The Affordable Care Act provides health insurance for individuals from birth up until they reach the age when they are ready for Medicare. However, many have questions about when that time actually is, and what they have to do to make that transition. CoverMile aims to clear up the confusion and guide those approaching the golden years about what the Medicare qualifications in Texas are. There are also a few medical reasons one can receive Medicare early. Let’s help you understand Medicare in Texas and all its parts and what it means to you.
What is Medicare?
Medicare is a health insurance program for those 65 or older, those 65 and younger with a qualified disability, and those with End Stage Renal Disease. One can enroll in Medicare during a seven-month window surrounding your 65th birthday: three months prior, the month of, and three months after. Those with a medical condition can apply upon diagnosis.
Medicare has three parts: Part A, Part B, (Part A and Part B are also known as Original Medicare), and Part D. Each covers a separate medical need. There is a Part C, which is a combination of Parts A, B, and D; it is commonly known as Medicare Advantage.
Medicare Part A – Hospital Insurance
Medicare Part A is hospital insurance and covers hospital care. Most people will not pay for this part of Medicare. As long as you have paid Medicare taxes for 10 years, or 40 quarters, it is free. You can also be married and rely on your spouse to have paid into the system for the same amount of time.
If you have not met Medicare tax requirements you will need to pay a premium. For 2024, Medicare Part A premium is $505 for those with fewer than 30 quarters, for those with 30 to 39 quarters this premium is reduced to $278.
Keep in mind that you must enroll in Part A when you first become eligible, otherwise you will face a penalty. This penalty will increase each year you do not enroll in Medicare. The good news is that if you have contributed Medicare taxes through payroll deductions, you may automatically be enrolled.
Medicare Part B – Medical Insurance
Medicare Part B is the doctor visit portion of Medicare. You can have it regardless of your Part A status. You pay a monthly premium for this portion of Medicare. For 2024, the standard premium for Part B is $174.70.
Part B covers medically necessary services:
While Medicare Part B does not cover prescription drugs, it has limited prescription coverage. Alzheimer’s drugs are included. Part B can also cover flu and pneumonia shots, in addition to COVID-19.
Like Part A, if you fail to enroll when first eligible, you must pay a penalty when enrolling. However, unlike Part A’s penalty which is double the time you went without enrolling, Part B’s penalty is lifetime.
Medicare Part C – Medicare Advantage
Medicare Part C is also known as Medicare Advantage. This insurance is purchased through private insurance companies. One must enroll in Medicare first, then you can select an Advantage plan.
A Medicare Advantage plan takes Medicare Part A, Part B, as well as Part D, then adds benefits such as Dental and Vision. Many insurance companies sell MA plans; thus, the cost of these plans can vary.
Insurance companies such as Blue Cross Blue Shield of Texas, Humana Medicare, and UnitedHealthcare offer Medicare Advantage plans. Each has similar Medicare qualifications in Texas.
Medicare Part D – Prescription Coverage
Medicare Part D is the prescription portion of Medicare as Part A and Part B do not include medication benefits. Unlike A and B it is not a plan you can purchase by itself, you must purchase either Part A or B, or both to enroll in Part D.
Medicare Part D will undergo major changes in 2025. The coverage gap is being eliminated. This will impact the Catastrophic Phase by lowering it from $3300 to $2000. Once you reach your $545 deductible, you pay your 75/25 portion until you reach $2000, then you are paid in full for the year. Medicare will begin to pick up that tab for the remainder of the year.
How Do I Qualify for Medicare in Texas?
There are five opportunities to qualify for Medicare in Texas. Each involves different ways to sign up for Medicare.
Your initial Medicare eligibility period begins three months before the month you turn 65. It includes the month of your birthday and continues for three months after.
This would apply if you had a job that provided benefits and are leaving that job. After that job ends you have an eight-month window to apply for Medicare without penalty. Coverage will start the month after the day you apply.
You can enroll in Medicare three months before the 25th month of your disability. Benefits will begin on the first day of the 25th month. If you enroll later, up to the 28th month, your coverage will begin the first of the month after you enroll.
You can also enroll:
Medicare Open Enrollment is between October 15th and December 7th of each year. You can enroll or make changes to your current Medicare coverage. Any such changes will go into effect on January 1st of the following year.
If you are currently enrolled in a Medicare Advantage plan, you have the opportunity to make changes to your current plan from January 1st through March 31st. Your new plan will take effect the month following your change.
Keep in mind that if you delay your enrollment in Medicare, there are penalties for both Part A and Part B you must pay in addition to your premiums.
Part A – if you have a premium you must pay up to 10 percent twice the number of years you did not sign up. Meaning if you did not sign up for two years, you will pay the additional premium amount for four years.
Part B – For 2024 your monthly premium is $174.70. Each year you do not sign up, you will pay an extra ten percent for each year you did not sign up. Keep in mind that each year Part B’s premium is recalculated, so this number will change.
Medicare also has supplement plans that can cover deductibles, coinsurance, and copays. These are Plans F through N. These are purchased through insurance companies such as Humana Medicare, the same as Part C (Medicare Advantage). You can enroll at the same time you enroll in Medicare. Contact our consultants if you have any questions. We can assist you with your Medicare qualifications in Texas.
Are There Alternatives to Medicare in Texas?
After one turns sixty-five, and you have contributed to Medicare through payroll taxes, oftentimes you will automatically be enrolled in Medicare Part A. It is Part B and your prescription portion Part D you will need to manually enroll in. You do have options to Medicare for your health insurance options:
Workplace or Spouse Insurance:
You can still have Medicare and have health insurance through an employer or a spouse’s health insurance plan. This would only apply to Medicare Part A. You cannot purchase Part B. Once that source of insurance ends, you have eight months to apply for Part B, Part D, or Medicare Advantage without penalty.
Medicare Savings Program (MSP)
Medicare Savings Programs are for those who have limited income. Three programs can assist low-income individuals. Federal Poverty Level (FPL) limits apply:
Qualified Medicare Beneficiary (QMB): Incomes less than 100 percent of the FPL. Resource qualifications also apply. Medicare premiums, deductibles, copays, and coinsurance are covered. Income limits also apply.
Specified Low-Income Beneficiary (SLMB): Seniors and adults with disabilities between 100 percent and 120 percent FPL and resource requirements. They cover Part B premiums. Income limits also apply.
Qualifying Individual (QI): Those with Medicare in Texas, first come first served. Between 120 and 135 percent FPL. Resource qualifications apply. They will cover the Medicare Part B premium. Income limits also apply.
Medicaid STAR+PLUS
Medicare does not cover long-term care. They only provide benefits for up to 100 days. After that, you pay all costs. Under Medicaid STAR+PLUS, those 65 and older who require nursing home care or foster care in an assisted living facility can receive the care they need. This can include personal care, adult day care, and home modifications.
Summary
If you are nearing Medicare age, there are many questions about which health plan you will qualify for and when you should apply for it. At CoverMile we are here to help you make the transition worry-free. Contact us today. Our experienced Medicare agents in Bastrop, Texas and surrounding areas can help you buy health insurance Texas today.
Frequently Asked Questions
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Is Medicare in Texas expensive?
For 2024, if you have to pay a premium for Part A it will be between $278 and $505 depending on how long you or your spouse paid Medicare taxes. For most, it will be free. For Medicare Part B, all will have a premium. For 2024, Medicare Part B has a premium of $174.70. This amount is reviewed and changes annually. You can also select a Medicare Advantage plan which will include prescription coverage, this premium varies as it is sold through individual insurance companies.
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Am I required to sign up for Medicare when I turn 65?
It depends. Under normal circumstances, yes, you will sign up for Medicare during the three months before, the month of, and the three months after your 65th birthday. If you have health insurance through an employer or a spouse’s employer, then you can wait to sign up until that coverage ends. You have eight months after that coverage ends to sign up without penalty. Call CoverMile to make sure you know what you need to do as every person’s situation is different.
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If I have both Medicare and employer insurance, which is billed first?
If you have health insurance through an alternative source like an employer, the group health insurance is billed first, then your Medicare insurance is billed for the remaining amount. There are some instances where Medicare would pay first.
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Can I get Medicare through Blue Cross Blue Shield of Texas?
Blue Cross Blue Shield of Texas offers Medicare Advantage plans that offer Medicare Part A, Medicare Part B, and Medicare Part D. They can be either an HMO or a PPO. Unlike their health insurance, which is available statewide, their plans are available in certain counties. Extra financial help and low-income subsidies are available for those who qualify for Medicare in Texas. You can also find Medicare coverage through insurance companies such as UnitedHealthcare Medicare and Humana Medicare.
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Are Medicare and Medicaid the same insurance?
No. Medicare is health insurance for those 65 and older and those younger who have certain disabilities. Medicaid is health insurance for pregnant women and low-income families. Contact one of our CoverMile Medicare insurance agents for Austin, Texas, and the surrounding area for further information.
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Is Medicare tax deductible?
Health insurance premiums can be tax deductible especially if you are self-employed. The primary reason is that when you were employed, your insurance premiums were taken out pretax, now that you are paying Medicare your payments are no longer under that tax rule. There are also ways to take this deduction if you are not self-employed.
