Although Medicare is a federal health insurance program, the state someone lives in can affect different aspects, like plan options and costs.
In the Lone Star State, beneficiaries have access to the standard structure of Medicare, comprising Parts A, B, C, and D, alongside supplementary Medigap plans.
Understanding these Medicare parts and plans and the different enrollment periods is important for Texans to make informed decisions and avoid late enrollment penalties. Understanding the variations in plan costs based on geographic location is also helpful.
Unlike some other states, Medicare coverage in Texas follows the standard structure and procedures you would expect from the insurance.
There are four parts to the program, including Medicare Part A, Part B, Part C, and Part D. Part A and Part B help cover inpatient and outpatient care, while Part D helps cover prescription medications.
Part C is another name for Medicare Advantage plans which is an alternative way to receive Medicare benefits through a private insurance carrier rather than the federal government. Advantage plans work differently than regular Medicare so understanding Original Medicare vs Medicare Advantage is important.
There are also Medicare Supplement plans, also known as Medigap plans. These plans work secondary to Medicare to help cover different costs like deductibles, coinsurance, and copays.
All the parts and different types of plans are available in Texas. So, Texas beneficiaries can expect various Medigap, Advantage, and Part D plan options through a wide range of insurance carriers.
Medicare Enrollment Process in Texas
People living in Texas can sign up for Medicare Part A and Part B directly through the Social Security website. They can also visit a local Social Security office to apply in person.
It’s important to know that there are several Medicare enrollment periods. Beneficiaries should know which enrollment period they need to use as people cannot enroll in Medicare anytime they want.
Initial Enrollment Period
Most new beneficiaries will want to sign up for Medicare Part A and Part B during their Initial Enrollment Period (IEP). Their IEP lasts seven months, beginning three months before their 65th birthday month and ending three months after their 65th birthday month.
If someone does not sign up for Medicare during their IEP, they may be subject to late enrollment penalties that increase over time. However, some people can delay Medicare past their IEP if they have health insurance from an employer with 20 or more employees based on active employment, not retiree coverage.
Special Enrollment Periods
Special Enrollment Periods (SEP) allow qualifying beneficiaries to sign up for Medicare past their IEP without late enrollment penalties. These SEPs can apply to various situations.
For example, many people continue to work past 65 for a large employer and decide to delay Medicare until they retire. Once they retire, they qualify for a SEP that allows them to enroll in Medicare without late feeds. This is not the only SEP, but it is the most used.
Medicare Costs in Texas
Although someone’s work history and income level can affect someone’s monthly premium for Medicare Part A and Part B, the state someone lives in does not. Social Security determines the costs for these two parts.
However, the state and zip code someone lives in does affect the monthly premium for Medigap and Advantage plans. Medicare Part D costs are affected by income level and where someone lives.
Some states are more expensive, while others aren’t relatively as high. For example, Florida is one of the most expensive states due to the large retiree population, the high cost of living, and more.
Fortunately, Texas is not known for being a more expensive state. Medicare beneficiaries in Texas will find that plan costs are fairly average and not as expensive or cheap as in other states.
Medicare Coverage in Texas
Medical coverage through Part A and Part B is standardized by the Centers for Medicare & Medicaid Services (CMS), a federal organization. This means that no matter the state someone lives in, the coverage available through these two parts will remain the same.
The same is true for Medigap plans as well. These plans are secondary to Part A and Part B, so they will only pay for services covered by Original Medicare (Part A and Part B).
Medicare Part D Coverage in Texas
CMS requires Part D plans to cover all medications under what are known as “protected classes,” regardless of state. However, Part D plans only have to cover at least two prescription drugs that do not fall under the protected classes.
Because of this, each Part D plan will cover different medications at different costs, so Medicare beneficiaries will want to look at the various plans available to see which will cover their specific medications.
The Part D plans available to someone are based on their zip code, so people in Texas will have different plan options depending on where they live.
Medicare Advantage Coverage in Texas
CMS also has coverage requirements for Medicare Advantage plans even though private insurance carriers offer them. These plans must provide at least the same coverage people can receive through Original Medicare. For example, Advantage plans must provide coverage for emergency and urgent care even outside of the plan’s network.
Advantage plans can offer additional benefits that Original Medicare does not cover, like gym memberships. However, these extra benefits can change from year to year.
However, costs, provider networks, and extra benefits differ from plan to plan. Like Part D plans, the Advantage plans someone can choose from are based on where someone lives. So, two people living in Texas may still have different Advantage plan options because they live in distant locations.
Medicare for Rural Texans
Texas is home to various rural communities. Living in a more isolated location can sometimes come with challenges and barriers to receiving adequate healthcare.
In recent years, CMS has been actively working towards ensuring that Medicare beneficiaries living in rural locations in the United States receive the care they need. Because of this, CMS has worked to expand certain services to people living in rural Texas and other states.
One service CMS has expanded is telehealth. Telehealth for behavioral/mental health services will continue to be available past 2024 for people in rural areas, hopefully making healthcare more accessible in rural areas.
Also Read : 3 Essentials For Your Next Texas Road Trip
Final Thoughts
Navigating Medicare in Texas involves understanding the standardized coverage provided by Parts A and B while also considering the varied options for supplementing and enhancing that coverage through Medigap, Part D, and Advantage plans.
Enrollment periods, costs, and available plans may differ based on individual circumstances and geographic location within the state. Despite these complexities, Texas generally offers Medicare beneficiaries a range of options at average costs compared to other states.
Furthermore, recent initiatives, such as expanded telehealth services, aim to address healthcare accessibility challenges in rural areas, underscoring ongoing efforts to ensure all Texans, regardless of location, can access the care they need.
As Medicare continues to evolve, staying informed and exploring available resources will remain crucial for Texans seeking to make the most of their healthcare coverage options.
