Medicare Part C enrollment has nearly doubled over the past decade. More commonly known as Medicare Advantage (MA), more than 28 million Medicare beneficiaries had an MA plan in 2022. This page explains Medicare Advantage plans in Texas and what to look for when comparing your options.
What Is Medicare Advantage in Texas?
At a minimum, every Medicare Advantage plan must provide the same benefits that you get with Original Medicare. This includes:
- Medicare Part A: Covers inpatient services that you'd receive in a hospital or skilled nursing facility (SNF)
- Medicare Part B: Covers outpatient services, such as doctor visits, lab work, outpatient procedures performed in a hospital, and durable medical equipment (DME)
Original Medicare does not include prescription drug coverage.
Medicare Advantage plans are not limited to the benefits provided by Parts A and B. In fact, over 90 percent of them offer additional coverage. The most common items are:
- Fitness programs like SilverSneakers
- Prescription drug coverage
- Routine vision and dental care
Please note that joining a Texas Medicare Advantage plan does not exempt you from the Medicare Part B premium.
Texas Medicare Advantage Plans with Prescription Drug Coverage
Medicare Advantage Prescription Drug plans (MA-PD) combine your Medicare Parts A, B, and D benefits into a single plan.
If you choose an MA plan that doesn't include a prescription benefit AND you do not have creditable coverage elsewhere, you need to join a standalone Medicare Part D plan. (Creditable means a plan that is comparable to Medicare.) If you fail to maintain creditable drug coverage, you'll have to pay the Medicare Part D late enrollment penalty for the entire time you have Part D (once you join a plan).
Who Is Eligible for Medicare Advantage in Texas?
You become eligible for Medicare Advantage in Texas once you sign up for Medicare Parts A and B.
If you are an American citizen or permanent legal resident aged 65 or older, you qualify for Medicare. If you start collecting Social Security benefits at least 4 months before your 65th birthday, enrollment in Parts A and B is automatic. Everyone else has to apply for Medicare.
Collecting Railroad Retirement Board (RRB) or Social Security disability benefits for 24 months also qualifies you for Medicare, even if you haven't turned 65 yet. Enrollment occurs automatically during month 25.
When Can You Sign Up for a Medicare Advantage Plan in Texas?
You may first join a Medicare Advantage during your Initial Enrollment Period (IEP). It lasts for 7 months and starts 3 months before your Medicare eligibility month. So, if your 65th birthday or 25th month of collecting disability benefits occurs in June, your IEP is from March 1 through September 30.
The General Enrollment Period begins January 1 and ends March 31. It is for anyone who did not sign up for Medicare Part A and/or Part B during their IEP. After General Enrollment ends, you can join an Advantage plan between April 1 and June 30.
You can also sign up for a Part C plan during the Medicare Annual Enrollment Period (AEP) that occurs every year from October 15 until December 7.
From January 1 through March 31, the Medicare Advantage Open Enrollment Period lets people who already have a Part C plan switch to a different one. You may also choose to return to Original Medicare. If that change causes you to lose your prescription drug coverage, you can join a standalone Medicare Part D plan.
You may be eligible for a Special Enrollment Period (SEP) if you experience certain life changes. Find the full list of qualifying special circumstances on Medicare.gov.
Types of Medicare Advantages Plans in Texas
There are four common types of Medicare Advantage plans in Texas.
Health maintenance organizations account for over half of all MA plans. HMO plans use provider networks to help control costs. Most HMO plans don't cover non-emergency care from an out-of-network provider. If you join an HMO plan, you'll also need to choose a primary care doctor and get a referral to see a specialist.
Preferred provider organizations (PPO) also use provider networks. But PPO plans allow members to get out-of-network services for a higher copay. You also don't have to choose a primary doctor or get a referral to see a specialist with a PPO plan.
Private fee-for-service (PFFS) plans set price points for all covered services. Most use a provider network but are like PPOs in that they allow members to receive out-of-network care for a higher price. They also don't require enrollees to have a primary doctor or get a referral for a specialist.
Special needs plans (SNPs) limit membership to people in one of the following populations:
- Have a chronic condition, such as diabetes, chronic heart failure, HIV/AIDS, dementia, or ESRD
- Require in-home healthcare or live in an institution, such as a nursing home
- Are dual eligible, meaning they qualify for both Medicare and Medicaid
Plan benefits are tailored to meet the needs of the population the SNP serves.
How to Choose a Medicare Advantage Plan in Texas
To get the best Medicare Advantage plan for your unique needs and budget, consider the following:
- Costs: May include an annual deductible, monthly premium, and copays or coinsurance.
- Coverage: Review the plan's benefits carefully to understand what that monthly premium gets you. If it's an MA-PD plan, don't forget to check the drug formulary.
- Network: Any entity that provides healthcare services – doctors, hospitals, etc. – may be included in the plan's network.
- Ratings: Medicare publishes its Advantage plan ratings each fall to help beneficiaries during Annual Enrollment.
Our Find a Plan tool makes comparing Medicare Advantage plans in Texas easy. Just enter your location information and estimated coverage start date to review Medicare plans in your area.
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