Ashford Insurance

Medicare Insurance Made Easy

Wise County Dual-Eligible Medicare Plans

Dual Eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare (title XVIII) and medical assistance from a state plan under Medicaid (Title XIX). States cover some Medicare costs, depending on the state and the individual’s eligibility.

Medicaid Eligibility Categories

The Medicaid eligibility categories encompass all categories of Medicaid eligibility including:

Full Medicaid (only);
Qualified Medicare Beneficiary without other Medicaid (QMB Only);
QMB Plus;
Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB Only);
SLMB Plus;
Qualifying Individual (QI); and
Qualified Disabled and Working Individual (QDWI).

States may vary in determining their eligibility categories; therefore, there may be state-specific differences in the eligibility levels in comparison to those listed here. For specific information regarding Medicaid eligibility categories, refer to the Medicaid website.

Special Needs Plans (SNPs), created by Congress in 2003, are a type of Medicare Advantage (MA) plan that limits membership to people with specific diseases or characteristics. Dual Eligible Special Needs Plans (D SNPs), one type of SNP, enroll only individuals dual-eligible for Medicare and Medicaid.

You can get your Texas Medicare benefits through Original Medicare, or you can choose a Medicare Advantage Plan. With Original Medicare, the government pays for your Medicare benefits when you get them. Medicare Advantage Plans, Part C of Medicare are offered by private companies that have been approved by Medicare. Medicare pays these companies to administer your Medicare benefits.

Medicare Advantage Plans combine coverage for the hospital (Part A) and doctor (Part B) visits all in one plan and are required to offer all the benefits included in Original Medicare (except hospice care which continues to be covered by Part A). However, many Medicare Advantage (Part C) plans also include prescription drug coverage and routine eye and dental care coverage not offered by Original Medicare.

Many Medicare Advantage (Part C) plans include prescription drug, vision, hearing, and dental coverage not offered by Original Medicare (Parts A & B). Additionally, each Medicare Advantage plan is required by law to feature an annual maximum cap on out-of-pocket costs, meaning once that limit is reached you will pay nothing for additional covered medical services.

If you join a Texas Medicare Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. They are completely different than a Medicare Supplement Insurance (Medigap) policy.

There are several types of Texas Medicare Advantage Plans:

Health Maintenance Organization (HMO) plans: In most HMOs, you may only go to doctors, other health care providers, or hospitals that are in the plan’s network, except in an emergency or urgent situation. You probably also need to get a referral from your primary care doctor for diagnostic tests or to see other doctors or specialists.

Preferred Provider Organization (PPO) plans: With a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You generally pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) plans: PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they agree to accept the plan’s payment terms. The plan will determine how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Special Needs Plans (SNPs): SNPs provide specialized and focused health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.

HMO Point-of-Service (HMO-POS) plans: These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.

Medical Savings Account (MSA) plans: These plans combine a high-deductible health plan with a bank savings account. Medicare will deposit money into the account (usually less than the deductible). You can use the money to pay for your health care services throughout the year. MSA plans do not offer any Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan, Part C of Medicare.

To be eligible to enroll in a Texas Medicare Advantage plan you must have both Medicare Parts A and B and live in the plan’s service area. People with End-Stage Renal Disease (permanent kidney failure) generally cannot enroll in a Medicare Advantage Plan.

You must continue to pay your Part B premium and generally pay one monthly premium for the services included in a Medicare Advantage Plan. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before you join. Some may have a $0 premium.

Texas Medicare Advantage Plans have to cover all of the services that Original Medicare covers except for hospice care. Original Medicare will cover hospice care even if you are in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you will always be covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.

Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for both the plan’s medical and prescription drug coverage.

Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.