How Does Medicare Work in Texas?

Medicare was enacted in 1966 and is the United States’ federal health insurance program to cover hospital (Part A) and medical (Part B) expenses for beneficiaries. Throughout the years, Medicare has expanded its program even further to offer more coverage, commonly referred to as Medicare Part C and Medicare Part D coverage. Medicare coverage is not limited to just the federal government but is also delivered by private insurance companies that are contracted by Medicare to provide benefits to beneficiaries.

Choosing your Medicare coverage can seem like a daunting task due to all the connecting parts and providers of coverage. Below we’ll detail some facts about the different parts of Medicare and how they all work together in Texas to help you decide which Medicare option is the best for you.

The Facts About Medicare

Original Medicare is a federal program that is offered to individuals once they reach the age of 65. It is also offered to people under the age of 65 if they have disabilities or certain conditions. These conditions can include Lou Gehrig’s disease (amyotrophic lateral sclerosis), end-stage renal disease (permanent kidney failure requiring continuous dialysis treatment or a kidney transplant), and others.

If you are a citizen or permanent legal resident of the United States for at least five straight years and meet the eligibility requirements, you can get Original Medicare regardless of your health status or income level. In Texas, the rules for Original Medicare are the same rules as those across the country. Your local Social Security Office can give you more personalized information about your eligibility and enrollment in Original Medicare. 

Original Medicare can be split into two parts:

  • Medicare Part A assists with paying for inpatient hospital care along with some post-hospitalization skilled nursing care, hospice care, and home health visits.
  • Medicare Part B assists with paying for doctor visits that are related to the diagnosis and treatment of an injury or illness; health check-ups and some preventive screenings; outpatient medical services including lab work and X-rays, physical therapy, durable medical equipment, and some other health services.

If you or your spouse worked at least 10 years and paid Medicare taxes then you can get Medicare Part A without a premium. Otherwise, you may have to pay a premium for your Part A coverage. The majority of Medicare beneficiaries pay a premium for their Part B coverage. Usually, you’ll also have to pay deductibles, copayments, or coinsurance costs for covered Medicare Part A and Part B services. 

Original Medicare Part A and Part B do not cover all healthcare services and health-related items. Here are some items you will be responsible for paying for:

  • Most prescription drugs. This excludes medications you receive in the hospital or certain medications you get in an outpatient treatment center.
  • Routine dental care
  • Routine vision care and eyeglasses
  • Nursing home care
  • Health services received outside the country

You can use a Medicare stand-alone Prescription Drug Plan that works alongside your Original Medicare coverage to get Medicare Part D prescription drug coverage. You can also get Medicare Prescription Drug coverage through a Medicare Advantage plan that includes prescription drug benefits. 

To be eligible for Medicare Part D prescription drug coverage, you must have Medicare Part A and/or Part B. You will probably have to pay a monthly premium for your Medicare prescription drug coverage plan. You may also qualify for help to offset some or all of your premium costs, depending on your income. This is known as the Low-Income Subsidy program. If you do not qualify for cost assistance, your Medicare Part D costs will be based on your Medicare plan.

Medicare Advantage

You may want to consider a Medicare Part C (Medicare Advantage) Plan as an alternative way to receive your Original Medicare benefits. Medicare Advantage plans come from private insurance companies that contract with the Centers for Medicare & Medicaid Services (CMS) to provide all your Original Medicare benefits. These plans exclude hospice care, which continues to be paid by Medicare Part A. If you decide to enroll in a Medicare Advantage plan, then the plan will provide your benefits and pay for the covered services you receive. 

Many Medicare Advantage plans provide more coverage than Original Medicare. Medicare Advantage plans can offer additional benefits, including routine dental and vision care, hearing, prescription drug coverage, and wellness plans. Medicare Advantage plans that include prescription drug coverage are referred to as Medicare Advantage Prescription Drug (MA-PD) plans. These plans offer the convenience of combining your Medicare medical and prescription drug benefits into one plan.

Medicare Advantage plans help to limit your out-of-pocket spending for services covered under Medicare Parts A and B. Every Medicare Advantage plan must include an annual out-of-pocket spending limit. After your out-of-pocket costs, including the deductible, reach this limit, your Medicare Advantage plan will pay 100% of your covered healthcare costs for the rest of the year. On the other hand, Original Medicare doesn’t have a maximum spending limit to cap your annual out-of-pocket costs. It is important to remember that Medicare Advantage members typically must continue to pay their Medicare Part B premium.

There are various types of Medicare Advantage plans. The two most common types are Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). Both PPOs and HMOs have networks of participating hospitals, doctors, and other healthcare professionals.

If you choose a Medicare PPO, your out-of-pocket costs will be lower when you use hospitals, doctors, and other healthcare professionals who participate in the PPOs network. If you use non-participating healthcare providers then your costs will be higher. 

If you choose a Medicare Advantage HMO, you will probably select a primary care physician who will provide or coordinate your care through referral to other participating providers. Other than emergencies, out-of-network providers’ services are not covered unless they are approved in advance by the plan. 

If you are interested in joining a Medicare Advantage PPO or HMO plan but want to maintain your current relationships with doctors or hospitals, make sure to check if your preferred healthcare providers participate in the Medicare Advantage plan’s network.  

You must be enrolled in Medicare Part A and Part B in order to enroll in a Medicare Advantage plan. You must also live in the plan’s service area. You cannot have end-stage renal disease and have a Medicare Advantage plan, although there are some exceptions.

Medicare Resources in Texas

The Texas Department of Insurance offers many services to Texas Medicare beneficiaries, including counseling, education, and finding financial assistance for healthcare costs. It is also the location of the Health Information Counseling and Advocacy Program (HICAP). HICAP provides statewide counseling and information about various insurance options, including Medicare plans. They also offer eligibility requirements for those who might qualify for additional financial assistance from the state. 

The Texas Health and Human Services Commission is the go-to office for beneficiaries who qualify for Medicaid and Medicare savings programs. Programs like the Qualified Medicare Beneficiary Program provide financial assistance to eligible beneficiaries who meet certain income requirements. Assistance from these programs can include partial or full payment for Medicare premiums, deductibles, and coinsurance costs. The Texas Health and Human Services Commission website provides more information about these eligibility requirements.

Your Texas Medicare Experts

You deserve to know your rights and choices about Medicare benefits in Texas. Knowing your rights and Medicare options is an important part of choosing the right Medicare coverage. At Coverage 2 Care, we take the stress out of enrollment by helping you compare plans to find the right benefits for you. Our licensed professional agents will help you find affordable solutions to maximize your savings and get the coverage you need.

Contact us today to have one of our agents help you get the benefits you deserve!

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