Texas Medicare Insurance - Most Frequently Asked Questions

Frequently Asked Questions
Please note: Information provided on this website can be updated, changed or or deleted at any time.

Q. What is Medicare?
A. It is a federal health insurance program referred to as Original Medicare, which includes people 65 years of age, or older, certain people with disabilities who are under age 65 and those with end-stage renal disease (permanent kidney failure). It pays for a large portion of the health care expense but not all of it. The portion that Medicare does not pay is what the individual must pay for out of pocket such as coinsurance, co-payments, and deductibles. The gaps in Original Medicare coverage are commonly filled by a Medicare Supplement plan. Medicare in Texas and Texas Medicare plans are the same as Medicare in any state because it is a federal government that defines what the benefits are. Search more on this Texas Medicare topic.

Q. What are the four parts of Medicare
A. •Texas Medicare Part A: This covers area such as inpatient hospital, inpatient skilled nursing facility, home health, and hospice services. Most people do not have to pay for Part A due their contributions over 10 years.

•Texas Medicare Part B: provides covers outpatient and physician services. It also pays for other areas such as durable medical equipment, prosthetic devices, supplies incident to physician's services and ambulance transportation. Most people pay monthly for Part B.
•Texas Medicare Part C: Are Medicare Advantage plans are offered by private insurance companies that serve as an alternative to Medicare. These plans can cover medical only or medical and dental. These plans are subsidized and regulated by the Federal government.
•Texas Medicare Part D: Prescription Drug Coverage plans are offered by private companies to provide coverage for prescription drug costs. These plans are subsidized and regulated by the Federal government. Search more on this Texas Medicare topic.

Q. Can you tell me more about Medicare Part A and Part B?
A. Part A referred to as hospital insurance, helps pay expenses for inpatient hospital care, some skilled nursing facility care, hospice care, and some home health care. The medical costs you incur with Medicare Part A include a large deductible per benefit period and copays if you are in the hospital for over 61 days. The benefit period for part A is your time in the hospital including 60 days after you are release.

Part B referred to as medical insurance, helps pay for outpatient hospital care, doctors' services, and some other medical services and supplies when they are medically necessary that Part A does not cover. The Part B deductible is based on a calendar year and is generally affordable. After the deductible is met you may be responsible for portion of ther Medicare Part B expenses. This can be quite expensive if you have any major medical treatment. Search more on this Texas Medicare topic.

Q. What is a Medicare Supplement plan?

A. A Medicare supplement insurance plan is a health insurance policy sold by private insurance companies (Texas Medicare carrier) to cover some or all of the gaps created my Original Medicare. In the end, a Medicare Supplement plan may help you save on out of pocket costs even though you have to pay a monthly premium to the insurance company you purchase the policy from. You are eligible for this plan if you have Medicare Part A and B and are at least 65 years of age (unless disabled). Since the Texas Medicare Supplement plans do not have an open enrollment period you can switch another Texas Medicare Supplement plan with another Texas insurance company at any point throughout the year as long as you qualify medically. Search more on this Texas Medicare Supplement Medigap topic.

Q. Which plan is right for me a Medicare supplement or a Medicare Advantage plan?
A. The answer will be based on what your individual needs, concerns and financial budget. Texas Medicare Advantage plans and Texas Medicare supplement plans have very different benefits. It is important to evaluate the premium, out-of-pocket expenses and who the Texas Medicare providers will be on each Texas Medicare plan. Determine what the Texas Medicare guidelines and Texas Medicare benefits are for each product and what that means to you having Medicare in Texas. Search more on this Texas Medicare Supplement or Medicare Advantage topic.

Q.How do I find the nearest Texas Medicare Office?

A. Contact your nearest Social Security Administration office - Monday through Friday 7 a.m. to 7 p.m., Central Time Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778

Q. What is included in Medicare's category for Durable Medical Equipment (DME)?
A. It includes, but is not limited to: diabetic supplies, canes, crutches, walkers, commode chairs, home oxygen equipment, hospital beds, and wheelchairs.

Q. How does Medicare cover me when I receive medical services aboard a cruise ship?
A. Medicare will only pay for medically necessary shipboard services if the services were provided while the ship was within United States waters (i.e., in a United States port, or within 6 hours of departure or arrival at a United States port). For more information read the brochure: Medicare Coverage Outside the United States.

Q. What is Part D?
A. In January 1, 2006 a federal program the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) called Medicare Part D was created to subsidize the costs of prescription drugs for Medicare beneficiaries

Q. Can I purchase the oxygen equipment I am using instead of renting? Will Medicare pay?
A. Medicare prohibits payments for purchase of oxygen equipment. If you want to buy your own oxygen equipment, Medicare cannot pay.

Q. Does Medicare Part A include a Hospice benefit?
A. Yes. Medicare Part A includes Hospice as a benefit. Medicare Part A beneficiaries are entitled to hospice benefits if they are terminally ill and have less than six months to live. Hospice benefits include doctor services, medical equipment and supplies, and nursing services among other things.

Q. I have a question about my bill, what should I do first?
A. You should contact your provider to discuss your concerns. If you have any additional questions to be answered or problems to resolve, then contact 1-800 MEDICARE.

Q. Is there a list of doctors and hospitals I must use with a Texas Medicare Supplement policy?
A. With a Texas Medicare Supplements you can go to any doctor or hospital in the United States as long as they accept Medicare. The Texas Medicare Supplements also have Select plans, which specifies the hospitals you can go to.

Q. What services are covered by Home Health Care?
A. Medicare services include: periodic and part-time skilled nursing care; speech, physical and occupational therapy; durable medical equipment (which includes wheelchairs, hospital beds, oxygen, and walkers); medical social services and supplies as well as other items.

Q. What is Social Security Disability Insurance (SSDI)?
A. Started in 1954, Social Security Disability Insurance or SSDI was created to provide individuals with an income if one was not able to work because of some sort of disability or even temporary injury or if your condition does not improve. It is a payroll tax funded federal insurance program where a certain amount of the FICA taxes are deducted for SSDI, Social Security Retirement and Medicare.

Q.Who qualifies for the Specified Low-income Medicare Beneficiary (SLMB) Program?
A. The SLMB program is for individuals where a Medicare Savings Program helps pay for Medicare Part B premiums that would normally be deducted from the Social Security checks. Search more on this Texas Specified Low-income Medicare Beneficiary (SLMB) topic.

Q.Where can I get information on the qualifications for a Texas Qualified Medicare Beneficiary (QMB)?
A. Covering the Cost of Medicare - If you cannot afford the additional expense of purchasing a Medicare supplement policy to supplement your Medicare coverage, there are a couple of programs you should be aware of. The Medicaid-sponsored Medicare Savings Programs may pay Medicare premiums, deductibles, and coinsurance amounts for eligible Medicare beneficiaries. These programs allow you to better direct your savings to cover health care expenses.

Medicaid is a state/federal assistance program that provides health care for people who meet income eligibility requirements. The Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, the Qualified Individuals (QI-1), and the Qualified Disabled Working Individuals (QDWI) are all called Medicare Savings Programs. Search more on this Texas Qualified Medicare Beneficiary (QMB) topic.

Q.What is the requirements for a Texas Qualified Individual-1 (QI-1)?
A. If you cannot afford the additional expense of purchasing a Medicare supplement policy to supplement your Medicare coverage, there are a couple of programs you should be aware of. The Medicaid-sponsored Medicare Savings Programs may pay Medicare premiums, deductibles, and coinsurance amounts for eligible Medicare beneficiaries. These programs allow you to better direct your savings to cover health care expenses.

Q. What is the qualifications to be a Texas Qualified Disabled Working Individual (QDWI)?
A. Covering the Cost of Medicare
If you cannot afford the additional expense of purchasing a Medicare supplement policy to supplement your Medicare coverage, there are a couple of programs you should be aware of. The Medicaid-sponsored Medicare Savings Programs may pay Medicare premiums, deductibles, and coinsurance amounts for eligible Medicare beneficiaries. These programs allow you to better direct your savings to cover health care expenses.

Q. Hospice Care covers what services?
A. Individuals with a terminal illness have services covered by Medicare Part A. These areas may include medical and support services from a Medicare-approved hospice, prescriptions to control pain, as well as additional services, which normally are not covered by Medicare. Hospice can be received by the individual in their home, while in a hospital (limited time) and respite care to give the main caregiver can time off to rest.

Q. Tell me about a Medicare Preferred Provider Organization (PPO) Plan?
A. A Medicare Advantage option that gives an individual the choice of visiting providers within the network or seeing a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician to see a specialist. If you want the option to be able to see any provider within or outside of the network (for an additional cost), then the PPO or Medicare Preferred Provider Organization Plan will suit you well. Any certain person will not require any referral from a physician to see any specialist.

Q. What is a Medicare Managed Care Plan?
A. Medicare Managed Care Plans are optional in some areas of the country, the plans must cover all Part A and Part B services and some may cover additional services such as prescription drugs. These plans are Medicare Advantage options that may have lesser co-payments than the Original Medicare Plan but generally limits individuals to services inside the plan’s networks such as primary doctors, specialists, and hospitals.

Q.Tell me about Medicare Advantage
A. Once known as Medicare Choice, Medicare Advantage is a program that gives benefits through private insurance companies. It includes, Private Fee for Service, Managed Care or Medicare HMOs, Special Needs Plans, and Preferred Provider Organization. These plans will give a larger spectrum of choice and other benefits. Everyone who has Medicare Parts A and B is eligible to join a plan with the exception of most people with End-Stage Renal Disease (ESRD).

Q. Is a Skilled Nursing Facility Care (SNF) covered by Medicare?
A. Once the individual has been an inpatient for three consecutive days, the Skilled Nursing Facility Care is covered by Medicare. This nursing care will include some or all of the following, rehabilitation care, the skilled nursing, semiprivate private room and meals and any other service and supplies.

Q. What is a Medicare Private Fee-for-Service Plan?
A. A Medicare Private Fee for Service Plan allows that person to see any Medicare approved hospital and or doctor and the insurance company determines what services it covers and what the associated costs are. This plan could cost more but tends to offer extra benefits that Original Medicare doesn’t cover.

Q.When does a person qualify for a Medicare Special Needs Plan?
A. This is a Medicare Advantage plan that offers health care based on certain diseases or conditions an individual has such as End-Stage Renal Disease (ESRD) and congestive heart failure. This program is not offered in every part of the country.

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