Medicare Advantage is a health insurance plan that’s available across the United States. It’s sometimes known as Medicare Part C, although unlike its counterparts, Part A and Part B, it is not administered by the federal government. Instead, Medicare Advantage is provided by private insurance companies, which results in plans that feature varying coverage levels and price points. In many cases, these plans provide additional coverage that isn’t included in Original Medicare, such as prescription medications and optometry.
Medicare Advantage programs vary between different states and as such, so do their enrolment rates. Across the United States, a total of 34% of Medicare’s beneficiaries are enrolled in a Medicare Advantage plan, and in Texas, the enrollment rate sits slightly above the national average at 36%. This rate is considerably higher than in neighboring states Oklahoma and Arkansas, which have enrolment rates of 20% and 24%. There are several states in the United States that have higher enrolment rates, including Florida, which sits at 43%, and Hawaii, where the enrolment rate is among the highest in the nation at 44%.
There are several options available to Texas seniors who are interested in Medicare Advantage. This includes HMO, PSO and PPO plans. In this guide, we review the details of the different types of Medicare Advantage plans that are available in Texas, as well as the qualification requirements that may be in place for each one and resources that are available to help Texans choose a plan that best suits their needs.
There are several Medicare Advantage plans that residents of Texas can choose from. This includes Managed Care Plans, also known as Health Maintenance Organizations, Preferred Provider Organizations and Provider Sponsored Organizations. In addition to these options, those living in the state of Texas can also access Special Needs Plans and Private Fee-For-Service Plans.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations (HMOs) act as Managed Health Care plans, so participants are required to seek care from providers within their HMO’s network and typically, any specialist appointments need to be arranged by the patient’s primary care physician. Care that is provided by a health care practitioner outside of the patient’s network is typically charged entirely to the patient. While these plans are typically less expensive than other Medicare Advantage plans, their limitations can prove inconvenient for some participants. This is especially true for seniors who require care from a provider that isn’t within the network. In most cases, receiving care from a provider outside of the HMO’s network means that the patient is responsible for 100% of the cost.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations are similar to HMOs in that they operate with a specific network of providers. While they don’t always require patients to seek care from providers within the network, they do offer higher co-payments to those who do. It’s important for patients to confirm coverage before selecting a provider, as PPOs may deny some coverage for out-of-network providers. When it comes to specialist care, patients in PPOs can typically access covered care services with a referral from their primary physician.
Provider Sponsored Organizations (PSOs)
A Provider Sponsored Organization (PSO) works similarly to an HMO in that participants are required to receive care within their network; however, PSOs are run by the health care providers themselves — typically doctors within a primary care or hospital setting. Patients are generally required to seek care from providers within the network, but in some cases, physicians may provide referrals to specialists or other care providers outside of the organization. Typically, these services are covered under the patient’s plan.
Special Needs Plans (SNPs)
Special Needs Plans are specifically for individuals with disabilities or chronic illnesses. These plans include prescription drug coverage and include care services that are coordinated between the patient’s physician and the insurance provider. Most SNPs require the patient to be diagnosed with a long-term condition or illness or be dually eligible for Medicare and Medicaid.
Private Fee-for-Service Plans (PFFPs)
Private Fee-for-Service Plans are the most flexible of Texas’ Medicare Advantage plans. In these plans, the provider pays a predetermined amount for each health care service while the patient is responsible for the remainder of the cost. Under a PFFP, the patient is free to receive care from any approved health care provider instead of being limited to practitioners within a specified network.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Texas, most Medicare Advantage plans do not include prescription drug coverage. However, seniors who require prescription drug coverage have the option of enrolling in Medicare Plan D, which is a prescription drug benefit plan that’s available to all Texans. The price of this plan varies and participants typically pay a monthly fee to have a portion of the cost of prescription drugs covered by Medicare.
Medicare Advantage plans are a great way for seniors to ease the financial pressure that’s associated with paying for health care. However, with so many options available to those living in Texas it can be difficult for seniors to determine the best plan to suit their needs. Below, we’ve listed some state and local resources in Texas that are available to help seniors better understand Medicare and select a plan that works best for them.
The Texas Health Insurance Counseling and Advocacy Program (HICAP) provides Medicare counseling for seniors and individuals with disabilities. The program provides benefit counselors who help seniors understand the difference between the different Medicare plans and determine the plan that’s best suited to their needs and budget. This service is free of charge and available to Medicare beneficiaries aged 60 and older and adults with disabilities.
Texas’ Managed Care Quality Assurance Office helps members of the public who are enrolled in managed care plans, including Medicare Advantage HMOs. The organization is responsible for licensing HMO providers and assuring that program participants have access to the care they’re promised by their insurance provider. This organization can provide answers to general questions that seniors may have about Medicare Advantage HMOs.
Seniors who have questions about their HMO or their Medicare Advantage provider can contact the Managed Care Quality Assurance Office by calling (866) 554-4926 and selecting option 8.
Area Agencies on Aging provide a broad range of services to seniors throughout the state, including benefits counseling. Its staff work with seniors to determine which Medicare, Medicaid or Medicare Advantage programs are best suited to their income and health care needs and can provide further assistance in coordinating care services with their insurance providers and helping with claims or appeals whenever necessary. Other Area Agency on Aging services include long-term care ombudsman access, nutrition services, and in-home support services.
The Texas Aging and Disability Resource Centers are available to seniors and disabled persons of all ages. These centers offer one-on-one options for counseling, which helps seniors and their loved ones to determine their long-term care needs, as well as how to navigate the benefit plans that are available to help them pay for it, such as Medicare and Medicare Advantage. Other services that are available at Texas’ Aging and Disability Resource Centers include caregiver training and advocacy for seniors in long-term care facilities.
Houston-Galveston Area Medicare Benefits Counseling services help older Texans to navigate the state’s Medicare system, providing detailed information about Medicare and Medicare Advantage plans that are available to them and helping them choose one that suits their needs. The program also provides assistance with seniors who need help with meals, transportation, or in-home care. Benefits counselors are available monthly at various locations in the Houston-Galveston area to provide in-person assistance.
Seniors can call (713) 627-3200 to speak with a benefits counselor or walk-in to any of the monthly clinics to meet with one in-person.
Low-income seniors who are Medicare beneficiaries can receive financial assistance with their premiums and assistance in navigating their benefits from the North Dallas Shared Ministry. This nonprofit organization also provides a broad range of other services specifically for low-income residents of the Dallas metropolitan area, including energy assistance, rent assistance, and Medicaid and SNAP assistance and counseling.