What Does Medicare Cover in Texas? A Guide for Consumers and Employers

Medicare can feel confusing, with several parts, deadlines, and private plan options to sort through. That is true whether you are choosing coverage for yourself or helping an employee understand how Medicare works with a group health plan.

Understanding what Medicare covers in Texas starts with separating federal benefits from the options that vary locally. Although Texas Medicare coverage follows the same basic federal rules, private plan premiums, provider networks, and benefits may differ across the state.

Medicare Eligibility and Coverage Basics in Texas

Most people become eligible for Medicare at age 65. Some qualify earlier because of a disability, end-stage renal disease, or amyotrophic lateral sclerosis (ALS).

Medicare has four main parts:

• Part A provides hospital insurance.
• Part B provides medical insurance.
• Part C refers to Medicare Advantage plans offered by private Medicare-approved insurers.
• Part D helps cover outpatient prescription drugs.

Parts A and B together are known as Original Medicare.

What Original Medicare Covers

Medicare Part A Hospital Coverage

Covered services under Part A generally include inpatient hospital care, limited skilled nursing facility care after a qualifying hospital stay, hospice care, and certain home health services.

Keep in mind that “covered” does not always mean free. Beneficiaries may still owe a deductible, coinsurance, or other costs depending on the service and length of the stay.

Medicare Part B Medical Coverage

Part B generally covers doctor visits, outpatient hospital care, diagnostic tests, durable medical equipment, ambulance transportation (when Medicare's requirements are met), certain preventive services, and some home health care.

Most beneficiaries pay a monthly Part B premium. Deductibles and coinsurance may also apply.

What Medicare Does Not Usually Cover

Original Medicare covers many important services, but it does not cover every health care need.

Six common exclusions are:

1. Most routine dental care
2. Routine eye exams for glasses or contact lenses
3. Hearing aids and fitting exams
4. Most long-term custodial care
5. Routine physical exams
6. Cosmetic procedures that are not medically necessary

The reason for a service can matter. Medicare may cover certain dental care when it is directly related to another covered medical procedure, even though routine cleanings, fillings, and dentures are generally excluded.

Some Medicare Advantage plans offer dental, vision, or hearing benefits that Original Medicare does not provide.

Prescription Drug Coverage Through Medicare Part D

Original Medicare generally does not cover most outpatient prescription drugs. Texas residents who choose Original Medicare can add a separate Part D plan.

Each plan has its own formulary, or covered-drug list, along with its own pharmacy network and premiums. Before enrolling, consumers should confirm that their medications and preferred pharmacy are covered.

Many Medicare Advantage plans include Part D coverage, but not all do.

Original Medicare, Medicare Advantage, and Medigap in Texas

Choosing Medicare coverage involves more than comparing premiums. Provider access, prescriptions, travel, and expected costs also matter.

Original Medicare allows beneficiaries to receive covered care from any doctor or hospital in the United States that accepts Medicare. A separate Part D plan can be added for prescription coverage.

Medicare Advantage plans provide Part A and Part B benefits through private insurers. Many include Part D and added benefits, although networks, referrals, or prior authorization may apply.

Medicare Supplement insurance, commonly called Medigap, works with Original Medicare to help pay certain deductibles, copayments, and coinsurance. Policies are standardized by plan letter, although premiums and available carriers can vary. Medigap does not work with Medicare Advantage.

Medicare Costs and Financial Assistance in Texas

Medicare is not automatically free at age 65, although most people qualify for premium-free Part A because they or a spouse paid Medicare taxes long enough while working. Most beneficiaries still pay a monthly Part B premium, along with deductibles, copayments, coinsurance, and prescription costs.

Medicare also does not cover 100% of all health care expenses. Certain preventive services may have no cost-sharing when Medicare's requirements are met, but many other costs remain.

Eligible Texans may receive help through a Medicare Savings Program or Extra Help with Part D costs. Free counseling is also available through the Texas Health Information, Counseling and Advocacy Program.

Medicare and Employer Coverage for Texas HR Departments

Many employees remain at work and keep their employer coverage after becoming eligible for Medicare. This can complicate enrollment timing and coordination.

Whether an employee should enroll while still working may depend on employer size, work status, and which plan pays first. Active employer coverage, COBRA, and retiree coverage do not always provide the same Medicare enrollment protections.

Delaying Part B because of COBRA or retiree coverage may lead to gaps or late-enrollment penalties. Employers should also provide notices explaining whether prescription coverage is creditable.

Health savings account (HSA) contributions require attention as well. Medicare enrollment can affect an employee's ability to continue contributing.

HR professionals can explain the employer plan, but employees should seek guidance before delaying Medicare or ending group coverage.

Common Medicare Enrollment Mistakes

Many Medicare mistakes begin with an assumption. Common problems include:

• Believing enrollment is automatic
• Delaying Part B without confirming eligibility for a Special Enrollment Period
• Choosing a plan without checking doctors, hospitals, pharmacies, and prescriptions
• Believing a $0-premium Medicare Advantage plan has no other costs
• Waiting too long to compare Medicare Supplement insurance

Deductibles, copayments, coinsurance, and other expenses may still apply even when a Medicare Advantage plan has no monthly premium. Reviewing coverage before employment or group benefits end can also help prevent rushed decisions.

Frequently Asked Questions About Medicare in Texas

Is Medicare free at age 65 in Texas?

Many people qualify for premium-free Part A, but most beneficiaries pay a monthly Part B premium. Other costs may also apply.

Does Medicare cover all hospital expenses?

Part A covers eligible inpatient hospital services, but beneficiaries may owe a deductible and coinsurance. Costs depend partly on the benefit period and length of the stay.

Can I keep employer health insurance after turning 65?

Possibly. The answer depends on whether you are actively working, your employer's size, the plan's rules, and how the coverage coordinates with Medicare.

Does Medicare cover dental, vision, and hearing care?

Original Medicare generally does not cover routine dental care, routine eye exams for glasses, or hearing aids. Some Medicare Advantage plans may offer these benefits.

How Selected Benefits Helps Texans Understand Their Options

Medicare decisions are personal and depend on health needs, providers, prescriptions, budget, and expected costs.

Selected Benefits helps Texas residents compare Medicare Supplement insurance from multiple carriers. Through a consultative approach, it considers Medigap benefits, premiums, provider preferences, and individual needs.

Selected Benefits also helps Texas employers review group health plans and support employees approaching Medicare eligibility. Contact Selected Benefits to request a Medicare Supplement quote or speak with a licensed Texas insurance professional.