Comparing Medicare plans in Texas
Medicare Part B is the medical insurance component of Original Medicare. If Part A is for the hospital bed you lie in, Part B is for the doctors who treat you, the tests they run, and the outpatient facilities where you receive care. For the vast majority of Texans turning 65, enrolling in Part B is the foundational step in securing their healthcare retirement strategy. Without it, you are entirely uninsured for everyday doctor visits, preventive care, and specialist consultations.
Understanding Part B is not just about knowing what it covers; it is about mastering how it costs, when you are legally required to enroll to avoid permanent financial penalties, and how it connects to the broader Texas healthcare market. Whether you plan to keep Original Medicare, purchase a Medigap policy, or choose from one of the 398 Medicare Advantage plans available across Texas, Part B is the mandatory starting line.
Medicare, the federal health insurance program primarily for adults aged 65 and older, is divided into distinct “Parts.” Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance).
While Part A is often premium-free for individuals who have worked and paid Medicare taxes for at least 10 years (40 quarters), Part B operates more like traditional health insurance. It requires a monthly premium, carries an annual deductible, and uses a coinsurance model to share the cost of your care.
Part B is designed to cover two broad categories of medical services:
It is helpful to think of Part B as the engine of your everyday healthcare. While Part A waits in the background for a major inpatient hospital admission, Part B is active every time you visit your primary care physician in Houston, see a cardiologist in Dallas, get an X-ray, or ride in an ambulance.
The scope of Part B coverage is extensive. Because it governs outpatient and physician care, it encompasses almost everything that happens outside of a formal, admitted inpatient hospital stay.
Whenever you see a physician, physician assistant, nurse practitioner, or clinical social worker, Part B covers the visit. This applies regardless of the setting. If you visit your doctor’s private clinic, Part B covers it. If you are admitted to a hospital as an inpatient under Part A, Part B still steps in to cover the distinct fees charged by the doctors and surgeons who treat you inside the hospital.
Surgeries and procedures that do not require an overnight inpatient admission fall under Part B. If you undergo a cataract surgery at an ambulatory surgical center in Austin, or have a colonoscopy at an outpatient clinic, Part B handles the facility fees and the physician charges.
To diagnose medical conditions, doctors rely on tests. Part B covers:
Medicare emphasizes preventive care to catch diseases early. When you use a provider who accepts Medicare assignment, most preventive services are covered at 100%, meaning you pay nothing out of pocket. Covered preventive services include:
A Critical Distinction: There is a sharp line between a preventive screening and a diagnostic test. If you get a screening colonoscopy (preventive) and the doctor finds and removes a polyp during the procedure, the classification changes to diagnostic. At that moment, your Part B deductible and 20% coinsurance rules suddenly apply.
If your doctor prescribes medical equipment for use in your home, Part B covers it. The equipment must be durable (can withstand repeated use), used for a medical reason, and typically only useful to someone who is sick or injured. Common examples include:
To have DME covered in Texas, both your prescribing doctor and the medical equipment supplier must be enrolled in Medicare.
Part B covers ground ambulance transportation to a hospital, critical access hospital, or skilled nursing facility when traveling in any other vehicle could endanger your health. In severe, life-threatening emergencies where ground transportation is too slow, Part B may also cover helicopter or airplane emergency transportation. Medicare will only cover the ambulance ride to the nearest appropriate medical facility capable of providing the required care.
Mental health is treated with the same priority as physical health under Part B. Outpatient mental health care coverage includes visits with a psychiatrist, clinical psychologist, clinical social worker, or other qualified medical professional. It covers individual and group psychotherapy, family counseling related to your treatment, and psychiatric evaluation.
Part B is not a comprehensive pharmacy benefit. It does not cover the pills you pick up at H-E-B or CVS. However, it does cover a very narrow subset of drugs, typically those you cannot self-administer. This includes:
Understanding what Part B excludes is critical for financial planning, as relying solely on Original Medicare will leave you fully responsible for these costs. Part B does not cover:
Original Medicare is not free. Part B comes with an interconnected system of premiums and cost-sharing mechanisms that dictate what you pay out of pocket.
Every enrollee must pay a monthly premium for Part B. The federal government sets a standard base premium annually. If you receive Social Security benefits, this premium is deducted directly from your monthly check before it hits your bank account. If you are not yet drawing Social Security, Medicare will bill you quarterly.
While most Texans pay the standard base premium, higher-income earners pay more through the Income-Related Monthly Adjustment Amount (IRMAA). Medicare looks at your Modified Adjusted Gross Income (MAGI) from your IRS tax return from two years prior.
For example, your 2026 Part B premium is determined by the tax return you filed for the 2024 tax year. If your income exceeds certain brackets established by the government, an additional surcharge is added to your standard premium. This surcharge scales up across several income tiers. If your income has dropped significantly due to a life-changing event (such as retirement or divorce), you can file an appeal with the Social Security Administration to have your IRMAA recalculated based on your current, lower income.
Before Part B begins to pay its share for your medical services, you must meet an annual deductible. This is a flat dollar amount that you must pay out of pocket each calendar year. Once you have spent this amount on Medicare-approved medical care, your coverage kicks in. The deductible amount resets every year on January 1.
After your annual deductible is met, Part B operates on an 80/20 cost-sharing model. Medicare pays 80% of the Medicare-approved amount for the service, and you pay the remaining 20% coinsurance.
Crucially, Original Medicare has no annual out-of-pocket maximum.
If you require $100,000 worth of outpatient chemotherapy and radiation, Medicare will pay $80,000, and you will be billed for $20,000. This lack of a safety net is the primary reason the vast majority of Texans do not rely solely on Original Medicare; they purchase supplemental coverage (Medigap) or transition to a Medicare Advantage plan to cap their financial risk.
| Cost Mechanism | Original Medicare (Part B) | Impact on You |
|---|---|---|
| Monthly Premium | Standard base rate (set annually) | Required to maintain coverage; higher for high-income earners (IRMAA). |
| Annual Deductible | Set annually by CMS | Must be paid out of pocket before 80/20 cost-sharing begins. |
| Coinsurance | 20% of the Medicare-approved amount | You pay 20% for almost all diagnostic and treatment services. |
| Out-of-Pocket Maximum | None | Unlimited financial exposure in the event of catastrophic illness. |
Timing your enrollment in Part B is one of the most critical regulatory hurdles in the Medicare system. The rules are rigid, and the penalties for making a mistake are permanent. Enrollment windows are strictly defined.
Determine which Medicare enrollment period applies to your current situation.
Your Initial Enrollment Period is a 7-month window tied to your 65th birthday. It includes:
Automatic vs. Manual Enrollment:
To ensure your coverage begins on the first day of your birthday month, you must enroll during the three months before your birthday.
Many Texans continue to work past age 65. If you are actively employed and covered by a group health plan from an employer with 20 or more employees, you can safely delay enrolling in Part B without penalty. Your employer plan remains your primary insurance.
When you (or your spouse, if you are on their plan) stop working, or when that group health coverage ends (whichever happens first), a Special Enrollment Period (SEP) opens. You have an 8-month window to enroll in Part B without a late enrollment penalty.
Important caveat: Retiree health plans, VA benefits, and COBRA do not count as active employer coverage. If you leave your job and transition to COBRA, your 8-month SEP clock starts ticking immediately upon your termination date, not when your COBRA coverage ends. Waiting for COBRA to expire before applying for Part B is a frequent and costly mistake.
If you missed your IEP and you do not have a valid reason for an SEP, you are locked out of Part B until the General Enrollment Period. The GEP runs from January 1 through March 31 every year.
If you enroll during the GEP, your Part B coverage will begin on the first day of the month following the month you enroll. For example, if you apply on February 15, your coverage starts March 1. Unfortunately, using the GEP almost always means you will face a late enrollment penalty.
Medicare enforces its enrollment deadlines through a financial penalty designed to prevent healthy people from waiting until they get sick to buy insurance.
If you fail to enroll in Part B when you are first eligible and do not have creditable employer coverage, you will be assessed a late enrollment penalty. The penalty is a 10% increase to your standard Part B premium for every full 12-month period you were eligible but did not enroll.
For example, if you delayed Part B for two and a half years (30 months) without creditable coverage, you have two full 12-month periods of delay. Your penalty will be 20% added to your premium.
This is not a one-time fee. The penalty is permanently attached to your monthly premium for the rest of your life. As the base premium increases over the years, the dollar amount of your penalty increases alongside it.
Understanding how Part B interacts with Medicare Advantage (Part C) is crucial, as nearly half of all Medicare beneficiaries now choose this route.
Medicare Advantage plans are offered by private insurance carriers approved by the federal government. To enroll in a Medicare Advantage plan in Texas, you must be enrolled in and continue paying for both Part A and Part B. You cannot drop Part B to join an Advantage plan.
In the Texas market, there are 398 Medicare Advantage plans available, offered by carriers such as:
When you enroll in an Advantage plan, the private carrier takes over the administration of your health benefits. The plan must, by law, provide all the coverage that Original Medicare Part A and Part B provide. However, it changes how you pay for that care.
Instead of the dangerous 20% uncapped coinsurance of Original Part B, Medicare Advantage plans institute predictable copayments (e.g., $15 for a primary care doctor, $40 for a specialist) and introduce a strict Annual Out-of-Pocket Maximum. Furthermore, Advantage plans typically bundle in Part D prescription drug coverage and extra benefits that Part B explicitly excludes, such as routine dental, vision, and hearing care.
A licensed producer can help you compare local Medicare Advantage plans to find the right coverage for your doctors and prescriptions.
Get a Free ConsultationIf you prefer the flexibility of Original Medicare—which allows you to see any doctor in the United States who accepts Medicare, without needing referrals or worrying about local HMO/PPO network boundaries—you will need a Medicare Supplement, or Medigap, plan.
Medigap policies are sold by private companies and are designed strictly to fill the financial “gaps” left behind by Part A and Part B. A comprehensive Medigap plan (like Plan G, the most popular choice for new enrollees) steps in to pay the 20% coinsurance that Part B leaves behind.
Once you meet your annual Part B deductible, Medigap Plan G covers 100% of your remaining Part B coinsurance for the year. This effectively caps your medical expenses, giving you absolute financial predictability while retaining the nationwide network of Original Medicare.
Unlike Advantage plans, Medigap policies do not include prescription drug coverage, so you will need to purchase a standalone Part D drug plan alongside it.
Not all doctors interact with Medicare Part B in the same way. Before seeing a new physician in Texas, it is important to understand their contract status with the federal government, as it dictates what you will be charged.
The vast majority of doctors and hospitals in Texas are “participating providers.” This means they accept “Medicare Assignment.” By accepting assignment, the provider agrees to accept the Medicare-approved amount as payment in full for the service. You are only responsible for your standard 20% coinsurance after the deductible. The provider submits the claim directly to Medicare for you, and they cannot balance-bill you for more than the approved rate.
Some doctors choose not to sign a permanent agreement to accept assignment, though they still participate in the Medicare program. These are “non-participating providers.”
A small percentage of doctors (often high-end specialists or boutique concierge practices) have completely opted out of the Medicare program. If a doctor has opted out, Medicare Part B will pay absolutely nothing for their services. The limiting charge rules do not apply, and the doctor can charge you whatever they wish. You must sign a private contract agreeing to pay the full cost out of pocket before you receive care.
Entering the Medicare system requires careful timing and an honest assessment of your health and financial capacity. Your roadmap for handling Part B should follow these steps: