Comparing Medicare Advantage Plans In Texas

Updated for November, 2021

Key Takeaways:
  • There are 4.2 million Medicare beneficiaries and over 2,500 Medicare Advantage plans in Texas
  • Average Medicare Advantage costs are lower in Texas than in the rest of the United States
  • You may have access to Medicare Advantage plans in Texas with expanded supplemental benefits
  • You can only enroll in Medicare Advantage or make changes to your coverage during certain times of the year

There are over 2,500 different Medicare Advantage plans in Texas, according to Medicare data. If you are new to Medicare, the myriad options available can seem overwhelming. Here’s what you need to know to find the best Medicare Advantage plan for your health care needs.

Medicare Advantage Plans in Texas at a Glance

There are over 4.2 million Medicare beneficiaries in Texas. While most of them still choose Original Medicare (also known as Medicare Part A and Part B), Texans are increasingly choosing Medicare Advantage plans as an alternative. As of April 2020, 1.8 million Medicare enrollees — a little over 42% of all enrollees — have a Medicare Advantage plan.

There are currently at least eight Medicare Advantage plans available in every county in Texas. Several counties — Dallas, El Paso, Ft. Bend, and Harris, for example — have 45 or more. Nearly all Texas Medicare Advantage plans include Part D prescription drug coverage.

Types of Medicare Advantage Plans in Texas

The following four types of Medicare Advantage plans are available in Texas:

Comparison of Texas Medicare Advantage Plan Types

HMO PPO PFFS SNP
Who is eligible? Anyone in the plan service area Anyone in the plan service area Anyone in the plan service area Dual-eligible for Medicare and Medicaid or long-term care resident or has a qualifying health condition
Includes prescription drug coverage? Yes Usually Sometimes Yes
Has a provider network? Yes and you must get all but emergency care from network providers Yes, but you can see any provider who accepts your plan May have a network, but you can see any provider who accepts your plan Yes and you must get all but emergency care from network providers
Must choose a primary care provider? Yes No No Yes
Requires referrals and prior authorization? Usually No No Usually

CMS sets an annual cap on out-of-pocket costs for Medicare Advantage plans. In 2020, the limit is $6,700. The average out-of-pocket cap for Medicare Advantage plans in Texas was $4,290.

Texas Medicare Advantage Costs

Medicare Advantage is private insurance, which means that costs are set by the insurance company that is offering the plan. Across the board, data from the Centers for Medicare and Medicaid Services (CMS) shows that plan premiums for 2020 are down 14%.

In Texas, there are over 1,300 zero-premium plans available. According to the Kaiser Family Foundation, 60% of Medicare Advantage plan enrollees pay no monthly premium (aside from the standard Part B premium). The average Medicare Advantage premium in Texas was $5 in 2019; nationally, it was $29.

CMS sets an annual cap on out-of-pocket costs for Medicare Advantage plans. In 2020, the limit is $6,700. The average out-of-pocket cap for Medicare Advantage plans in Texas was $4,290. Nationally, the average out-of-pocket cap was $5,050.

Texas Medicare Advantage vs National Plans

Texas Nationally
Percent enrolled 42% 36%
HMO Enrollment 82.5% 62%
Average monthly premium $5 $29
Maximum out-of-pocket limit $4,290 $5,050

Benefits Summary — Medicare Advantage Plans

Many people turn to Medicare Advantage for both the predictable costs and extra benefits. All Medicare Advantage plans must offer, at a minimum, the same coverage as Original Medicare. However, these private insurance plans may also include additional benefits not available with Part A and Part B.

Most Medicare Advantage plans include Part D prescription drug coverage, which means you won’t pay an additional premium for your drug plan. In addition, most plans offer additional benefits such as routine vision, dental, and hearing care, and discounted fitness memberships.

In 2018, CMS authorized Medicare Advantage plans to offer expanded benefits to help seniors age safely at home. These benefits include in-home meal delivery, home safety modifications, caregiver support and coverage for over-the-counter medications and devices. Some Medicare Advantage plans in Texas offer one or more of these new benefits.

Understanding Medicare Advantage Prescription Drug Coverage

Although most Medicare Advantage plans in Texas include Part D, the benefits and cost-sharing structures vary by plan.

Medicare requires all Part D plans to cover certain prescription medications. Beyond that, plans are free to choose which medications they will cover and how much they will pay for each. Plans provide this information in their formulary.

Most plans use a tiered formulary, where less expensive generic drugs are usually in Tier 1 and have the lowest copayment, followed by other generic medications and preferred brand-name drugs in Tier 2. The more expensive drugs and specialty medications are in the top tiers. You may have to get prior authorization for these top-tier medications.

Some plans have a separate deductible for Part D. The insurance company sets the deductible, but it still is regulated and can’t be more than the limit allowed by Medicare. In 2020, the Part D deductible maximum is $435. Medications in the lowest tiers of the formulary may be exempt from the deductible requirement.

Insurance companies frequently make changes to their plans, which means that your preferred doctor might be in your plan network this year, but leave it in the next.

Finding the Best Medicare Advantage Plans in Texas

Texas Medicare Advantage plans vary widely in cost and coverage. Also, insurance companies frequently make changes to their plans. This means that your preferred doctor might be in your plan network this year, but leave it in the next. Likewise, medications you take every day might be removed from the plan formulary from one year to the next.

For these reasons, it’s important to read your Annual Notice of Changes (ANOC) every fall to make sure there are no major changes occurring that will affect your coverage. It’s also a good idea to compare available plans in your area each fall during the Annual Election Period, as you might find a new Medicare plan that better meets your current needs.

The Medicare Advantage Rating System

Medicare rates all Medicare Advantage and Part D prescription drug plans every year. They do this by assigning one to five stars for each of the following five quality measurements:

  • Health screenings, tests, and vaccines
  • Managing chronic health conditions, such as diabetes or heart disease
  • Member satisfaction — based on the number of complaints and the number of people who leave the plan
  • Overall customer service

Part D plans are also rated on drug pricing and patient safety.

Plan star ratings are updated each October and available using the Medicare Plan Finder tool. Although you can usually only enroll in Medicare Advantage plans in Texas during certain times of the year, there is a Special Enrollment Period (SEP) for 5-Star plans.

You can use the 5-Star SEP at any time during the year to join or switch to a Medicare Advantage plan with an overall five-star rating. However, it is important to note that you can only use the SEP once each year.

Texas Medicare Advantage Plans 2020 with Overall 5-Star Ratings

Plan Name Service Area SNP 5-star in 2019
KelseyCare Advantage 13 counties in Texas No Yes
UnitedHealthcare Duo Complete HMO 53 counties in Texas Yes No

Enrolling in Medicare Advantage Plans in Texas

You can enroll in a Medicare Advantage during one of the following three periods:

  • Medicare Initial Enrollment Period: This period begins three months before your 65th birthday, includes your birthday month, and extends an additional three months for a total of seven months.
  • Medicare Annual Election Period: This period takes place each year between October 15 and December 7. This is when you can switch from Original Medicare to Medicare Advantage or enroll in a new Medicare Advantage plan.
  • Medicare Advantage Open Enrollment Period (OEP): This option is only available to current members of Medicare Advantage. During this window, you can switch from one Medicare Advantage plan to another or drop Medicare Advantage and return to Original Medicare. The OEP runs from January 1 through March 31.

You may also be eligible for a Special Enrollment Period during the year (aside from the 5-Star SEP). If you leave your plan’s service area, for example, or you qualify for an SNP, you may be able to enroll in Medicare Advantage outside the periods that are listed above.

Medicare has a wealths of resources to help you find the right Medicare Advantage plan for you. You can also get information about Texas Medicare programs from the Texas Department of Health and Human Services. Insurance agents are also a great source of information to help you compare Medicare Advantage plans in Texas. Don’t be afraid to take advantage of these resources to help you find the health coverage you need.