation with your doctor or a video office visit.
  • Additional Perks: Many plans provide benefits like gym membership reimbursement, transportation services, or fitness classes.

When and How to Enroll in Medicare Advantage?

First you need to enroll in Medicare Part A and B, which you can do from the three months before you turn 65 to the three months after you turn 65. If you miss your initial enrollment period, you can enroll during the General Enrollment Period (GEP) that takes place from January 1 to March 31 each year. You can apply for Medicare online, in person or by phone through Social Security.

Once you’ve enrolled in Original Medicare, you can start comparing MA plans in Texas. You have several opportunities to sign up for a plan:

• Initial Enrollment Period: This is the same period when you can enroll in Original Medicare. 
• Medicare Annual Election Period: Change your plan or join Medicare Advantage for the first time each year during Medicare Open Enrollment, which runs October 15 to December 7.
• Medicare Advantage Open Enrollment Period: Already have an MA plan? You can switch plans or change to Original Medicare during this annual period, which runs from January 1 to March 31.
• Special Enrollment Period: You can enroll in a plan or change your plan anytime under certain circumstances, such as:
  • You’re moving outside your plan’s service area.
  • You’re getting coverage from a different plan, like a union or employer plan.
  • You’re losing your current coverage or becoming ineligible for Medicaid.
  • Your plan is no longer going to be offered or is leaving Medicare.
  • You’ve been diagnosed with a condition that requires an SNP.

How Much Do Medicare Advantage Plans Cost in Texas?

Plan costs can vary a lot in Texas, especially depending on where you live. 

For example, if you’re in Houston, you might pay between $0 and $199 a month for a Medicare Advantage plan.⁴ Remember to consider costs like deductibles or copays when comparing plans.

What If You Want to Change Your Medicare Advantage Plan?

The easiest time to change your Medicare Advantage plan is during one of the enrollment periods. After choosing a new plan, fill out the application to enroll. When your new coverage begins, your old plan will automatically be canceled.

What Are Alternatives to Medicare Advantage?

An MA plan isn’t your only option in Texas. Alternative options include:

• Texas Program of All-Inclusive Care for the Elderly (PACE): This program provides community-based medical care and services for seniors. You must meet certain eligibility requirements to qualify.⁵
• Original Medicare: You can stick with Medicare Part A and B if you don’t think you need additional coverage.
• Medicare Supplement: These private insurance plans, also called Medigap policies, help with costs not covered by Original Medicare.
• Medicare Supplement with Part D: Medigap policies don’t include prescription drug coverage, but you can add a Medicare Part D plan to your policy.

What Are Medicare Resources in Texas?

• Texas Health Information, Counseling, and Advocacy Program (HICAP): This free service provides information and resources to help you navigate Medicare and sign up for a plan.⁶
• Texas Department of Insurance: You can reach out online or by phone to get answers to questions about health insurance, including Medicare.⁷
• Medicaid: This federal program helps those with low income or disabilities afford medical services.⁸

State Medicare Advantage Data in Texas

Next Steps

Learn more about Medicare Advantage plans and start searching for the best plan for your needs.