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Medicare Insurance in Texas

Medicare insurance is any of the combination of health insurance coverages designed for:

  • Individuals who are 65 years or older;
  • Persons with certain disabilities under 65 years; or
  • Persons with End-Stage Renal Disease (ESRD) (permanent kidney failure needing dialysis or a kidney transplant).

Medicare is a government-administered health program that seeks to provide these persons with comprehensive coverage at affordable rates.

If you qualify for Medicare in Texas, you usually have a choice between using:

  • Original Medicare (with or without Medigap supplemental assistance), or
  • Medicare Advantage.

The Center for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services (HHS), administers Medicare in Texas and for all states in the country. The Texas Health Information, Counseling, and Advocacy Program assists Texas residents in finding and sorting through the available Medicare options in the state.

Consult with a state-licensed health insurance agent prior to signing up for any private Medicare alternatives.

What is Considered Medicare Insurance?

Medicare insurance in Texas is a federal government insurance program that provides health coverage for eligible persons. They include people:

  • who are 65 years or older,
  • under 65 years with disabilities,
  • with end-stage renal disease (ESRD) (permanent kidney failure requiring dialysis or transplant), and
  • with Lou Gehrig’s disease, which is also called amyotrophic lateral sclerosis (ALS).

Medicare is divided into four parts:

  • Part A (Hospital Insurance) is free for the majority of the persons that qualify for it and is funded through a part of the federal income tax (FICA). If you or your spouse worked for at least ten years (40 quarters) and paid Medicare taxes, you can get Medicare Part A without paying a premium. Otherwise, you may have to pay a premium for your Part A coverage. It covers hospitalization, inpatient care in a skilled nursing facility, hospice care, and home health care.
  • Part B (Medical Insurance) is funded by monthly premiums paid by insureds and federal government revenue. It covers various in and out of the hospital medical services, such as visits, lab tests, clinical trials, mental health care, preventive care, and surgeries.
  • Part C (Medicare Advantage) enables individuals to get medical care services from a network of available providers. They are provided by private Medicare-approved companies, such as:
    • Health Maintenance Organizations (HMO)
    • Medicare Medical Savings Account Plans (MSA)
    • Preferred Provider Organizations (PPO)
    • Private Fee-for-Service Plans (PFFS)
    • Special Needs Plans (SNP)
  • Part D (Prescription Drugs) covers the cost of prescription drugs, including vaccines and shots. It is an optional coverage sold by commercial prescription drug plans (PDPs) that have a Medicare contract.

The combination of Medicare Part A and Part B is called Original Medicare. It is administered by the Government. Enrollees of Original Medicare that are interested in getting drug coverage have to get a separate drug plan (Part D). Also, while Original Medicare covers many benefits, there are still costs that enrollees have to settle. They can do this by getting a Medicare Supplement Insurance (Medigap) policy. Medigap is basically an add-on to Original Medicare that can help settle coverage gaps by paying out-of-pocket costs like copayments, coinsurance, and deductibles. Medigap policies are also sold by private insurers.

Medicare Part C (usually called Medicare Advantage) is the alternative to Original Medicare. It combines features of Part A, Part B, and usually Part D. They are plans sold by private insurance companies that have yearly contracts with Medicare. Some Medicare Advantage plans provide extra benefits that Original Medicare does not cover, like vision, hearing, and dental services.

Medicare enrollees are given a red, white, and blue Original Medicare card. For beneficiaries of Original Medicare, they need to show this card when they receive services. Medicare Advantage beneficiaries will also get a Medicare Advantage Plan card in addition to the Original Medicare Card. They are to show this Medicare Advantage Plan card when they get services. No matter how you get your Medicare health benefits, only give your Medicare number to your doctors and health care providers.

Choosing your Medicare coverage can be a complex task, with so many interconnected aspects and sources of coverage. Contact a licensed Texas health insurance agent to help you with understanding Medicare and how it works.

What is the Purpose of Medicare Insurance?

Medicare in Texas is a health insurance program created by the federal government in 1965 to help aged people and people with disabilities meet health-related expenses. It provides health and financial security for millions of older people and younger people with disabilities.

Medicare is not designed primarily for individuals with the lowest incomes and financial resources. Instead, it serves as a safety net for people who might otherwise be unable to obtain inexpensive health insurance due to age or bad health. 65 years is the traditional retirement age in the United States. Consequently, it is the time when an employer may terminate the retiree’s health coverage. That is also the time when health insurance tends to become more expensive for people in that age bracket. People with disabilities, ESRD, or ALS, cannot work because of the disability or possible kidney failure and may get coverage from their jobs. Medicare provides access to affordable health care services that will most likely have been expensive for these categories of persons.

What is Medicare Insurance For?

Medicare insurance in Texas is for providing health insurance to:

  • Adults who are 65 years and older,
  • People under 65 years with certain disabilities, and
  • People under 65 years and with End-Stage Renal Disease (ESRD).

What are the Types of Medicare Insurance?

In Texas, there are two main types of Medicare insurance coverage: (1) Original Medicare; and (2) Medicare Advantage.

  1. Original Medicare: The term “Original Medicare” relates to Part A (Hospital Insurance) and Part B (Medical Insurance) alone. The federal government manages original Medicare on a fee-for-service basis. It has different subtypes. Generally, Original Medicare includes medical services from any Medicare-accepting doctor, healthcare provider, hospital, or facility. In most cases, you will have to pay deductibles, copayments, and coinsurance for Medicare Part A and Part B services. As long as the specialist is enrolled in Medicare, there is no need for a referral or for the patient to select a primary care physician under Original Medicare. You can visit any doctor or hospital that takes Medicare to receive treatment. It has a major advantage of national coverage. That is, you can enjoy the benefits of Original Medicare in any part of the country, as long as the provider or institution accepts Medicare enrollees. It should be noted that prescription drugs are usually not covered under Medicare Part A and B services. A Medicare stand-alone Prescription Drug Plan that runs alongside your Original Medicare coverage can provide Medicare Part D prescription drug coverage.

  2. Medicare Advantage: Medicare Advantage plans are government-approved but are only available through private insurance companies. They cover all of the services covered by Original Medicare, except for hospice care and some treatment in authorized clinical research studies. Out-of-pocket costs may be cheaper with these plans than with Original Medicare. Additional coverage, including vision, hearing, dental, and other health and wellness programs, as well as prescription medications, may be available. A Medicare Advantage plan is an alternative to getting prescription drug coverage (Medicare Advantage Prescription Drug, or MA-PD). To be eligible for Medicare Part D prescription drug coverage, you must have Medicare Part A and/or Part B. If you choose to enroll in Medicare prescription medication coverage, you will most likely be required to pay a monthly premium for your plan. Depending on your income, you may be eligible for “extra help” to pay some or all of your premium costs (also known as the Low-Income Subsidy program). If you are not qualified for cost assistance, the costs of Medicare Part D are determined by your Medicare plan.

  3. Medigap: Medigap, also called Medicare Supplemental plan, provides additional coverage options to Original Medicare. is not a type of Medicare insurance. It is a plan that helps with covering an enrollee’s out-of-pocket costs like copayments, coinsurance, and deductibles. They will help pay the healthcare cost that Original Medicare will not cover. For example, Original Medicare covers 80% of services, leaving an enrollee with the remaining 20% cost, after deductibles have been paid. If you get a Medigap plan, it will cover the remaining 20%. Medigap plans are sold by Medicare-approved private insurance companies. Medigap plans only work with Original Medicare, not Medicare Advantage. If an enrollee receives medical care and Medicare pays its part of the Medicare-approved costs, the enrollee’s Medigap plan will pay its share too. These Medigap plans are standardized and they are named after letters — Plans A-N. Every standardized Medigap policy under the same plan letter must provide the same fundamental benefits.

Do You Need Medicare Insurance?

Everyone needs health insurance. So, you need Medicare insurance if you qualify for it and do not have any health coverage. It is accessible and affordable healthcare for persons who qualify for it. Health coverage and medical expenses outside Medicare for the aged, people with disabilities, and people with ESRD can be costly. With Medicare coverage, you can get quality health coverage at affordable rates.

The amount of coverage you need depends on your income and how much coverage you need. The coverage options are Original Medicare (with or without Medigap and Prescription Coverage) and Medicare Advantage.

It is important that you sign up in time if you qualify for Medicare, because there are penalties for late enrollment.

Why Do You Need Medicare Insurance?

If you qualify for Medicare Insurance in Texas, you need it because:

  • It is accessible and affordable. Medicare makes health coverage, which would have been expensive for the people who qualify, accessible and low-cost. You can easily sign up for Medicare and get health coverage, possibly for as low as $0 per month. Also, healthcare services under Original Medicare can be received from a doctor of your choice.
  • It provides you with quality health care. You have access to a full range of services, both inpatient and outpatient.

Generally, you need Original Medicare because it provides you with basic coverage benefits at affordable rates. If you have Original Medicare, you will need Medigap to handle your out-of-pocket costs and to help prevent major expenses.

You need Medicare Advantage if you want something more than the basic benefits of Original Medicare, like prescription coverage and vision, dental, hearing benefits all in the same plan.

How Much Medicare Insurance Do You Need?

Generally, the question of how much Medicare, or any other health insurance, you need in Texas usually depends on your income and how much coverage you need. However, to a large extent, the cost and coverage of Original Medicare coverage are fixed. Hence, you need to know if the coverage provided is what you want. If not, you can get a Medigap plan to cover these excluded services or a Medicare Advantage Plan that covers these services from a Medicare-approved private insurer.

Always discuss your insurance buying options with a state-licensed insurance professional. A Texas-licensed health insurance agent can help answer questions about how much Medicare Insurance you need, based on your particular needs.

What Medicare Insurance Coverage Do You Need?

In Texas, you need either an Original Medicare or a Medicare Advantage plan. These two plans provide comprehensive health coverage. However, Original Medicare does not cover certain medical services like vision, hearing, and dental services. To get coverage for this, you can get a supplemental insurance plan to cover services that your Medicare Parts A and B do not cover. If you are under Original Medicare, you should consider getting a Medigap plan to cover your out-of-pocket.

An alternative to Original Medicare is Medicare Advantage. They provide the services and benefits that Original Medicare provides. It also includes services that are excluded from Original Medicare, such as drugs, dental, hearing, and vision services.

Texas insurance agents are legally restricted with what information they can volunteer on their own, without the client bringing it up first. Medicare is one of the touchy subjects. Do your own research and ask your health insurance agent about all available Medicare insurance options.

Is Medicare Insurance Required by Law?

Getting Medicare Insurance in Texas is not mandatory. However, it is automatically offered in some instances and may take some work to decline because there are penalties for declines and late enrollment. The penalty for failing to enroll in Medicare or registering late can be as complicated. The penalty for failing to enroll when you initially become eligible for Medicare varies depending on the program.

  • Part A: The penalty for not enrolling for Medicare Part A when you become qualified depends on why you did not enroll. If you choose not to sign up without a justifiable reason, your monthly premium, when/if you ever decide to enroll, will rise by 10% for two times the number of years you did not enroll. That is, if you delay enrolling for two years, you will pay the late enrollment penalty for four years after you enroll.
  • Part B: If you decide not to enroll for Part B when you become qualified, the penalty may last longer than Part A. You will have to pay 10% of the standard premium for each year you did not enroll and for as long as you sign up for Medicare. For example, your premium price will rise by 10% for the remainder of your enrollment period if you sign up for Part B one year after your first enrollment period ends. If you wait two years after your original enrollment, your premium will rise by 20% for the remainder of your enrollment period.
  • Part C: Enrolling in Part C is not mandatory and does not have penalties on its own. However, penalties may apply if you enroll late in the parts of Medicare that are covered by your Medicare Advantage plan.
  • Part D: Part D is also optional; however, you may still face penalties for enrolling late. Late enrollment may attract a penalty of 1% of the beneficiary premium multiplied by how long you did not have Part D coverage.

You can appeal any decision if you disagree with the assessment of your penalty for failing to enroll for Medicare on time.

If you consider rejecting Medicare coverage, talk to a licensed agent in Texas about the benefits and drawbacks of such a decision. It is important to understand how or if your existing plan will operate with Medicare, to select the most comprehensive coverage available.

How Does Medicare Insurance Work in Texas?

You first have to enroll in Medicare once you qualify in Texas. There is a seven-month window for initial enrollment to Medicare if you are just about to turn 65 years. This enrollment period starts three months before you turn 65 and ends three months after your 65th birthday. If you have ESRD, ALS, or a chronic condition or disability which qualifies you to get Social Security benefits, you qualify for Medicare irrespective of your age.

Once you qualify to enroll for Medicare insurance, you can either choose to get health coverage through Original Medicare (Parts A and B) or a Medicare Advantage Plan from a private insurance company.

  1. Original Medicare: This is a combination of Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). It is a traditional fee-for-service program offered directly through the federal government. That is, you pay for the services as you receive them. Part A coverage is usually premium-free. If it is not for you, you will have to pay $274 or $499 per month (2022). Part B monthly premiums in 2022 were $170.10. After you have paid premiums, Medicare covers part of your medical expenses. For example, there is coinsurance, where Medicare covers 80% of cost, while you cover the remaining 20%. As of 2022, the yearly deductible for Part A coverage with original Medicare was $1,556. You will also have to pay a coinsurance of $389 if you stay in the hospital for more than 60 days within a benefit period. In 2021, original Medicare also required you to pay a $233 annual Part B medical deductible and 20% of many procedures after the deductible.

    Original Medicare does not cover some essential health benefits (dental, vision, and hearing services). You can also add a separate drug plan if you desire drug coverage (Part D). Your insurance company determines the cost of your Part D plan. Original Medicare covers a large portion of the cost of covered health care services and supplies, but not all of them.

    Elective Medicare Supplement (Medigap) coverage helps cover the remaining healthcare expenditures, such as copayments, coinsurance, and deductibles.

  2. Medicare Advantage Plans: These are Medicare-approved plans offered by private insurers that provide hospital and medical insurance like Original Medicare and prescription drugs coverage. Sometimes, they offer extra services excluded by Original Medicare, like dental, hearing, and vision.

    Medical Advantage insurers have annual agreements with Medicare, and they follow Medicare coverage rules. They must inform the insured of any changes with their plans before the next enrollment period. Your premiums, deductibles, coinsurance, and copayments depend on your insurance company and plan. Each Medicare Advantage Plan charges a different amount for out-of-pocket expenses. They may also have various restrictions regarding how you obtain services.

  3. Medigap: Medigap insurance is also called Medicare Supplemental Insurance. From the name, it is used to supplement coverage by paying for the healthcare costs that Original Medicare does not. These healthcare costs include deductibles, copayments, and coinsurance under Original Medicare. Medigap plans are sold by private insurance companies approved by Medicare. Under Medigap, you pay monthly premiums directly to the insurance provider. You can only buy a Medigap plan if you are an Original Medicare enrollee. Medigap is not used with Medicare Advantage Plans.

The Medicare annual open enrollment is from October 15 to December 7 every year. During this period, you get to choose the coverage you want to sign up for or if you want to change your current coverage. For example, you can choose to switch from Original Medicare to Medicare Advantage or vice versa.

The Medicare special enrollment period also allows you to sign up for Medicare or switch plans. You qualify for the special enrollment period to switch plans if you experienced a qualifying life event. These situations include:

  • You leave the service area of your plan.
  • Your plan closes, stops serving your area, dramatically lowers its provider network, or continuously gets low Medicare star ratings.
  • You desire to switch to a 5-star plan at any time or cancel your first Medicare Advantage plan within the first 12 months of enrollment.
  • You enter or leave a qualifying institutional establishment, including a nursing home.
  • You are eligible for Medicare financial help, such as Medicaid, a Medicare Savings Program, or Extra Help, or you obtain or lose eligibility for any of these.
  • You join or leave the Program of All-Inclusive Care for Elderly (PACE)
  • You get or lose your qualifications for a Special Needs Plan.

You qualify for special enrollment to sign up for Medicare if you are 65 years or older, you or your spouse is still working, and insurance provided by your employer covers you.

A red, white, and blue Original Medicare card is given to everyone who has Medicare. If you pick Original Medicare coverage, you must present this card when receiving services. You will still receive an Original Medicare card if you choose Medicare Advantage coverage, but you need to show your Medicare Advantage Plan card while receiving services.

You may be automatically enrolled in a Medicare Advantage Plan sponsored by a union or current or previous employer if you get health coverage from them when you become eligible for Medicare. You have the option of staying with this plan, switching to Original Medicare, or enrolling in a different Medicare Advantage Plan; however, before making any changes, you should consult with your employer or union.

It is crucial to be aware of your Medicare coverage options and to select your plan carefully. The way you get your benefits and from whom you get them might have an impact on your out-of-pocket payments and where you can seek care. For example, Original Medicare covers you to visit practically all doctors and hospitals in the United States. On the other hand, Medicare Advantage Plans are more likely to include network restrictions, limiting your access to doctors and hospitals. However, you may access additional benefits, like regular vision and dental care that Original Medicare does not provide.

What Does Medicare Insurance Cover?

Both Original Medicare and Medicare Advantage plans in Texas cover both inpatient and outpatient services. These include inpatient care in a skilled nursing facility, hospice care, home health care, visits, lab tests, clinical trials, mental health care, preventive care, and surgeries. However, Original Medicare does not cover prescription drugs and regular dental, hearing, and vision services. You can get a supplemental insurance plan to cover these excluded services. However, your Medicare Advantage Plans may cover these regular services and provide you with prescription coverage and other health benefits. Also, note that Original Medicare may leave with a number of out-of-pocket costs, which you can handle by getting a Medigap plan. Medigap can assist you with covering part of your health care costs.

What is Medicare Insurance Good for?

Medicare insurance in Texas is good for providing affordable quality health coverage for the people who qualify. This includes people:

  • over 65 years old
  • with certain disabilities,
  • that have ESRD (permanent kidney failure requiring dialysis or transplant), and
  • with ALS or Lou Gehrig’s disease.

What Does Medicare Insurance Typically Include?

  • Part A covers hospital insurance, including inpatient hospital care, skilled nursing facility care, hospice care, and home medical care.
  • Part B covers medical insurance, which can be divided into medically essential services and preventive services. The medically essential services include services that are required to diagnose or treat illnesses and medical conditions. Preventive services include services that help prevent illnesses or that identify them in their early stages. Generally, Part B covers outpatient care, doctors’ services, medical supplies, and preventative services.
  • Part C covers both hospital and medical insurance that Parts A and B cover. The insurer may cover other benefits like periodic vision, hearing, and dental checkups. This is called Medicare Advantage.
  • Part D covers prescription drugs, including shots and vaccines, by covering their costs.

The benefits of each Part are provided under either Original Medicare or Medicare Advantage. The benefits of Medicare Part A and Part B are enjoyed under Original Medicare. Original Medicare does not include prescription coverage (Part D). To get prescription coverage, you have to buy a plan from a private company. Original Medicare also excludes vision, hearing, or dental services. Most beneficiaries of Original Medicare tend to get a Medigap plan to help cover their out-of-pocket costs. Because Original Medicare has annual limits on out-of-pocket costs, the insured purchase supplemental insurance (Medigap) to handle their copays, coinsurance, deductibles, and even costs related to insurance while traveling outside the U.S. Medigap plans are sold by private companies.

On the other hand, is Medicare Advantage. These are plans sold by Medicare-approved private insurers. They offer an all-inclusive plan of Original Medicare benefits, prescription drugs coverage, and other benefits. These other benefits include services for vision, dental, and hearing coverage.

Who is Covered by Medicare Insurance?

Medicare in Texas is a federal insurance program that primarily covers U.S. citizens and permanent residents aged 65 and up who have paid into the system through payroll taxes. For example, Medicare covers everyone who qualifies for Social Security and the majority of federal employees. Their spouses, widows, widowers, and dependents are also covered.

Some persons who have not paid enough payroll taxes may get Medicare if they pay premiums.

Medicare also covers people who have received Social Security disability benefits for more than two years and some disabled workers. It also covers people with permanent kidney failure who require a transplant or dialysis and those who have ALS.

What Types of Items Does Medicare Insurance Cover?

The items covered by Medicare can be divided into Part A, Part B, and Part D. Part A covers in-patient services, Part B covers out-patient services, and Part D covers prescription drugs. The services under Parts A and B are available in both Original Medicare and Medicare Advantage. However, Part D is only available in Medicare Advantage.

Here is a breakdown of services covered under Medicare Part A and B (Original Medicare), which are both covered under Medicare Part C (Medicare Advantage) in Texas:

  • Hospital Stays (Part A): Semi-private room, meals, general nursing, and other hospital services and supplies. It includes care that you get in critical access hospitals and inpatient mental health care. However, it does not include private duty nursing, a television, or a telephone in the room. It also does not include a private room, unless medically necessary;
  • Skilled Nursing Facility Care (Part A): Semi-private room, meals, skilled nursing, rehabilitative services, and other services and supplies (after three days stay in the hospital);
  • Home Health Care (Part A and B): Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services;
  • Hospice Care (Part A): Medical and support services from a Medicare-approved hospice for people with a terminal illness, drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. Hospice care is given in a patient’s home. However, short-term hospital and inpatient respite care (care given to a hospice patient by another caregiver so that the usual caregiver can rest) are covered when needed;
  • Blood (Part A): Pints of blood you get at the hospital or skilled nursing facility during a covered stay or as an outpatient as part of a Part B covered service.
  • Medical and Other Services (Part B): Doctors’ services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). It also covers second surgical opinions, outpatient mental health care, and outpatient physical and occupational therapy, including speech-language therapy;
  • Clinical Laboratory Services (Part B): Blood tests, urinalysis, and more; and
  • Outpatient Hospital Services (Part B): Hospital services and supplies received as an outpatient as part of a doctor’s care.
  • Prescription Coverage (Part D): It covers a wide range of outpatient prescription drugs.

Medicare also covers the following:

  • Ambulance services (when other transportation would endanger your health);
  • Artificial eyes;
  • Artificial limbs that are prosthetic devices and their replacement parts;
  • Braces - arm, leg, back, and neck;
  • Chiropractic services (limited), for manipulation of the spine to correct a subluxation;
  • Emergency care;
  • Eyeglasses - one pair of standard frames after cataract surgery with an intraocular lens;
  • Immunosuppressive drug therapy for transplant patients;
  • Kidney dialysis;
  • Macular degeneration of the eye (age-related) treatment, using ocular photodynamic therapy with verteporfin;
  • Medical nutrition therapy services for people with diabetes or kidney disease with a doctor’s referral;
  • Medical supplies - items like ostomy bags, surgical dressings, splints, casts, and some diabetic supplies;
  • Outpatient prescription drugs (very limited). For example, some oral medications for cancer;
  • Preventive services;
  • Prosthetic devices, including breast prosthesis after mastectomy;
  • Second opinion by a doctor (in some cases);
  • Services of practitioners such as clinical social workers, physician assistants, and nurse practitioners;
  • Telemedicine services in some rural areas;
  • Therapeutic shoes for people with diabetes (in some cases);
  • Transplants - heart, lung, kidney, pancreas, intestine, bone marrow, cornea, and liver (under certain conditions and when performed at approved facilities);
  • X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests.

What is Not Covered by Medicare Insurance?

In Texas, Medicare expenses that Original Medicare does not cover include, but are not restricted to, the following:

  • Acupuncture;
  • Deductibles, coinsurance, or copayments when one receives health care services;
  • Dental care and dentures (in most cases);
  • Cosmetic surgery;
  • Custodial care (help with bathing, dressing, using the bathroom, and eating) at home or in a nursing home;
  • Health care one receives while traveling outside of the United States (except in limited cases);
  • Hearing aids and hearing exams;
  • Orthopedic shoes;
  • Outpatient prescription drugs (with only a few exceptions);
  • Routine foot care (with only a few exceptions);
  • Routine eye care and most eyeglasses (except for one pair of standard frames after cataract surgery with an intraocular lens);
  • Routine or yearly physical exams;
  • Screening tests with some exceptions;
  • Shots (vaccinations) with some exceptions.

What Does Medicare Insurance Typically Exclude?

Although Texas Medicare insurance covers a large number of services, it does not cover everything:

  • Original Medicare does not cover most dental treatment, eye tests, hearing aids, acupuncture, dentures, or cosmetic operations. Also, long-term care is not covered by Medicare. Consider purchasing a separate long-term care insurance coverage for yourself or a loved one if you believe you or a loved one will require it.
  • Medicare Advantage typically excludes non-medical services, even if they are connected to medical services. Non-emergency transportation, private hospital rooms, missed appointments, and transportation to and from the appointments is usually not covered.
  • Medigap covers the Gap in coverage between Original Medicare and Medicare Advantage. While it covers the copayments and deductibles, it does not provide any extra coverage, like vision, dental, or hearing aid. Medigap only assists Original Medicare to provide a better solution as a total package.

What is an Example of Medicare Insurance?

When you first sign up for Medicare in Texas, you can choose how you get your Medicare coverage through two main ways:

  1. Original Medicare: This is a combination of Medicare Parts A (Hospital Insurance) and B (Medical Insurance). These Parts together cover you for inpatient and outpatient services that you receive from Medicare-approved hospitals. Original Medicare does not include prescription drugs coverage under Part D. You can get a different drug plan If you want drug coverage.
  2. Medicare Advantage: This is called Medicare Part C, and private Texas insurance companies provide them. It is the only alternative to Original Medicare. It bundles the benefits of Medicare Parts A, B, and D and sometimes offers additional benefits. Original Medicare does not cover these additional benefits. They include vision, hearing, and dental.

Medigap is a type of supplemental policy that helps pay Original Medicare out-of-pocket like copayments, coinsurance, and deductibles. It works only with Original Medicare.

Generally, your Medicare coverage choice affects your coverage costs, covered services, access to doctors, and quality of care. For example, under Original Medicare, you have wide access to multiple medical professionals all over the country. In contrast, with Medicare Advantage, your access to doctors is restricted to your insurer’s network, but overall you may have better coverage.

Find out more about Texas Medicare coverage choices and get help with comparing plans by talking to a licensed insurance agent in Texas.

What is the Most Common Use of Medicare Insurance?

People above 65 years mostly use Medicare to get quality health coverage at affordable rates. This is because their workplace health coverage will most likely end, and health coverage for older adults is expensive. As of 2019, Texas was one of the states with the highest number of adults who are 65 years and older.

What is the Difference Between Medicare Insurance and Medicaid Insurance?

In Texas, Medicare and Medicaid are two different government-run programs. Different sectors of the government run and finance them, and they mainly serve different groups.

Medicare is a federal program that covers you regardless of your income if you are 65 years or older or under 65 years with a disability, ESRD, or ALS.

Medicaid is a state-federal program that provides health insurance to low-income people.

There are variances in the services that are covered and the cost-sharing that is required. You can have both if you are qualified for both Medicare and Medicaid (dually eligible). They will work together to provide you with health insurance and reduce your medical expenses.

Make sure to talk to a licensed insurance agent in Texas to learn more about both types of coverages, particularly if you qualify for both. You can also call Medicare at (800) 633-4227 or the Texas Health and Human Services Department for information on Medicaid on 211 or (877) 541-7905.

Do I Need Long-Term Insurance if I Have Medicare Insurance?

Medicare does not cover long-term care. So if you or your family member who qualifies for Medicare needs long-term care, you will have to get it as a separate plan from an insurer. Long-Term Care is a broad term that refers to various medical, social, and personal services. If a person has a long-term sickness, disability, or specific bodily impairments, they may require this care.

Individual or group long-term care (LTC) insurance plans are available from private insurers, which provide benefits for some treatments that are often not covered by Medicare. You should speak to a licensed insurance agent in Texas if you need long-term care.

Do I Need Medigap If I Have Medicare Insurance?

Yes, Medicare Supplement Insurance (Medigap) fills the “gaps” of your Original Medicare. Original Medicare covers some services and supplies costs, while you must cover the rest. A Medigap plan can help you pay for the remaining medical expenses like deductibles, copays, and coinsurance. Hence, Medicare covers its part when you get healthcare costs, and your Medigap plan covers the rest. It is private insurers that sell Medigap plans. There are ten types of standardized Medigap plans. Medigap plan costs vary depending on the type of plan, where you reside, and the company selling the plan. You pay monthly premiums, deductibles, and coinsurance, and copays. Medicaid insurer decides your premiums based on your age, sex, health status, and when you buy the plan.

Some costs that Medigap covers include:

  • Medicare Parts A and B deductibles
  • Medicare Parts A and B coinsurance or copayments
  • Medicare Part B excess costs
  • Healthcare expenses during foreign travel
  • The first three pints of blood

Note: You do not need a Medigap plan if you have a Medicare Advantage Plan. It is unlawful for someone to sell a Medigap plan to you if you have a Medicare Advantage Plan, unless you want to move back to Original Medicare.

Discuss your needs with a Texas state-licensed health insurance agent, who can professionally advise you on the available options.

When Does Medicare Insurance Coverage Begin?

All the different forms of Medicare in Texas — Original Medicare, Medicare Advantage, Prescription Coverage, and Medigap — have the same date when the coverage begins. Once you enroll, your coverage begins on the first day of the month after you signed up.

What Happens if You Don’t Use Medicare Insurance?

Under federal law, enrollees of ACA-compliant plans are entitled to a premium rebate where the insured person did not use at least 80-85% of the total premium on health costs. A rebate is a partial reimbursement of paid premiums by the insurer to the insured.

Rebates can be made through premium credit, lump-sum check, or, by lump-sum reimbursement to the account used to pay the premium (when the insured consumer paid premiums using a credit or debit card. In 2020, according to the Centers for Medicare & Medicaid Services (CMS), about $2 billion in rebates were issued to about 9.8 million insured Medicare users.

Who Can Get Medicare Insurance?

A citizen or a legal resident of the United States who qualifies for Medicare by age and/or health conditions can get Medicare insurance. Qualified Texans can get Medicare insurance through Original Medicare or Medicare Advantage.

Always consult with a state-licensed insurance professional who can explain the particular differences between the plans.

Who Qualifies for Medicare Insurance?

To be eligible for Medicare, you typically must be:

  • At least 65 years old and a U.S. citizen or a legal permanent resident for at least five years; or
  • Under 65 but have a qualifying disability or condition, such as Lou Gehrig’s Disease (ALS) or End-Stage Renal Disease (ESRD) and a U.S. citizen or legal resident.

Overall, a person qualifies for Medicare if the person:

  • Is 65 years or older and qualified for Social Security or Railroad Retirement benefits — Aged; or
  • Is 65 years or older and entitled to monthly Social Security benefits based upon the spouse’s work record, and their spouse is not younger than 62 years; or
  • Is below 65 years, but has been entitled to Social Security disability benefits for 24 months — Disabled;
  • Has End-Stage Renal Disease (ESRD) — permanent kidney failure that requires dialysis or a transplant; or
  • Has Amyotrophic Lateral Sclerosis (ALS), also called Lou Gehrig’s disease.

You can check if you are eligible for Medicare and your expected premium with the Medicare.gov eligibility tool.

Who Needs Medicare Insurance?

Medicare is not for everyone. Only the persons who qualify for Medicare may get Medicare insurance.

Once qualified to apply, you need Medicare insurance if you are currently not employed by a company with at least 20 employees, which provides an employer-sponsored health plan.

Who Should Get Medicare Insurance?

You should get Medicare insurance if you qualify for the coverage and do not have a better health care insurance already in place.

Once qualified, you can either get Original Medicare or Medicare Advantage. You should get Medicare advantage if you want extra benefits that Original Medicare will not cover like prescription drugs and hearing, vision, and dental services. If you are enrolling in Original Medicare, then you should consider getting a Medigap plan to cover your out-of-pocket costs.

Learn more about Medicare insurance from a licensed insurance agent in Texas. They can explain Medicare and its benefits to you.

What are the Benefits of Medicare Insurance?

The benefits of Medicare Insurance are below:

  • Millions of people are covered by Medicare: Medicare works in various ways. Over 4 million of Texas seniors use the coverage provided by either of the Medicare plans. Medicare also covers many younger Americans with disabilities or life-threatening conditions. Medicare is regarded as beneficial because it covers a large number of individuals. Without Medicare, people must rely on relatively expensive private insurance plans to get adequate health coverage.

  • Medicare eligibility requirements are simple: Medicare does not have strict eligibility requirements. If you are a 65 years old U.S. citizen or legal permanent resident who has been in the U.S. for at least five years, you will most likely be eligible for Medicare. You are also eligible for Medicare if you receive disability benefits from Social Security or the Railroad Retirement Board. Furthermore, people with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS, popularly known as Lou Gehrig’s disease) are eligible for Medicare coverage.

  • Medicare monthly premiums are usually low: Many Medicare subscribers are eligible for premium-free Part A. Those who do not qualify paid $274 or $499 each month (in 2022), depending on how long they paid taxes while working. For Part B, the standard monthly premiums in 2022 were $170.10. Medicare Advantage (Part C) Plans also have relatively cheap monthly premiums, going for as low as $0 every month. These fees are significantly lower when compared with the cost of most comprehensive insurance plans. The savings for Medicare enrollees can be significant when comparing these fees with the actual costs of medical procedures and other related charges.

  • A broad range of coverage: Medicare covers many services, including inpatient hospital stays, outpatient procedures, and medical equipment like wheelchairs and walkers. Medicare also covers important preventative care, health screenings, and a variety of other services. Medicare began paying COVID-19 diagnostics, treatments, and vaccines for all eligible beneficiaries during the COVID-19 pandemic of 2020 and 2021.

  • Medicare is a combination of public and private coverage: Medicare is a good example of public-private collaboration. Many of the health services required by older adults and younger people with disabilities are covered by the public portion of Medicare (Parts A and B). Private Medicare plans, like Medicare Part D prescription drug plans, Medicare Advantage (Part C) plans, and Medicare Supplement (Medigap) plans, may provide additional benefits or cover some out-of-pocket health care expenditures. Beneficiaries may have various options accessible to them based on where they live if they wish to take advantage of the benefits and advantages of having private Medicare plan coverage.

  • Medicare Advantage Plans provide extensive coverage: Every year, an increasing number of Americans enroll in Medicare Advantage (Part C) plans, and enrollment is expected to continue to rise in the future. State-wide, between 1.5-2 million Texans annually choose the Medicare Advantage over the Original Medicare.

    Medicare Advantage plans provide beneficiaries with an alternative method of receiving Medicare benefits through plans marketed by approved insurance companies. When you enroll in Medicare Advantage, you receive all the Original Medicare (Part A and Part B) program benefits. Furthermore, various Medicare Advantage plans might include extra benefits (dental, vision, hearing, etc.) at a low cost.

  • Medigap: Like other major health insurance, Original Medicare allows you to get a supplemental plan in the form of Medigap. Medigap helps cover the “gaps” in Original Medicare by paying out-of-pocket costs. They are sold by private companies.

Why is Medicare Insurance Good?

Medicare Insurance is good because it provides its enrollees with access to a broad range of medical care for very affordable costs.

Why is Medicare Insurance Bad?

  • Medicare is expensive to run: Medicare spending in 2020 was estimated to reach $858.5 billion. That figure is not anticipated to decrease, with CMS projecting that it will exceed $1 trillion by the end of the decade.

  • Hospital stays can be expensive: Hospital stays can be expensive for Medicare enrollees, easily ranging into hundreds of thousands dollars. If a Medicare enrollee gets inpatient hospital care, the high out-of-pocket Medicare costs may be an issue.

    Frequent hospitalization increases the pressure on hospitals, which may therefore raise overall prices for all patients. Furthermore, because many Medicare enrollees are considered low-income, they frequently cannot afford to fund such stays, putting a burden on them and putting the hospital in a tough position. While Medicare can assist those in medical need, it can also place huge pressure on the healthcare system both inside Texas and across the U.S.

  • Medicare is expensive for taxpayers: Payroll taxes contribute to a percentage of Medicare funds. As long as you are employed in a job covered by Social Security (regardless of your age) - you must pay the Federal Insurance Contribution Act (FICA) taxes. The total is equally split between you and your employer, based on the income limits set for the year. A portion of the FICA taxes finances the Medicare system.

  • Limited coverage of certain important health needs: Original Medicare often does not cover prescription medicines and periodic dental, vision, and hearing care. These are all critical to the health of several older persons. Original Medicare enrollees have to get other coverage or pay out of pocket for these treatments. However, this drawback can be resolved by getting Medicare Supplement Insurance or enrolling for a Medicare Advantage plan that covers these needs.

You should talk to an insurance agent licensed in Texas to help and clarify any questions about Medicare Insurance.

Is Medicare Insurance Worth it?

Yes. Medicare is worth it because everyone who qualifies for it pays much less for health care, than they would pay for similar health coverage outside of the Medicare system. If you do not get Medicare coverage as soon as you qualify, you may face penalties and higher out-of-pocket costs.

What Happens if You Don’t Have Medicare Insurance in Texas?

If you are 65 years and older and do not have Medicare insurance:

  • No coverage: You need to find another way to get coverage for health care costs, which tend to increase with age.
  • Penalties: You may face late enrollment penalties (Part A, Part B, Part D)

Why is Medicare Insurance Important?

Medicare is important because it provides comprehensive health coverage at affordable rates for people who would have had to pay a lot more if they got such quality coverage outside Medicare.

What Happens When Your Medicare Insurance Lapses?

You can lose your coverage if your Medicare insurance lapses. Your Medicare insurance lapses when you fail to pay your premiums after proper notice and the grace period. In Texas, the grace period is usually three months for Original Medicare and two months for Medicare Advantage, Medigap, or Prescription Drugs coverage.

If your Medicare Advantage, Medigap, or Prescription Drugs disenrolls you, you cannot join another plan until the next enrollment period. However, you will automatically be enrolled in Original Medicare. Commonly, Medicare enrollees make changes to their coverage between October 15 and December 7 every year, except for when they may qualify for a Special Enrollment Period.

Speak to a Texas-licensed insurance agent to answer your questions about Medicare.