Medicare Advantage Plans in Texas
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: October 14, 2020
Medicare Advantage, or Medicare Part C, is offered as an alternative to Original Medicare. In contrast to the government-run Medicare program, Medicare Advantage plans are only available through approved private insurance companies. These plans must include the same basic hospital and medical coverage as Medicare Parts A and B. Still, most offer extra benefits, such as prescription drug coverage — through Medicare Part D — vision, dental, and hearing services. Medicare Advantage plans may also provide additional benefits that aren't available through Original Medicare, such as wellness programs, adult daycare, transportation to medical appointments, safety-wise home modifications, and telehealth services.
Key Point Module
- 1 In 2019, there were 137 Medicare Advantage plans available in Texas.
- 2 36% of the total Medicare population in Texas was enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $11,627 per beneficiary in Texas, which is 15% higher than the national average.
- 4 Available Medicare Advantage plans range from eight to 72 across Texas’ 254 counties.
If you’re considering enrolling in Medicare Advantage, you have a choice of several types of plans. Some are similar to private health insurance plans offered by employers, which you may already be familiar with if you’ve previously had job-related healthcare coverage.
The availability of the different types of plans varies depending on your geographic location and individual insurance providers. When comparing available Medicare Advantage plans, it’s important to weigh relevant factors, such as your healthcare status, lifestyle, and budget, to determine which plan best suits your needs.
Medicare Advantage Plans in Texas
Types of Medicare Advantage Plans
There are various types of Medicare Advantage plans offered in Texas. The plan you enroll in can impact where and how you receive medical care as well as your premiums and out-of-pocket costs, which is why it’s important to understand your options so you can make an informed decision. The types of plans offered through the Texas Medicare Advantage program include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.
Health Maintenance Organizations (HMO)
Health Maintenance Organization (HMO) plans typically have the lowest premiums, but they’re also one of the most restrictive types of Medicare Advantage plans. Once you enroll in an HMO, you must access healthcare services through the plan’s network of physicians, hospitals, and other service providers. Most HMOs only cover the cost of care received through these approved providers. You’re responsible for any charges related to care received from out-of-network providers, with the exception of emergency services.
As an HMO member, you also must choose an in-network primary care physician, and your PCP has to provide referrals for visits to specialists.
Preferred Provider Organizations (PPO)
Preferred Provider Organization (PPO) plans are similar to HMOs in that they have a network of doctors, hospitals, and other healthcare providers. In contrast to HMOs, as a member of a PPO, you’re not restricted to receiving care only from in-network providers. PPOs pay for services received from out-of-network providers, but they typically cover a lower percentage of the cost. By staying in-network, you’ll pay the lowest copays and coinsurance for your healthcare services. That said, not all providers accept PPO plans. Check with each provider before scheduling your services.
PPOs don’t require that you choose an in-network primary care physician, and they also enable you to see a specialist without a referral. Overall, PPOs offer more choices and fewer restrictions than HMOs, but you’ll pay higher premiums for the additional freedom.
Private Fee-For-Service Plans (PFFS)
Private Fee-For-Service (PFFS) plans have set rates they pay for covered doctors’ visits, hospital stays, and other healthcare services. As a member, you can receive services from any Medicare-approved provider who agrees to the plan’s payment terms. Some PFFSs will work with a network of providers who’ve agreed to the terms and always treat enrollees.
As with PPO plans, PFFSs don’t require that you choose a primary care physician, and referrals for specialist visits aren’t necessary. In exchange for the enhanced flexibility offered by a PFFS, you can expect to pay higher out-of-pocket costs compared to most other Medicare Advantage plans.
Special Needs Plans (SNP)
Special Needs Plans (SNPs) are Medicare Advantage plans that limit enrollment to individuals with specific medical or care needs. A plan may serve Medicare beneficiaries who are dually eligible for Medicaid, individuals who live in a nursing home or other institution, or those who suffer from a chronic or debilitating condition, such as dementia or diabetes. The benefits offered by each plan focus on the specific needs of the members it’s designed to serve.
As a member of an SNP, you must seek medical care and services from the plan’s network of providers, who usually specialize in your condition or care needs. Emergency care is an exception. With some SNPs, you must choose a primary care doctor or coordinator to manage your care, and most plans require referrals for visits to specialists. SNPs usually have higher premiums, copays, and coinsurance costs than other types of Medicare Advantage plans.
Enrollment & Eligibility for Medicare Advantage Plans in Texas
To enroll in a Medicare Advantage plan, Texas residents must be U.S. citizens or legal permanent residents and be enrolled in Original Medicare Parts A and B. To qualify for Original Medicare, an individual must be:
- Aged 65 or older, or
- Disabled and receiving Social Security Disability Insurance benefits for at least 24 months, or
- Receiving dialysis or have had a kidney transplant
Additionally, individuals may not be currently enrolled in a Medigap plan and must live in an area of the state where their preferred Medicare Advantage plan is offered. Generally, those with end-stage renal disease aren’t eligible for coverage through most Medicare Advantage plans, with the exception of certain SNPs.
If you meet the eligibility requirements, you can sign up for a Medicare Advantage plan during one of four Medicare-mandated enrollment periods:
- Initial enrollment period: If you become eligible for Medicare at age 65, this seven-month period begins three months before your birthday and ends three months after your birthday month. If you qualify for SSDI, the seven months begin three months before your 25th month of receiving benefits and extends three months beyond.
- Annual open enrollment period: Between October 15th and December 7th of each year, Original Medicare beneficiaries can enroll in a Medicare Advantage plan, and current Medicare Advantage members can switch plans. Changes made during this period take effect on January 1st of the following year.
- Medicare Advantage open enrollment period: Between January 1st and March 31st of each year, those already enrolled in a Medicare Advantage plan can switch to another plan or back to Original Medicare. If you’re currently an Original Medicare beneficiary, you can’t enroll in a Medicare Advantage plan during this period.
- Medicare general enrollment period: January 1st through March 31st is also the general enrollment period for Original Medicare. If you missed your initial enrollment period, you can sign up for Medicare and possibly qualify for a special enrollment period that runs from April 1st through June 30th, when you can switch to a Medicare Advantage plan.
Prescription Drug Coverage
Prescription drug coverage, also known as Medicare Part D, is a valuable cost-saving benefit available to Original Medicare beneficiaries and Medicare Advantage enrollees. There are specific rules about the availability of Part D coverage with different types of Medicare Advantage plans.
PFFS plans usually include prescription drug coverage, but if yours doesn’t, you can enroll in a separate Part D plan. By law, all SNPs must provide prescription drug coverage. Most HMOs and PPO plans offer a Part D component, but you can’t sign up for a separate Part D plan if you choose a Medicare Advantage plan that doesn’t include this coverage. If you do, you’ll be automatically switched back to Original Medicare coverage.
Medicare Advantage Resources in Texas
Comparing the various types of Medicare Advantage plans and coverage options can be overwhelming, making it difficult to decide on a particular plan. Factors, such as premiums, out-of-pocket costs, provider networks, and covered services, must be considered to make a wise choice. Fortunately, there are resources available across the state where you can receive answers to your questions and clear, unbiased information about your Medicare Advantage options.
Texas Legal Services Center
The Texas Legal Services Center is a nonprofit organization that provides free legal and public benefits assistance to residents aged 60 and older. Medicare beneficiaries can call the organization’s statewide Legal Hotline for Texans concerning personalized, unbiased advice and guidance about their available Medicare options, including Medicare Advantage coverage. The helpline is open Monday through Friday, from 9 a.m. to 5:00 p.m.
Contact Information: Website | 800-622-2520, Option 3
Texas Health and Human Services Department
The Texas Health and Human Services Department oversees the statewide Health Information, Counseling, and Advocacy Program (HICAP). The department trains and certifies benefits counselors who can help Medicare-eligible individuals learn about their coverage options for Original Medicare, Medicare Advantage plans, and Part D prescription drug plans as well as the applicable eligibility requirements and enrollment process. Seniors and eligible disabled individuals can visit the HHS website to access a directory of HICAP counseling partners across the state.
Contact Information: Website | 800-252-9240
Texas Area Agencies on Aging
There are 28 Area Agencies on Aging (AAAs) offices located throughout Texas to help residents aged 60 and older access aging-related programs and resources. Free benefits counseling is one of the many services offered by AAAs, and it includes information and advice about Medicare, Medicare Advantage plans, and prescription drug coverage. The Texas HHS Department oversees AAAs statewide, and the Department’s website offers a map and directory to help residents find the AAA serving their area.
Contact Information: Website | 800-252-9240
- Sources [-]
https://www.tdi.texas.gov/pubs/consumer/medsup.html Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp Last accessed April 2021
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html Last accessed April 2021
https://www.medicare.gov/manage-your-health/i-have-end-stage-renal-disease-esrd Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan Last accessed April 2021
https://www.medicare.gov/Pubs/pdf/11135-prescription-drug-coverage-with-ma-mcp.pdf Last accessed April 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.