Medicare is the United States health insurance program managed by the federal government for individuals aged 65 or older, and even so for younger individuals who receive benefits based on disability. Medicare coverage in Texas consists of Original Medicare, which is divided into two parts: Part. A and Part B. Part D is an additional stand-alone plan which is your drug coverage. You can also get additional coverage with Medicare by purchasing Medicare Supplement Plans or Medigap plans which help beneficiaries to cap out the costs that are left by Original Medicare. Part C or Medicare Advantage also provides coverage for Medicare beneficiaries but those plans are sold by private insurance companies and they include Part A and Part B coverage, drug prescription, and often some other benefits all into one plan.
How Does Original Medicare Work In Texas
Original Medicare works the same in every state because it is regulated by law on the federal level. There are two parts of Original Medicare: Part A and Part. B. Beneficiaries will get their hospital insurance under Part A and medical insurance under Part B. Original Medicare works on a cost-sharing principle which means that it covers 80% of the costs and beneficiaries are responsible for the other 20%. Medicare enrollees pay their part of the cost in form of deductibles, coinsurance, and monthly premiums.
Medicare Eligibility
Every beneficiary in Texas is eligible for Medicare coverage if:
- is 65 or older
- younger but receive disability benefits (at least 2 years)
- U.S. citizen or legally admitted citizen ( who lives in the U.S. for five years minimum)
- has ERSD or ALS
Medicare Part A In Texas
Medicare Part A is hospital insurance. It covers benefits like inpatient hospital care, nursing care, medications related to the treatment, hospice care, and some health care.
Most beneficiaries will get Part A free premium if they have worked and paid Medicare taxes for a minimum of 40 quarters. If you didn’t work that amount of time but your spouse is you can still qualify for Part A free premium through your spouse’s coverage. Also, you will be automatically enrolled in Part A if you have received Social Security benefits.
However, if you don’t meet these requirements you still can buy Part A – the costs in 2023 will be either 278$ or 506$, and that depends on how long you or your spouse have worked. Before Part A starts to cover the expenses beneficiaries need to meet Part A’s deductible which will be 1600$ in 2023.
Medicare Part B In Texas
Medicare Part B is medical insurance. It covers doctor visits, durable medical equipment, diagnostic tests, preventive screenings, mental healthcare, ambulance services, etc.
Even though most of the beneficiaries qualify for Part A free premium, all enrollees must pay Part B monthly premium which will be 164.90$ in 2023. However, people with higher incomes might pay more due to IRMAA or Income Related Monthly Adjustment Amount which is a surcharge for Part B and Part D premiums. Beneficiaries may also pay more if they didn’t enroll in time, so they pay higher due to late enrollment penalties. Your Part B coverage also starts when you meet the Part B deductible which is 226$ in 2023.
Medicare Part D in Texas
Medicare Part D is designed to help beneficiaries cover the costs of generic and brand-name drug prescriptions. It is a stand-alone drug plan sold by private insurance companies like Turning 65 Solutions which works alongside Original Medicare benefits. You will not be automatically enrolled in Part D which means that you must do it yourself. Everyone is eligible of getting Part D coverage if they are enrolled in Part A and B.
Be aware that each Medicare plan that covers the prescription of drugs has its own formulary, usually divided into tiers. Included coverage must have certain categories of medications in the formulary, but specific medications in the categories may vary from plan to plan. Because of that, we advise you to always check the formulary before enrolling in a plan, because drugs that you may need will not be on the list.
However, all plans must cover a minimum of two prescription drugs in each of these categories:
- anti-psychotics
- anti-depressants
- immunosuppressants
- anticonvulsant
- antineoplastic (for cancer treatment)
- anti-retroviral ( HIV and AIDS treatment
Your Medicare Part D costs can differ from plan to plan, and Part D monthly premium can be higher for beneficiaries who have higher income due to IRMAA (they calculate your premium based on income from tax return from 2 years ago).
Phases of Part D Coverage
There are four different phases of Part D coverage and they go as follows:
- deductible period: deductibles may vary from plan to plan, but usually no plan has a higher deductible than 505$ in 2023. Until beneficiaries meet the deductible, they have to pay the full price for covered drugs.
- initial coverage period: after you’ve met the deductible, your plan will help pay the costs for your covered drugs. Also, you will cover some part of the costs in form of copayment or coinsurance. The initial coverage limit is 4660$ in 2023. This period ends when you reach this total limit. The cost includes both how much you and your plan have paid for covered drugs.
- coverage gap: after you meet the total amount of 4660$ you enter the coverage gap also known as the donut hole. In this phase, you are responsible for 25% of the cost of your drugs. For example, if the cost of the drug was 100$ you will have to cover 25%, but in the initial coverage period, you may have 20% of the copay.
- catastrophic coverage: you may enter this phase if you reach the maximum out-of-pocket limit for covered drugs which is 7400$ in 2023. During this period, you pay lower copays or coinsurance for your covered drugs for the rest of the year. Calculated out-of-pocket costs that may lead you to catastrophic coverage include your deductible, the amount you have paid during the initial coverage period, almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap, and amounts paid by others, including family members, most charities, and other persons on your behalf. You will pay 5% for each drug during this phase.
Costs that are not included in an amount that can reach you to catastrophic coverage are monthly premiums, what your plan pays towards drug costs, non-covered drugs cost, cost of drugs from pharmacies that are outside the plan’s network, and 75% of generic discount.
However, your plan’s drug list is subject to change each calendar year so it is important to check the formulary each year to see if something has changed. You always can change your plan during the Annual Enrollment period which happens from the 15th of October till the 7th of December.
You always can enroll in Part D during the Initial Enrollment Period which is a 7-month open window and starts 3 months before your 65th birthday and ends 3 months after you turn 65. If you miss this period you can enroll during AEP but may pay a late enrollment penalty.
Medicare Supplement Plans In Texas
Medicare Supplement plans help cover out-of-pocket costs that are left by Original Medicare. There are 10 standardized supplement plans and the amount of coverage depends on which letter you choose. They are divided from letters A to N, and some have less coverage than others. Medicare Supplement Plans in Texas help out with costs like copayments, deductibles, premiums, and coinsurance. Drug coverage is not included in any of these plans.
Medicare Supplement Plans provide a number of benefits by each letter (A, B, C, D, F, G, K, L, M, N) as follows:
- Medicare Part A coinsurance and hospital costs: all plans cover 100% of the costs
- Medicare Part B coinsurance or copayment: Plan K covers 50%, Plan L 75%, while other plans cover 100% of costs
- first three prints of blood for the medical procedure: Plan K covers 50%, Plan L 75%, while other plans cover 100% of the costs
- Part A hospice care coinsurance or copayment: Plan K covers 50%, plan L 75%, while other plans cover 100% of the costs
- Skilled nursing facility care coinsurance: Plans A and B don’t cover this benefit at all, Plan K covers 50%, Plan L 75% while others cover 100% of the cost
- Part A deductible: Plan A doesn’t cover this benefit, Plan K and M cover 50%, Plan L 75%, while all other plans cover 100% of the costs
- Part B deductible: only Plans C and F cover this benefit, but these plans are no longer available for beneficiaries who weren’t eligible for Medicare prior to the 1st of January 2020.
- Part B excess charges: only plans F and G cover Part B excess charges
- Foreign travel emergencies: Plans A, B, K, and L doesn’t cover this benefit, but other plans cover these benefits up to plan limits
Plan K and Plan L have maximum out-of-pocket costs, and after you reach this limit your plan must cover all other costs for the rest of the year. The maximum out-of-pocket cost for plan K in 2023 is 6940$ and for plan L 3470$.
Medicare Savings Program In Texas
Medicare Savings Program is designed for people on Medicare who have lower income and limited recourses. This program helps beneficiaries pay the costs of Original Medicare.
You are eligible for Medicare Savings Programs if:
- Qualified Medicare Beneficiary: you can qualify if your income is less than 100% of the Federal Poverty Level and have resources lower than 8400$ if single and 12600$ if married. If you meet these requirements QMB will cover Part A and B premiums, deductibles, copayments, and coinsurance.
- Specified Low-Income Beneficiary: seniors and adults with certain disabilities may qualify if their overall income is not larger than 8400$ if single and 12600$ if married. If you meet this requirement your Part B premium will be covered, and the cost of it is 164.90$ in 2023.
- Qualifying Individual: people with Medicare may qualify if have resources under 8400$ as an individual and 12600$ if married. QI will cover Medicare Part B premium, but you can’t be eligible for QI and Medicaid at the same time.
- Qualified Disabled Working Individual: you qualify for this if you are younger than 65 and disabled but have returned to work which means you don’t. have a free Part A monthly premium. To qualify your income must be lower than 4000$ as a single and 6000$ if married.