Medicare is a federal program, but the decisions Texans make around it are shaped by Texas insurance rules, Texas Medicaid, and the timing of retirement, employer coverage, and long-term care. A missed enrollment window can mean a permanent late penalty or months without coverage, and choosing between Original Medicare with a Medigap policy and a Medicare Advantage plan can be difficult to reverse in Texas later on. A Texas Medicare attorney helps you understand how the enrollment rules work, where the traps are, how Texas Medigap protections differ from those in other states, and how to appeal when coverage is denied.
Holmes Law is the practice of Michael Holmes, an attorney licensed in Texas who works with clients remotely across the state. Holmes Law does not sell insurance or recommend particular plans. Instead, Michael Holmes helps clients fit Medicare decisions into their larger Texas elder law and estate plan, including long-term care, Medicaid eligibility, and incapacity planning. This page is general information and intentionally avoids premium and deductible figures, which change every year; check Medicare.gov or the Texas SHIP program for current amounts.
The Parts of Medicare in Brief
- Part A (hospital insurance) covers inpatient hospital care, limited skilled nursing facility care after a qualifying hospital stay, hospice, and some home health care. Most people receive it without a premium based on their own or a spouse’s work history.
- Part B (medical insurance) covers physician services, outpatient care, durable medical equipment, and many preventive services. It carries a monthly premium, which can be higher for people with higher incomes.
- Part C (Medicare Advantage) lets you receive Part A and Part B benefits through a private plan approved by Medicare, usually with a network and prior authorization rules, and often with Part D drug coverage included.
- Part D (prescription drug coverage) is offered through private plans. Beginning in 2025, Part D includes an annual cap on out-of-pocket drug costs, and enrollees can choose to spread their costs over the year through the Medicare Prescription Payment Plan.
Texas is a large and varied market. The Medicare Advantage options available in Harris or Dallas County can look very different from those in a rural West Texas county, and provider networks matter more than the marketing suggests.
Enrollment Windows Every Texan Should Know
Initial Enrollment Period
Your Initial Enrollment Period is seven months long: the three months before the month you turn 65, the month you turn 65, and the three months after. If you are already receiving Social Security retirement benefits, you are enrolled in Parts A and B automatically. If you are not, you must sign up through the Social Security Administration. Enrolling before your birthday month generally avoids a gap in coverage.
General Enrollment Period
If you miss your Initial Enrollment Period and do not qualify for a Special Enrollment Period, you can enroll during the General Enrollment Period from January 1 through March 31 each year. Coverage now begins the month after you enroll. You may owe a late enrollment penalty added to your Part B premium for as long as you have Part B.
Annual and Medicare Advantage Open Enrollment
From October 15 through December 7 each year, you can switch between Original Medicare and Medicare Advantage and change Part D plans. From January 1 through March 31, people already in Medicare Advantage can switch to another Advantage plan or return to Original Medicare. Returning to Original Medicare does not guarantee you can buy a Medigap policy in Texas, as discussed below.
Part B Special Enrollment Traps
The Part B Special Enrollment Period is where many well-informed people go wrong. If you or your spouse are still working and covered by an employer group health plan based on current employment, you may delay Part B without penalty and enroll later during an eight-month Special Enrollment Period that begins the month after employment or the coverage ends, whichever comes first. The traps include:
- COBRA is not current-employment coverage. If you leave a job and elect COBRA, the eight-month clock starts when employment ends, not when COBRA ends. Waiting until COBRA runs out can mean a late penalty and a coverage gap.
- Retiree coverage does not count. Coverage from a former employer, including many Texas public and private retiree plans, generally does not qualify you for the Special Enrollment Period, and retiree plans often assume Medicare is primary at 65.
- Small employers. If your employer has fewer than 20 employees, Medicare is generally the primary payer, and the employer plan may pay very little if you do not have Part B.
- Health savings accounts. You cannot contribute to an HSA once you are enrolled in any part of Medicare. Premium-free Part A enrollment can be retroactive up to six months when you apply after 65, so stop HSA contributions well before you apply.
- Veterans’ coverage. VA health care is not employer coverage for Medicare purposes. Veterans who skip Part B may face a penalty if they later want it.
Federal rules also recognize “exceptional condition” Special Enrollment Periods for situations such as a natural disaster, an employer or health plan error, loss of Medicaid coverage, or incarceration. Documentation is essential.
Medigap in Texas: What State Law Adds
Medicare Supplement insurance, or Medigap, fills gaps in Original Medicare such as deductibles and coinsurance. Policies are standardized by letter plans nationwide but regulated in Texas by the Texas Department of Insurance. Texas-specific points include:
- Six-month open enrollment at 65. Your Medigap open enrollment period begins when you are 65 or older and enrolled in Part B and lasts six months. During that window, an insurer cannot refuse to sell you a policy or charge more because of your health.
- Under-65 access is limited. Texans under 65 who have Medicare because of a disability have a six-month open enrollment period after enrolling in Part B, but under the Texas Department of Insurance rules that right applies only to Medigap Plan A. They receive another open enrollment period during the first six months after turning 65.
- No annual “birthday rule.” Several states, including California and Idaho, give Medigap policyholders an annual window to switch plans without medical underwriting. Texas has not adopted such a rule, so once your open enrollment period passes, changing Medigap plans in Texas usually requires medical underwriting.
- Guaranteed issue rights. Federal guaranteed issue rights apply in Texas, for example when a Medicare Advantage plan leaves your area, when you lose certain employer coverage, or during a Medicare Advantage “trial right” period. You generally must apply within 63 days after the prior coverage ends.
- Free look. Texas Medigap buyers have 30 days to return a policy for a refund.
- Pricing methods. Texas policies may be issue-age, attained-age, or community-rated. Attained-age policies increase as you age, which affects long-term cost.
The practical upshot is that the choice you make at 65 in Texas carries more weight than in states with a birthday rule. Someone who chooses Medicare Advantage and later develops a serious condition may not be able to get a Medigap policy without underwriting.
Texas SHIP: Free Counseling Through HICAP
Texas’s State Health Insurance Assistance Program (SHIP) is the Health Information, Counseling, and Advocacy Program of Texas, known as HICAP. It is administered by the Texas Health and Human Services Commission and delivered through local Area Agencies on Aging, with support from the Texas Department of Insurance. HICAP counselors provide free, unbiased help comparing plans, understanding bills, and applying for assistance. HICAP is a good first stop for plan comparison, and Holmes Law often works alongside it on the legal and planning side.
Help With Costs: Medicare Savings Programs and Extra Help
Texans with limited income and resources may qualify for Medicare Savings Programs administered by HHSC, which can pay Part B premiums and, for some, Medicare cost sharing. The Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individual programs each have their own limits. The federal Extra Help program reduces Part D costs. People eligible for both Medicare and Texas Medicaid, often called dual eligibles, typically receive Medicaid long-term services through STAR+PLUS and may have access to Medicare Advantage special needs plans designed to coordinate with Texas Medicaid. For more about Texas Medicaid rules, see Texas Medicaid planning.
IRMAA: Income-Related Surcharges
Higher-income beneficiaries pay an Income-Related Monthly Adjustment Amount on Part B and Part D premiums. Social Security generally uses your modified adjusted gross income from the tax return filed two years earlier. That look-back can produce a surprise after a one-time event such as selling a business, a Roth conversion, or selling appreciated real estate. If your income has dropped because of a life-changing event, such as retirement, work reduction, marriage, divorce, or the death of a spouse, you can ask Social Security to use more recent income by filing form SSA-44. Coordinating large income events with your Texas estate and business plans can reduce IRMAA exposure. For business owners, see Texas business law.
Medicare Appeals
You have the right to appeal Medicare decisions, and appeals are often successful when they are well documented.
Original Medicare
Original Medicare appeals move through five levels: redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, a hearing before an Administrative Law Judge in the Office of Medicare Hearings and Appeals, review by the Medicare Appeals Council, and judicial review in federal district court. Each level has its own filing deadline and amount-in-controversy requirements.
Medicare Advantage and Part D
Medicare Advantage and Part D appeals begin with the plan itself, through an organization determination or coverage determination and then a reconsideration or redetermination. Expedited review is available when waiting could seriously jeopardize your health. Denials are then reviewed by an independent entity.
Fast-Track Discharge and Termination Appeals
If a hospital plans to discharge you, or a skilled nursing facility, home health agency, or hospice plans to end covered services, you can request a fast-track review by the Beneficiary and Family Centered Care Quality Improvement Organization for Texas. The notices you receive explain how and by when to ask. These appeals matter for long-term care planning because an early end to Medicare skilled coverage shifts costs to the family or to Medicaid. See Texas long-term care.
Medicare and Your Estate Plan
Medicare decisions intersect with other planning. An agent under a Texas durable power of attorney may need authority to deal with Medicare, Medigap insurers, and Social Security, and a medical power of attorney and HIPAA authorization let family members talk to plans and providers. Veterans should coordinate Medicare with VA health care; see Texas veterans benefits. And because Medicare does not pay for long-term custodial care, a complete plan also addresses how that care will be funded.
Timing also matters for couples. When one spouse turns 65 while the other is still working, or when a working spouse retires and the family loses employer coverage, each spouse’s enrollment windows run separately. A younger spouse who is not yet eligible for Medicare may need individual coverage through the marketplace or COBRA. Mapping out both spouses’ dates in advance avoids gaps and penalties, and it lets the family coordinate Medicare choices with retirement account withdrawals, the sale of a business, or other events that can affect IRMAA.
How a Texas Medicare Attorney Helps
Holmes Law does not sell insurance. Michael Holmes helps clients with the legal side of Medicare, including enrollment timing around employer coverage and retirement, avoiding Part B penalties, requesting equitable relief when an enrollment error was caused by misinformation, IRMAA reconsiderations, appeals strategy, and coordination with Medicaid and estate planning. Holmes Law serves clients throughout Texas remotely by phone and video.
Frequently Asked Questions
Can I switch Medigap plans every year in Texas?
Not without medical underwriting in most cases. Texas does not have an annual birthday rule. Outside your open enrollment period or a guaranteed issue situation, an insurer can review your health before selling you a new policy.
I’m under 65 and on Medicare due to disability. Can I buy Medigap in Texas?
Yes, but with limits. Texas gives you a six-month open enrollment period after you enroll in Part B, and that right applies to Medigap Plan A. You get a full open enrollment period again when you turn 65.
Does COBRA let me delay Part B?
No. COBRA is not coverage based on current employment. Your Special Enrollment Period runs from when employment ends, so waiting for COBRA to end can create a penalty and a gap.
Where can I get free Medicare counseling in Texas?
Through HICAP, the Texas State Health Insurance Assistance Program, available through Area Agencies on Aging across the state.
Can I reduce IRMAA if my income dropped?
If the drop resulted from a qualifying life-changing event, you can ask Social Security to use more recent income by filing form SSA-44 with supporting documents.
Should I choose Medicare Advantage or Original Medicare with Medigap in Texas?
It depends on your health, budget, preferred doctors and hospitals, and travel plans. Because Texas has no birthday rule, the decision at 65 is harder to undo later, so it deserves careful thought. HICAP can compare specific plans, and a Texas Medicare attorney can help you weigh the choice against your long-term care and estate planning goals.
Speak With a Texas Medicare Attorney
Medicare choices in Texas can be hard to undo, and they interact with long-term care, Medicaid, and estate planning. Holmes Law can help you make those decisions with the full picture in view. Contact Holmes Law to schedule a remote consultation with Michael Holmes.