What Is Medicare Advantage in Texas?
The Medicare Advantage plan in Texas, also known as MA plan or Medicare Part C, is a popular option for Medicare benificiaries who want to expand their Medicare coverage. Eligibility and enrollment in Original Medicare is required before you apply for a Medicare Advantage plan in Texas. You can purchase the plan from a private Medicare-approved insurance company.
- Once you join an MA health insurance plan, you will continue to have Original Medicare.
- The Centers for Medicare and Medicaid Services require MA insurance plans to cover Original Medicare benefits at minimum. Plans may offer additional coverage.
- Your insurer will be responsible for all claims, customer service and administration.
- Any premium due to the insurer for MA health plans is separate from the Part B premium due to Medicare.
- In most cases, benefits are tied to network healthcare providers.
For a Texas Medicare Advantage plan that includes prescription drug coverage, look for plans denoted as MAPD (Medicare Advantage Prescription Drug).
Following are some of the extra benefits many MA plans offer:
- Vision services
- Dental care
- Hearing services
- Gym memberships
- Over-the-counter (OTC) drugs
- Prescription Medicare allowances
- Round-trip transportation for doctor visits
- Meal delivery
What is the best Medicare Advantage plan in Texas in 2022?
Best network freedom: Medicare Advantage PPO
PPO stands for Preferred Provider Organization. With PPO plans:
- You have access to a larger network.
- Referrals are not required.
- Monthly premiums range from $0 to $100.
Best for lowest out-of-pocket: Medicare Advantage HMO Plan
HMO stands for Health Maintenance Organization. With HMO plans:
- You are limited to HMO network providers.
- Your out of pocket costs for covered health care are minimal.
- Monthly premiums are generally $0.
Best for low income or health conditions: Medicare Advantage D-SNP
The Special Needs Plan (SNP) is designed to lower out of pocket costs, such as deductibles and copays, for people with special health care needs or limited income. You may qualify for this plan if you:
- Reside in an institution, such as a nursing home, or need nursing care in your own home
- Are dually eligible, meaning you have both Medicare and Medicaid
- Have certain chronic conditions like diabetes, end-stage renal disease (ESRD), dementia, HIV/AIDS or chronic heart disease
What Medicare Advantage Plans are available in Texas?
Following are the number Texas Medicare Advantage plans in 2019 in these categories:
- Local HMO: 80
- Local PPO: 46
- Regional PPO: 4
How Much does Medicare Advantage cost in 2022?
Though availability and cost may vary from one county to the next, the average 2021 premium for a Texas MAPD plan is $21.52 per month. Exact 2022 averages are TBD.
When can I make changes to my Medicare Advantage Plan?
The most common time to make changes is during the Open Enrollment Period, sometimes referred to as the Annual Election Period (AEP). This is held annually from October 15 to December 7.
During the AEP, you can join an MA plan as well as switch or drop a plan you already have. This is different from the Medicare Advantage Open Enrollment Period, which is only available to beneficiaries who already have an MA plan and want to switch or end it.
If the insurance company receives your application by December 7, your coverage start date will be January 1.
When can I enroll in a Medicare Advantage plan in Texas for 2022?
Initial Enrollment Period
Upon eligibility for Medicare Part A and Part B, you will be eligible to enroll in Medicare Advantage. If you select an MA plan that does not include Part D, you can review stand-alone prescription drug plans and sign up for Medicare Part D.
Initial Enrollment Period: Starts three months before the month of your 65th birthday and ends three months after the month of your 65th birthday
Open Enrollment Period – aka Annual Election Period
During the Open Enrollment Period, you can join, change or leave your Texas Medicare Advantage plan.
Annual Election Period: October 15 to December 7
Medicare Advantage Open Enrollment Period
The Medicare Advantage Open Enrollment Period is available only to active Medicare Advantage members. During this time, you can switch to a different MA plan or return to Original Medicare. If your MA plan does not include a Part D plan, you can enroll in a Medicare drug plan.
Annual Medicare Advantage Open Enrollment Period: January 1 – March 31
Special Enrollment Periods
Normally, when you join an MA plan, you must keep it for the calendar year. However, if you have special circumstances that qualify you for a Special Enrollment Period (SEP), you can join, switch or leave an MA plan earlier.
Special circumstances may apply if you:
- Move to a location outside your plan’s service area or to a service area where more plan options are available
- Lose other insurance coverage, such as Medicaid, employer health insurance or union group coverage
- Have an opportunity to get employer or union coverage
- Are in a plan no longer contracted with Medicare
If you switch to Original Medicare, you may want to consider purchasing a Medicare supplement plan (Medigap). Medigap policies cover coinsurance, copayments and other out of pocket costs. These plans also include benefits not available through Medicare Part A and Part B.
Special Enrollment Period: Timing varies with the type of SEP
5-star Special Enrollment Period
Medicare assigns star ratings to Medicare plans on a scale from one to five. This enables you to compare coverage options based on plan performance and quality. A 5-star Special Enrollment Period gives you a one-time opportunity to switch from your active Medicare plan to one that has a 5-star quality rating available in your service area.
5-star Special Enrollment Period: December to November 30
Special Enrollment Periods if you get “Extra Help”
The Extra Help program helps beneficiaries with limited income and financial resources by covering certain Medicare-approved costs and waiving the late enrollment penalty.
If you qualify, you may be eligible to join, change or drop your Medicare Advantage plan outside the standard enrollment periods. You qualify automatically if you get one of the following:
- Full Medicaid coverage
- Help from the Texas Medicaid program to pay your Medicare Part B premiums
- Benefits from the Supplemental Security Income (SSI) program
Extra Help periods if you have both Medicare and Medicaid: January to March, April to June, and July to September (once during each period)
Are Medicare Advantage Plans bad in Texas?
Medicare Advantage plans offer very good, comprehensive coverage. Medicare Advantage bundles Part A, Part B and often prescription drug plans into one plan. Following are 2018 statistics that demonstrate the popularity of MA plans.
1. Number of lives enrollment in Medicare Advantage in Texas: 1,453,573
2. Number enrolled by plan in Texas
- Local HMO: 770,950
- Local PPO: 472,168
- Regional PPO: 174,295
3. Percentage of Medicare beneficiaries enrolled in Medicare Advantage in Texas: 36%
4. Number of lives enrollment in Medicare Advantage nationwide: 19,838,319
5. Percentage of Medicare beneficiaries enrolled in Medicare Advantage nationwide: 34%
FAQ's Frequently Asked Questions about Medicare Advantage in Texas
What's the downside to Medicare Advantage plans?
- Network restrictions – limited provider choice, especially for HMOs that require referrals from your primary care physician to see specialists
- Less financial predictability – significantly lower premiums but higher out of pocket costs than Medicare supplement plans
- Greater responsibility – more demand on members to stay abreast of annual plan changes and manage cost sharing payments
- Less-long-term stability – subject to change unlike Medicare supplement plans that are standardized and consistent
What are 4 types of Medicare Advantage plans in Texas?
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Special Needs Plans (SNP)
- Private Fee-for-Service (PFFS)
What are the top 3 Medicare Advantage plans?
Following are the top three plans with a combined Medicare Advantage market share of 59% in 2021:
- United Healthcare: 27%
- Humana: 18%
- BlueCross BlueShield (BCBS): 14%
What are the special needs plans?
A Special Needs Plan (SNP) is a type of MA plan that offers benefits and services to Medicare recipients who have certain diseases, specific health care needs or limited financial means. The plan tailors benefits, provider options and medications to help the groups served.
Does Medicare Advantage cover drugs?
Most Medicare Advantage plans include prescription drug coverage, identified as MA-PD plans.
Do Medicare Advantage plans use the Silver Sneakers program in Texas?
Many MA plans partner with a program called Silver Sneakers to provide access to fitness facilities and exercise videos. Confirm with your insurance agent if your plan offers Silver Sneakers or a comparable wellness benefit
Texas Medicare Resources
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