What are Medicare Advantage Plans and Can I Get One in Texas?
The advantages of Medicare Advantage (MA) health plans are found in what they can cover that Original Medicare cannot. Specifically, the MA plans (aka, Part C of Medicare) available in Texas can include minor healthcare benefits such as prescription drug coverage, vision, hearing, dental, fitness, telehealth, and more. In contrast, Original Medicare only covers major medical healthcare services. To join an MA plan you must first be enrolled in both Medicare Part A and Part B.
Many people love the extra benefits they get with their MA plan, particularly a prescription drug plan. However, before you jump in with both feet, take the time to fully understand the trade-offs. The extra benefits and perks are nice, but they come at a cost. Specifically, when you become a Medicare Advantage plan member in Texas you are agreeing to accept the plan's managed care health system. As an MA plan member, you agree to let the insurance plan be a gatekeeper and fully control your access to doctors and other healthcare providers.
Medicare Advantage vs. Medicare: Is There a Big Difference?
The best way to understand the differences between Medicare Advantage and traditional Medicare coverage is to evaluate the pros and cons of each type of coverage.
Pros and Cons: Medicare vs. Texas Medicare Advantage Plans
- When you have Original Medicare you are free to use any Medicare-approved doctor you choose. When you join a Medicare Advantage plan, your choices are limited to the plan's network of Texas providers.
- If you travel frequently or you are a snowbird and winter or summer in another state, your Original Medicare coverage remains the same. It goes where you go. This is not true with Texas Medicare Advantage plans, which are only required to cover you if you have a medical emergency.
- With OriginalMedicare there are no limits on your out-of-pocket costs. However, all Texas Medicare Advantage plans have an annual maximum out-of-pocket (MOOP) limit. If you reach the MOOP spending limit on your copays and coinsurance, the plan picks up the tab for the remainder of the year.
- If you want prescription coverage and have Original Medicare you must purchase a Medicare Part D plan. However, most Medicare Advantage plans include a Texas Medicare Part D plan. Just be aware that a stand-alone Part D plan gives you the best opportunity to get your most expensive prescriptions at the lowest cost.
- In the Medicare Advantage program, the government allows plans to set their own copays and coinsurance for each healthcare service offered. This makes comparing plans difficult, at best. However, in the Original Medicare system deductibles and coinsurance are fixed, making them predictable. Plus, you can get a Medigap plan to help pay these costs.
- There are eligibility requirements with Medicare Advantage plans. For example, you must have both Medicare Part A and Medicare Part B to join, and you cannot have end-stage renal disease (ESRD) or one of a handful of other diseases.
Texas Medigap vs. Medicare Advantage
Three of the most common questions we get from Texas seniors are:
- Why are Medicare Advantage plans bad?
- What are the disadvantages of Medicare Advantage plans?
- Is it better to have Medicare Advantage or Medigap?
Let's answer these three questions right now.
Why Texas Medicare Advantage Plans are Bad
This is a myth. There's nothing wrong with Medicare Advantage plans. In fact, over 20 percent of all Medicare beneficiaries in Texas choose Medicare Advantage enrollment over traditional Medicare.
What you really need to know is that these plans are not for everyone, and for some Texas seniors they are a disadvantage. Some people are better served with Original Medicare and a Medicare supplement. The question is, which option is best for you?
MedicareWire advises people who have one or more serious chronic conditions to keep their Original Medicare, particularly if you have specialists treating you and you want to stay with them. Our opinion is that Medicare Advantage is an excellent option for those who qualify for both Medicare and Medicaid (dual eligible), for those with retiree healthcare benefits, and for extremely healthy, active seniors.
Similarly, traditional Medicare, plus Medicare supplement insurance, work best for people with chronic health conditions, as well as those who can afford a higher monthly premium. Most experts agree that this is the best health insurance seniors can get in Texas.
You can learn more about Medicare supplements in Texas on our Texas Medicare supplements page.
The Disadvantage of Medicare Advantage Plans if You Live in Texas
The disadvantage of Medicare Advantage plans is the strength of Texas Medigap plans. You see, when you take doctor choice out of the equation, the big difference between Medicare Advantage and Medigap is when you pay for services. It's that same no matter what type of Medicare Advantage plan you're evaluating (e.g., HMO, PPO, PFFS, Cost, or HSA).
Medicare Advantage plans have a monthly premium, but it's generally less than a Medicare supplement, and some plans even have a $0 premium. But, you also pay when you use health care. These are the copayments. It does not matter if you have a Health Maintenance Organization (HMO) plan or a Preferred Provider Plan (PPO). Most of your out-of-pocket costs come when you use healthcare services.
With a Medicare supplement plan you pay most of your costs in advance with monthly premiums. Depending on the level of coverage you choose, the plan can cover all of your copays, coinsurance, and deductibles except the annual Part B deductible. This makes your monthly healthcare costs more predictable, particularly if or when you have serious health problems.
Which is Best in Texas, Medicare Advantage or Medicare Supplement Insurance?
- If you can afford Medigap Plan F or G, then keep your Original Medicare and add one of these supplements. These plans help you manage your out-of-pocket costs the best, giving you complete peace-of-mind.
- If you are a healthy senior and have good health in your family heritage, Medigap Plan N will let you save money by sharing some costs when you see your doctor. The plan benefits are excellent and pay just a little to see your doctor (up to $25 per visit).
- If you are a healthy senior but you cannot afford a Medigap Plan F, G, or N, Medicare Advantage is a good choice. Both Original Medicare and Medicare Advantage cover preventive care at no additional cost to keep you healthy
- If you are turning age 65, have one or more chronic health conditions that require frequent doctor visits, and you do not qualify for both Medicare and Medicaid (dual eligible), the most Medigap coverage you can afford is the best option.
- If you qualify for both Medicare and Medicaid, regardless of your health condition, Medicare Advantage is your best option.
- If you have special needs (i.e., a full-time nursing home resident, diabetes, etc.) and an appropriate Medicare Advantage Special Needs Plan (SNP) is available, this is your best option.
- With both Medigap and Medicare Advantage, you must continue to pay your Medicare Part B premium (it typically comes straight out of your Social Security income, unless you're not yet taking it).
- With Medicare supplement insurance there are no service area restrictions. With Medicare Advantage, you must receive care within the plan's provider network unless you need emergency care.
- Medicare Advantage plans have an enrollment period. You get an individual enrollment period when you're first eligible. After that, there's an annual enrollment period to switch plans or go back to Original Medicare. Medigap plans do not have the same restrictions, but you can be turned down if you leave a Medigap plan and later want to come back. Medicare Advantage plans cannot generally turn you down as a Medicare supplement insurance company can.
Frequently Asked Questions About Texas Medicare Advantage Plans
Medicare Advantage plans vary from County to County in Texas. This is due to the local nature of healthcare provider networks. If you enter your zipcode into this tool it will show you all of your plan options and 5-star ratings.
More than 90% of all Medicare Advantage plans in Texas include a Part D plan for prescriptions, but not all. However, coverage is different with each plan. It is very important to verify that a plan covers your most important medications before you join. You can do so using this tool.
To understand the pros and cons of Medicare Advantage, you need to compare it with Original Medicare and factor in your health and financial situation. This article can help you compare which type of plan is best.
Compare the Best Medicare Advantage Plans in Texas by County
Citations & Referencesmedicare.gov
- Medicare.gov: the official U.S. government site for Medicare | Medicare http://www.medicare.gov/
- Medicare.gov: the official U.S. government site for Medicare | Medicare https://www.medicare.gov/
- Find a Medicare plan https://www.medicare.gov/plan-compare/
- Medicare Benefits | SSA https://www.ssa.gov/medicare/
- Extra Help with Medicare Prescription Drug Plan Costs | SSA https://www.ssa.gov/medicare/prescriptionhelp/
- Medicare Benefits | SSA https://www.ssa.gov/benefits/medicare/
- Five-Star Quality Rating System | CMS https://www.cms.gov/medicare/provider-enrollment-and-certification/certificat...
- Medicare Open Enrollment | CMS https://www.cms.gov/Outreach-and-Education/Reach-Out/Find-tools-to-help-you-h...
The Medicare Advantage plan information on this page is maintained by David Bynon and was last updated on .