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Advantage Plans

Medicare Advantage (Part C) Plans in Texas

Depending on where you live, you may be able to join a Medicare Advantage plan. Medicare Advantage is an alternative to original Medicare. If you join a Medicare Advantage plan, the plan will provide your Medicare parts A and B benefits. You will still be part of the Medicare program. Private companies that contract with the Centers for Medicare and Medicaid Services (CMS) sell these plans. According to the TDI and HICAP:

You’ll usually pay less out-of-pocket in a Medicare Advantage plan than you would with original Medicare. In exchange for lower costs, however, some types of Medicare Advantage plans require you to go to doctors in your plan’s network. Medicare Advantage plans aren’t right for everyone. Consider your options carefully before joining a Medicare Advantage plan.

Each year, Medicare Advantage plans decide whether or not to stay in Medicare. Plans can also change the services or prescriptions they cover or increase their charges. Your plan will tell you if it decides to leave Medicare.
The TDI and HICAP give special emphasis to one form of Medicare Advantage coverage that other states tend to offer—but not focus on as much. According to the TDI:

Private fee-for-service (PFFS) plans are a different Medicare Advantage option available in Texas. Private insurance companies under contract with Medicare offer these plans. PFFS plans differ from managed care plans, such as Medicare HMOs or PPOs, in several important ways:

  • PFFS members may go to any doctor, hospital, or other provider that agrees to accept the private fee-for-service plan's terms of payment and is eligible to be paid by Medicare.
  • Members don’t have a primary care physician to oversee their care, so they don't need a referral to go to a specialist.
  • Although members must live in the plan's service area to be eligible, they can receive treatment anywhere in the United States, as long as the provider is willing to accept the plan's terms of payment. Similar to Medicare HMOs and PPOs, the PFFS plan may require prior approval before obtaining some specific services.

As with Medicare HMOs, PFFS members are eligible to join a Medicare Advantage plan if they have both Medicare Part A and Part B and do not have end-stage renal disease. The PFFS plan’s contract with Medicare is for one year. Each year, the PFFS plan decides whether to stay in or leave Medicare. If the plan leaves Medicare, members must either return to original Medicare or join another Medicare Advantage plan.
Several companies are approved by the Centers for Medicare & Medicaid Services to offer a private fee-for-service plan in Texas.