Texas Medicare: A Clear Path to Your Health Coverage

For many Texans, turning 65 is a major life event that includes the critical decision of enrolling in Medicare. This choice significantly impacts your health and financial future for years to come. The process can seem complex, with unfamiliar rules and numerous options.

Understanding Medicare is essential, whether you are approaching 65, helping a loved one, or are a younger Texan with a qualifying disability . The decisions you make affect which doctors you can see and your total healthcare spending. This resource provides a clear, step-by-step roadmap tailored to the plans and programs available in the Lone Star State.

What is Medicare?

Medicare is the U.S. federal health insurance program for individuals aged 65 or older. It also covers certain younger people with disabilities and those with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

While Medicare's core benefits are the same nationwide, how you receive them is localized. Private insurance companies offer plans at the state or county level, and Texas administers key financial aid programs . This resource focuses on these Texas-specific details to help you make a confident decision.

Who Qualifies for Medicare in Texas?

Medicare eligibility is determined by federal criteria based on age, work history, or specific health conditions. Knowing these pathways is the first step in your Medicare journey.

Age and Work History

• Age 65: The most common way to qualify for Medicare is by turning 65, regardless of your employment status.
• Work Requirement: To receive Medicare Part A (Hospital Insurance) without paying a monthly premium, you or your spouse must have worked and paid Medicare taxes for at least 10 years (40 quarters) . If you don't meet this requirement, you may still be able to purchase Part A coverage. 

Disability-Based Qualifications

Younger Texans can qualify for Medicare if they meet specific disability criteria set by the Social Security Administration (SSA).

• Social Security Disability Insurance (SSDI): You become eligible for Medicare after receiving SSDI benefits for 24 months.
• End-Stage Renal Disease (ESRD): Individuals of any age with permanent kidney failure requiring dialysis or a kidney transplant are eligible.
• Amyotrophic Lateral Sclerosis (ALS): If you are diagnosed with ALS (Lou Gehrig's disease), you are eligible for Medicare the first month you receive SSDI benefits, with no waiting period.

The Importance of Timely Enrollment

Becoming eligible for Medicare is different from enrolling. Enrollment is a time-sensitive process with strict deadlines. Missing your enrollment window can lead to gaps in coverage and lifelong financial penalties. It is critical to understand when you need to act on your eligibility to avoid costly mistakes.

The Four Parts of Medicare Explained

Medicare is divided into four parts—A, B, C, and D—each covering different healthcare services.

Medicare Part A: Hospital Insurance

Part A is your hospital insurance, covering costs associated with inpatient care.

What Part A Covers

• Inpatient Hospital Stays: Semi-private rooms, meals, and nursing services.
• Skilled Nursing Facility (SNF) Care: Short-term skilled care after a qualifying hospital stay. This is not long-term custodial care.
• Hospice Care: Comfort and pain management for individuals with a terminal illness.
• Home Health Care: Part-time skilled care if you are homebound and a doctor certifies the need.

Part A Costs (2025)

• Premium: Most Texans get Part A premium-free. If you need to buy it, the monthly premium is either $285 or $518, depending on your work history.
• Deductible: You will pay a deductible of $1,676 for each benefit period.
• Coinsurance: After the deductible, you have daily coinsurance payments for extended stays:
• Hospital Days 61-90: $419 per day.
• Lifetime Reserve Days (91-150): $838 per day.
• SNF Days 21-100: $209.50 per day.

Medicare Part B: Medical Insurance

Part B is your medical insurance, covering a wide range of outpatient services and supplies.

What Part B Covers

• Doctors' Services: Visits to primary care doctors and specialists.
• Outpatient Care: Services in a hospital outpatient department or clinic.
• Preventive Services: Screenings, flu shots, and wellness visits.
• Medical Supplies: Durable medical equipment (DME) like walkers and wheelchairs.
• Ambulance Services: When medically necessary.
• Mental Health Services: Outpatient therapy and counseling.

Part B Costs (2025)

• Premium: The standard monthly premium is $185. Beneficiaries with higher incomes may pay more.
• Deductible: You must pay an annual deductible of $257.
• Coinsurance: After the deductible, you typically pay 20% of the Medicare-approved amount for most services.

Medicare Part C: Medicare Advantage

Medicare Part C, or Medicare Advantage, is an alternative way to receive your benefits through a private insurance company.

• All-in-One Plans: These plans bundle Part A and Part B benefits. Most also include prescription drug coverage (Part D).
• Extra Benefits: They often include benefits not covered by Original Medicare, such as dental, vision, and hearing care.

Medicare Part D: Prescription Drug Coverage

Part D provides coverage for outpatient prescription drugs through private insurance companies.   

• How to Get Part D: You can get this coverage through a standalone Prescription Drug Plan (PDP) to go with Original Medicare, or as part of a Medicare Advantage (MA-PD) plan.
• Formulary: Each plan has a list of covered drugs, called a formulary. It's vital to check that your medications are included.
• Tiers: Drugs are often grouped into tiers, with lower tiers (generics) having lower copayments than higher tiers (specialty drugs).

Your Core Decision: Original Medicare vs. Medicare Advantage

After enrolling in Parts A and B, you must choose how to receive your coverage. This is a critical decision between two main paths.

Path 1: Original Medicare

This is the traditional, federally administered fee-for-service program.

• Provider Choice: You have the freedom to see any doctor or visit any hospital in the U.S. that accepts Medicare.
• Referrals: You generally do not need a referral to see a specialist.
• Costs: You are responsible for a 20% coinsurance for most Part B services with no annual limit on out-of-pocket costs. Many people buy a Medigap policy to cover this gap.
• Drug Coverage: You must enroll in a separate Part D plan for prescription coverage.
• Extra Benefits: It does not cover routine dental, vision, or hearing services.

Path 2: Medicare Advantage (Part C)

This is the private insurance alternative that bundles your benefits.

• Provider Choice: You must use doctors and hospitals within the plan's network (like an HMO or PPO), which is often limited to a specific area.
• Referrals: You may need a referral from a primary care physician to see a specialist, especially in an HMO.
• Costs: Plans have an annual maximum out-of-pocket limit, providing a financial safety net. You pay fixed copayments for services instead of a 20% coinsurance.
• Drug Coverage: Prescription drug coverage is usually included.
• Extra Benefits: Most plans offer extra benefits like dental, vision, hearing, and fitness programs.

The Critical "Lock-In" Effect

Your first choice between these two paths can have long-term consequences. This is because of the rules for Medicare Supplement (Medigap) insurance.

You have a one-time, 6-month Medigap Open Enrollment Period when you are first eligible. During this window, you have a "guaranteed issue right" to buy any Medigap policy without being denied or charged more for pre-existing conditions.

If you choose a Medicare Advantage plan, you cannot also have a Medigap policy. By picking an Advantage plan at 65, you give up your guaranteed-issue Medigap window. If you later develop a health condition and want to switch back to Original Medicare for more provider flexibility, you may be denied Medigap coverage or face very high premiums.

Path 1 in Detail — Original Medicare with Supplemental Coverage

Choosing Original Medicare gives you maximum freedom, but it requires adding other plans for complete financial protection.

Filling the Gaps with Medigap

Medicare Supplement Insurance, or Medigap, is private insurance that helps pay for out-of-pocket costs like deductibles and the 20% coinsurance.

Standardized Medigap Plans

Medigap plans are standardized and identified by letters (A, B, C, D, F, G, K, L, M, and N). A Plan G from one company offers the same basic benefits as a Plan G from another; only the price differs.

Popular Plans in Texas

• Plan G: This is the most comprehensive plan for new beneficiaries. It covers nearly all out-of-pocket costs, including the 20% Part B coinsurance. You only have to pay the annual Part B deductible ($257 in 2025).
• Plan N: This plan offers strong coverage with lower premiums than Plan G. In return, you pay small copayments for some doctor visits (up to $20) and ER visits (up to $50).
• Plan F: This plan is only available to those eligible for Medicare before January 1, 2020. It was popular because it covered the Part B deductible, which is no longer allowed for new enrollees.

Medigap Enrollment Window

The best time to buy a Medigap policy is during your 6-month Medigap Open Enrollment Period. This one-time window starts the month you are 65 or older and enrolled in Part B. During this period, you have a guaranteed right to buy any policy sold in Texas.

Adding a Part D Prescription Drug Plan

To complete your coverage, you will need a standalone Part D plan.

How to Choose a Plan

The best tool is the official Medicare Plan Finder on Medicare.gov. You can enter your specific medications and pharmacy to compare the total annual costs for every plan in your Texas ZIP code.

What to Compare

• Formulary: Ensure all your prescriptions are on the plan's covered drug list.
• Total Costs: Look at the total estimated annual cost, not just the monthly premium.
• Pharmacy Network: Check that your preferred pharmacy is in-network.
• Star Ratings: Medicare rates plans from 1 to 5 stars based on quality and customer service.

Path 2 in Detail — Medicare Advantage in Texas

Medicare Advantage plans consolidate your healthcare and drug coverage into a single plan from a private insurer.

How Advantage Plans Work

You are still in Medicare and must pay your Part B premium. However, a private company manages your Part A and Part B benefits. Medicare pays the company a fixed amount each month to provide your care, often through a network of providers.

Common Plan Types in Texas

• HMO (Health Maintenance Organization): You must use in-network doctors and hospitals. You typically need a referral from a Primary Care Physician (PCP) to see a specialist.
• PPO (Preferred Provider Organization): You have more flexibility to see providers both in and out of network, but your costs are lower if you stay in-network. You usually don't need referrals.
• Special Needs Plans (SNPs): These plans are for specific groups, such as those with both Medicare and Medicaid (D-SNPs) or those with chronic conditions like diabetes (C-SNPs).

Pros and Cons of Medicare Advantage

Advantages

• Lower Premiums: Many plans in Texas have a $0 monthly premium (beyond your Part B premium).
• Out-of-Pocket Maximum: Plans have a yearly limit on your out-of-pocket costs, protecting you from catastrophic expenses.
• Extra Benefits: Most plans include dental, vision, hearing, and prescription drug coverage.

Disadvantages

• Network Restrictions: Your choice of doctors and hospitals is limited to the plan's network. 
• Prior Authorization: Plans often require approval before covering certain services or procedures.
• Geographic Limits: Coverage is generally tied to a specific service area, which can be a drawback if you travel often.

A Guide to Medicare Enrollment

Understanding when to sign up for Medicare is crucial to avoid penalties and coverage gaps.

Key Enrollment Periods

• Initial Enrollment Period (IEP): This is your main 7-month window to sign up. It starts 3 months before your 65th birthday month, includes your birthday month, and ends 3 months after.
• Annual Open Enrollment Period (AEP): From October 15 to December 7 each year. During this time, you can switch between Original Medicare and Medicare Advantage or change your Part D or Advantage plan.
• Medicare Advantage Open Enrollment Period (MA-OEP): From January 1 to March 31 each year. If you are in an Advantage plan, you can switch to another one or return to Original Medicare.
• Special Enrollment Periods (SEPs): Triggered by life events like retiring and losing employer coverage. This gives you a window to enroll without penalty.

How to Apply for Parts A and B

The Social Security Administration (SSA) handles enrollment for Original Medicare.

1. Automatic Enrollment: You will be automatically enrolled if you are already receiving Social Security or Railroad Retirement Board benefits before you turn 65. Your Medicare card will be mailed to you.
2. Manual Enrollment: If you are not receiving those benefits, you must sign up yourself. You can do this:
   • Online: The fastest way is at SSA.gov.
   • By Phone: Call the SSA at 800-772-1213.
   • In Person: Visit a local Social Security office.

Penalties for Late Enrollment

• Part B Penalty: If you delay enrollment without having other qualifying coverage, your monthly premium will increase by 10% for each full 12-month period you waited. This penalty lasts for life.  
• Part D Penalty: If you go 63 or more consecutive days without creditable drug coverage after your IEP, you will face a lifetime penalty added to your Part D premium.

Medicare Costs in Texas (2025)

Budgeting for healthcare requires understanding Medicare's various out-of-pocket costs.

Types of Costs

• Premiums: Fixed monthly payments to maintain your coverage.
• Deductibles: The amount you pay before your plan starts paying.
• Coinsurance: Your share of the cost, calculated as a percentage (e.g., 20% for Part B).
• Copayments: A fixed dollar amount you pay for a service (e.g., $20 for a doctor visit).

2025 Cost Breakdown

Part A (Hospital Insurance) Costs

• Premium: $0 for most people. If you must buy it, the cost is $285 or $518 per month.
• Deductible: $1,676 per benefit period.
• Coinsurance (per day): $419 for hospital days 61-90; $209.50 for skilled nursing facility days 21-100.

Part B (Medical Insurance) Costs

• Premium: $185 per month (standard). Higher for those with higher incomes.
• Deductible: $257 per year.
• Coinsurance: 20% of the Medicare-approved amount for most services.

Part C (Medicare Advantage) Costs

• Premium: Varies by plan; many plans in Texas have a $0 premium (you still pay the Part B premium).
• Out-of-Pocket Maximum: Cannot exceed $9,350 for in-network services in 2025.

Part D (Prescription Drug) Costs

• Premium: Varies by plan; the national average is about $38 per month.
• Deductible: Cannot exceed $590 in 2025.
• Out-of-Pocket Maximum: Beginning in 2026, out-of-pocket drug costs will be capped at $2,000 per year.

Financial Help for Texans on Medicare

Several federal and state programs can help Texans with limited incomes afford their Medicare costs.

Medicare Savings Programs (MSPs)

MSPs are administered by the Texas Health and Human Services Commission (HHSC) and help pay for premiums, deductibles, and copayments.

1. Income Limit: $1,761/month (individual), $2,380/month (couple).
2. Resource Limit: $9,660 (individual), $14,470 (couple).

• Qualifying Individual (QI) Program: Helps pay the Part B premium.
• Qualified Disabled & Working Individual (QDWI) Program: Helps pay the Part A premium for certain working individuals with disabilities.
  • Income Limit: $2,609/month (individual), $3,525/month (couple).
  • Resource Limit: $4,000 (individual), $6,000 (couple). 

Extra Help for Prescription Drugs

The Extra Help program, or Low-Income Subsidy (LIS), helps pay for Part D costs . If you qualify for any Texas MSP, you are automatically enrolled in Extra Help. You can also apply directly through the Social Security Administration.

Texas Medicare Resources and Helplines

You don't have to navigate Medicare alone. Texas offers a network of free, unbiased assistance.

Your First Call for Unbiased Help

The Texas Health Information, Counseling and Advocacy Program (HICAP) is your most valuable resource. As the official State Health Insurance Assistance Program (SHIP), HICAP provides free, confidential, and objective counseling. Certified counselors can help you compare plans, understand benefits, and apply for financial assistance.

• Statewide HICAP Helpline: 800-252-9240.

Local Support: Area Agencies on Aging (AAAs)

HICAP services are delivered locally through 28 Area Agencies on Aging (AAAs), which serve all 254 Texas counties.

Directory of Texas AAAs

• Alamo AAA: 866-231-4922 | Counties: Atascosa, Bandera, Comal, Frio, Gillespie, Guadalupe, Karnes, Kendall, Kerr, McMullen, Medina, Wilson.
• Ark-Tex AAA: 800-372-4464 | Counties: Bowie, Cass, Delta, Franklin, Hopkins, Lamar, Morris, Red River, Titus.
• Bexar County AAA: 210-477-3275 | County: Bexar.
• Brazos Valley AAA: 800-994-4000 | Counties: Brazos, Burleson, Grimes, Leon, Madison, Robertson, Washington.
• Capital Area AAA: 888-622-9111 | Counties: Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, Travis, Williamson.
• Central Texas AAA: 800-447-7169 | Counties: Bell, Coryell, Hamilton, Lampasas, Milam, Mills, San Saba.
• Coastal Bend AAA: 800-252-9240 | Counties: Aransas, Bee, Brooks, Duval, Jim Wells, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio.
• Concho Valley AAA: 877-944-9666 | Counties: Coke, Concho, Crockett, Edwards, Irion, Kimble, Mason, McCulloch, Menard, Reagan, Schleicher, Sterling, Sutton, Tom Green.
• Dallas County AAA: 800-252-9240 | County: Dallas.
• Deep East Texas AAA: 800-256-6848 | Counties: Angelina, Houston, Nacogdoches, Newton, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, Tyler.
• East Texas AAA: 800-442-8845 | Counties: Anderson, Camp, Cherokee, Gregg, Harrison, Henderson, Marion, Panola, Rains, Rusk, Smith, Upshur, Van Zandt, Wood.
• Golden Crescent AAA: 800-574-9745 | Counties: Calhoun, DeWitt, Goliad, Gonzales, Jackson, Lavaca, Victoria.
• Harris County AAA: 800-213-8471 | County: Harris.
• Heart of Texas AAA: 254-292-1800 | Counties: Bosque, Falls, Freestone, Hill, Limestone, McLennan. 
• Houston-Galveston AAA: 800-437-7396 | Counties: Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Liberty, Matagorda, Montgomery, Walker, Waller, Wharton.
• Lower Rio Grande Valley AAA: 800-365-6131 | Counties: Cameron, Hidalgo, Willacy.
• Middle Rio Grande AAA: 800-224-4262 | Counties: Dimmit, Kinney, Maverick, Real, Uvalde, Val Verde, Zavala.
• North Central Texas AAA: 800-272-3921 | Counties: Collin, Denton, Ellis, Erath, Hood, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somervell, Wise.
• North Texas AAA: 800-460-2226 | Counties: Archer, Baylor, Clay, Cottle, Foard, Hardeman, Jack, Montague, Wichita, Wilbarger, Young. 
• Panhandle AAA: 800-460-2226 | Counties: Armstrong, Briscoe, Carson, Castro, Childress, Collingsworth, Dallam, Deaf Smith, Donley, Gray, Hall, Hansford, Hartley, Hemphill, Hutchinson, Lipscomb, Moore, Ochiltree, Oldham, Parmer, Potter, Randall, Roberts, Sherman, Swisher, Wheeler. 
• Permian Basin AAA: 800-491-4636 | Counties: Andrews, Borden, Crane, Dawson, Ector, Gaines, Glasscock, Howard, Loving, Martin, Midland, Pecos, Reeves, Terrell, Upton, Ward, Winkler.
• Rio Grande AAA: 800-333-7082 | Counties: Brewster, Culberson, El Paso, Hudspeth, Jeff Davis, Presidio.
• South East Texas AAA: 800-395-5465 | Counties: Hardin, Jefferson, Orange.
• South Plains AAA: 888-418-6564 | Counties: Bailey, Cochran, Crosby, Dickens, Floyd, Garza, Hale, Hockley, King, Lamb, Lubbock, Lynn, Motley, Terry, Yoakum.
• South Texas AAA: 800-292-5426 | Counties: Jim Hogg, Starr, Webb, Zapata.
• Tarrant County AAA: 817-258-8102 | County: Tarrant.
• Texoma AAA: 800-677-8264 | Counties: Cooke, Fannin, Grayson.
• West Central Texas AAA: 800-928-2262 | Counties: Brown, Callahan, Coleman, Comanche, Eastland, Fisher, Haskell, Jones, Kent, Knox, Mitchell, Nolan, Runnels, Scurry, Shackelford, Stephens, Stonewall, Taylor, Throckmorton.

Other Important Contacts

• Social Security Administration (SSA): For enrollment in Parts A & B and applying for Extra Help.
  • Phone: 800-772-1213
  • Website: SSA.gov
• Medicare: For general questions and official plan comparison tools.
  • Phone: 1-800-MEDICARE (1-800-633-4227)
  • Website: Medicare.gov
• Texas Department of Insurance (TDI): For questions about Medigap policies and consumer protection.
  • Phone: 800-252-3439.

Your Next Steps to Confident Coverage

The Medicare journey involves a series of important decisions. Your main choice is between the flexibility of Original Medicare (best paired with supplemental plans) and the all-in-one convenience of a Medicare Advantage plan. Timing is everything—enrollment deadlines are strict, and missing them can lead to lifelong penalties.

Your Action Plan

1. Check Your Timeline: If you are approaching 65, mark your 7-month Initial Enrollment Period on a calendar and start your research now.
2. Do Your Research: Use the official Plan Finder tool on Medicare.gov. Enter your ZIP code and prescriptions to get a personalized comparison of the plans available in your part of Texas.
3. Look into Financial Help: Review the income limits for the Texas Medicare Savings Programs. If you think you might qualify, prepare to apply.
4. Make the Call: Contact the Texas HICAP helpline at 800-252-9240. A certified counselor can review your situation and guide you through the process for free.

By understanding your options and using the expert resources available in Texas, you are now equipped to make the best choice for your health and financial future.

Frequently Asked Questions