It’s important for Texans to be familiar with the basics of Medicare, and stay updated on changes. To help, here are answers to some of the most common questions we get asked.
What are the basics of Medicare?
Medicare consists of four parts:
- Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care. Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes while working.
- Part B (Medical Insurance): Covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Most people pay a standard monthly premium for Part B.
- Part C (Medicare Advantage): An alternative to Original Medicare (Parts A and B) offered by private companies approved by Medicare. These plans often include Part D coverage and additional benefits like vision, dental, and wellness programs.
- Part D (Prescription Drug Coverage): Helps cover the cost of prescription drugs, available through Medicare-approved private insurers.
You should also be aware of enrollment requirements and periods.
How does Medicare Advantage differ from Original Medicare?
Medicare Advantage (Part C) plans are offered by private insurers and must cover all services provided by Original Medicare (Parts A and B) except hospice care. It also offers additional benefits like vision, dental, and hearing, and most include prescription drug coverage. However, these plans may have network restrictions, so you’ll need to use specific healthcare providers.
What is Medigap and do I need it?
Medigap, or Medicare Supplement Insurance, is offered by private companies to cover costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles. Medigap may be beneficial if:
- You have frequent medical needs or require extensive services.
- You want predictable out-of-pocket costs.
- You prefer seeing any doctor who accepts Medicare.
Medigap policies are standardized, and in Texas, you can choose from 10 different plans (A, B, C, D, F, G, K, L, M, and N), each offering a different level of coverage.
Are new cards being issued? Is Medicare calling people about cards?
If you are getting a call about this, it is a scam. Increasing numbers of people are receiving calls asking for personal information for you to receive a new card. However, Medicare is not sending out new cards, and Medicare will never call you and ask for your number or other personal information.
What’s new in 2024?
Medicare has introduced a few measures in 2024, including ones to save on prescription drugs and other healthcare costs.
- For those with Medicare Part D, you’ll pay 25% of drug costs after your deductible, with a cap of about $3,300 and will no longer pay 5% of drug costs in the catastrophic phase. If you reach the catastrophic coverage threshold, you won’t have to pay copayments and coinsurance
- The Extra Help program has expanded to cover more costs for eligible individuals with limited income and resources.
- Insulin costs are capped at $35 for a one-month supply under Part D, with no deductible; the same cap applies to insulin through a traditional pump covered under Part B.
- Recommended adult vaccines are now free. Telehealth services will continue to be available from any location in the U.S. until the end of 2024, after which most services will require being in a rural medical facility, except for certain services like mental health.
- Medicare now covers monthly services for those living with chronic pain for more than three months and offers intensive outpatient program services for mental health care.
- Individuals who have recently lost or are about to lose Medicaid may have new opportunities to sign up for or change their Medicare coverage.
- Under Medicare Advantage, mental health services and chronic disease management programs have been expanded.
What are the 2024 Texas Medicare Limits?
If you’re in a Medicare Advantage Plan or have other insurance such as Medigap, Medicaid, employer, or others, your copayments, coinsurance, or deductibles may differ. The 2024 premium and deductible limits are:
- Medicare Part A monthly premium: $505
- Medicare Part B monthly premium: $174.70 or more
- Part B Medical annual deductible: $240
- Skilled nursing facility co-pay, for days 21 to 100: $204/day
- Hospital stay deductible: $1,632
- Hospital co-pay, for days 61 to 90: $408/day
- Hospital co-pay, for days 91 to 150: $816/day
Details are available in the Medicare & You Official U.S. Government Medicare handbook.
Are there any differences in Medicare in Texas compared to other states?
Medicare is a federal program with consistent benefits nationwide, but there are some state-specific factors in its administration. The number and specifics of plans can vary across regions. Texas offers many plans, with more options in urban areas than in rural ones. Costs and extra benefits may vary, too.
What is the 2024 Medicare Part D “donut hole”?
The “donut hole” is a gap in prescription drug coverage under Part D. You fall into the donut hole when your total drug costs reach a set limit. The limit for 2024 will be $5,030. While in the gap, you pay 25% of the cost for both brand-name and generic drugs until you reach the catastrophic coverage threshold of $8,000. After reaching this threshold, you pay a small coinsurance amount or copayment for the rest of the year.
Are there programs to help with Medicare costs?
Yes, several programs can assist:
Medicare Savings Programs: Help with Part A and B premiums, deductibles, coinsurance, and copayments based on income and resources.
Extra Help (Low-Income Subsidy): Assists with Part D premiums, deductibles, and copayments.
State Pharmaceutical Assistance Programs (SPAPs): Some states, including Texas, offer additional assistance with prescription drug costs.
What preventive services does Medicare cover?
Medicare covers many preventive services that are free to eligible individuals. These include:
- Annual Wellness Visit
- Screenings for cancer (breast, colorectal, prostate, etc.)
- Cardiovascular disease screenings
- Diabetes screenings
- Flu and pneumonia vaccines
- Bone density tests
- Depression screenings
At Wise Insurance, we answer all of your Medicare and health insurance questions. We understand it can be confusing, and we know you want to be sure you are getting the right plans for your needs to save you money. Working closely with you, we can help you navigate your insurance options.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.
