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ABN (Advance Beneficiary Notice of Noncoverage)
A form a doctor, lab or supplier with Original Medicare gives you before a service when they think Medicare may not pay for it. If you sign it and get the service, you may have to pay if Medicare denies the claim. You can still ask them to bill Medicare so you keep your right to appeal.
AEP (Annual Enrollment Period)
October 15 to December 7 each year. You can join, switch or drop a Medicare Advantage plan or a Part D drug plan, and changes start January 1. Medicare also calls it the Open Enrollment Period. The AEP for 2027 coverage runs October 15 to December 7, 2026. See Medicare open enrollment in Texas.
Appeal
A request to review a decision not to cover or pay for a service, item or drug. Medicare appeals have five levels, and the first step and deadline are printed on your notice. See Medicare appeals in Texas.
Assignment
A provider's agreement to accept the Medicare-approved amount as full payment for covered services. If your doctor accepts assignment, you pay only your deductible and coinsurance, and the doctor bills Medicare for you.
Benefit period
How Original Medicare measures your use of hospital and skilled nursing care. It starts the day you're admitted as an inpatient and ends when you've had no inpatient or skilled nursing care for 60 days in a row. You pay the Part A deductible ($1,736 in 2026) for each benefit period, so you can owe it more than once a year.
BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization)
The organization Medicare contracts with to handle fast appeals when you think a hospital is discharging you too soon or your skilled nursing, home health or hospice services are ending too soon, and to review complaints about the quality of care. The notice you get, such as "An Important Message from Medicare About Your Rights," names the one that serves Texas and gives its phone number.
CMS (Centers for Medicare & Medicaid Services)
The federal agency that runs Medicare, approves Medicare Advantage and Part D plans, and oversees state Medicaid programs such as Texas Medicaid. Social Security handles Medicare sign-up.
Coinsurance
Your share of a covered cost, as a percentage. After the Part B deductible, you usually pay 20% of the Medicare-approved amount for doctor visits and outpatient care under Original Medicare.
Colonias
Unincorporated residential communities, mostly along the Texas–Mexico border, that may lack basic services such as safe drinking water, sewer service, paved roads or electricity. The Texas Secretary of State's Colonia Initiatives Program works to improve conditions there and has staff in the border counties with the largest colonia populations, including Hidalgo, El Paso, Starr, Webb, Cameron and Maverick. For residents with Medicare, distance to doctors, pharmacies and plan networks often matters as much as the plan itself. See border communities and colonias.
Copayment (copay)
A set dollar amount you pay for a service or prescription, such as a doctor visit or a 30-day supply of a drug. Medicare Advantage and Part D plans set their own copays.
Coverage determination
A Part D plan's decision about whether it will cover a drug and how much you pay. You can ask for one, including an exception to the plan's formulary or rules, and appeal if the answer is no.
Creditable coverage
Drug coverage expected to pay on average at least as much as standard Part D. Keeping creditable coverage, for example from a job, the VA or TRICARE, protects you from the Part D late enrollment penalty. Your plan tells you each year in a creditable coverage notice. Medicines bought across the border in Mexico aren't creditable coverage.
D-SNP (Dual Eligible Special Needs Plan)
A Medicare Advantage plan only for people who have both Medicare and Medicaid. D-SNPs coordinate the two programs and must have a contract with the state Medicaid agency, which in Texas is HHSC. For 2027 there are 173 special needs plans of all types in Texas (CMS plan data). See dual eligible special needs plans in Texas.
Deductible
What you pay before Medicare or your plan starts to pay. In 2026 the Part B deductible is $283 a year, the Part A deductible is $1,736 per benefit period, and Part D plans can have a deductible of up to $615.
Dual eligible
A person who has both Medicare and Medicaid. Full dual eligibles get full Texas Medicaid benefits, often through STAR+PLUS; partial dual eligibles get help only through a Medicare Savings Program. Medicare pays first, then Texas Medicaid. See Texas Medicaid and Medicare.
EOB (Explanation of Benefits)
A statement from a Medicare Advantage or Part D plan showing the services or drugs it paid for, what it paid and what you may owe. It is not a bill. Part D EOBs also show your progress toward the yearly out-of-pocket cap.
ERS (Employees Retirement System of Texas)
The state agency that runs retirement and group health benefits for Texas state employees and retirees. Retirees with Medicare get coverage that works with Medicare, and ERS requires Part A and Part B for its Medicare Advantage coverage for retirees. See TRS-Care, ERS retirees and Medicare.
Evidence of Coverage (EOC)
The full legal description of what a Medicare Advantage or Part D plan covers, what you pay, and your rights and appeal steps. Plans send it each fall for the next year. It has more detail than the Summary of Benefits.
Excess charge
The extra amount a doctor who doesn't accept assignment can bill you, above the Medicare-approved amount, under Original Medicare. Federal law caps it at 15% over the amount Medicare allows for that doctor. Medigap Plans F and G cover excess charges.
Extra Help
A federal program, also called the Part D Low-Income Subsidy, that helps pay Part D premiums, deductibles and copays. In 2026 the yearly income limit is $23,940 for one person, and the resource limit is $16,590. People with full Texas Medicaid, a Medicare Savings Program or Supplemental Security Income qualify automatically; others apply through Social Security. Try the savings programs screener.
Formulary
A plan's list of covered drugs, usually sorted into tiers. Formularies differ from plan to plan and can change each year, so check that your drugs are on it before you join.
GEP (General Enrollment Period)
January 1 to March 31 each year, for people who missed their Initial Enrollment Period and don't qualify for a Special Enrollment Period. Coverage starts the month after you sign up, and a late enrollment penalty may apply.
Guaranteed issue rights
Situations in which a Medigap company must sell you a policy and can't charge more for health conditions, for example when your Medicare Advantage plan leaves your area or stops offering coverage. If your plan is ending in 2027, the right lasts until 63 days after your plan coverage ends. See Medigap in Texas and plans ending in 2027.
HealthSelect
The name ERS uses for the health plans in the Texas Employees Group Benefits Program. Retired state employees with Medicare are offered a Medicare Advantage plan under the HealthSelect name; to join it, you need Part A and Part B and must live in the U.S. or Puerto Rico. ERS also has other HealthSelect options for retirees who live out of state or don't join.
HHSC (Texas Health and Human Services Commission)
The state agency that runs Texas Medicaid, including STAR+PLUS, the Medicare Savings Programs and Medicaid for the Elderly and People with Disabilities (MEPD), along with many aging and disability services. You apply for its programs through Your Texas Benefits.
HMO (Health Maintenance Organization)
A type of Medicare Advantage plan that generally requires you to use doctors and hospitals in its network, except for emergencies and urgently needed care. Some HMOs require referrals for specialty care.
IEP (Initial Enrollment Period)
Your first chance to sign up for Medicare: seven months that start three months before the month you turn 65 and end three months after it. Signing up before your birthday month means coverage starts the month you turn 65. See turning 65 in Texas.
Inpatient
Formally admitted to a hospital on a doctor's order. Inpatient care is covered by Part A. Staying overnight doesn't by itself make you an inpatient; see observation status.
IRMAA (Income-Related Monthly Adjustment Amount)
An extra amount added to Part B and Part D premiums for people with higher income. For 2026 it applies when modified adjusted gross income from your 2024 federal tax return was above $109,000 (single) or $218,000 (married filing jointly). Texas has no state income tax, so only the federal return matters. The brackets are cliffs: one dollar over a line moves you to the next amount. Try the IRMAA calculator.
Late enrollment penalty
An amount added to your premium if you sign up late. For Part B it is 10% for each full 12 months you could have had Part B but didn't, usually for as long as you have Part B. For Part D it applies after 63 days or more in a row without Part D or creditable coverage. See the penalty calculator.
Lifetime reserve days
Sixty extra hospital days Original Medicare covers over your lifetime after day 90 of a hospital stay. In 2026 you pay $868 for each one you use. Once used, they don't come back.
MA OEP (Medicare Advantage Open Enrollment Period)
January 1 to March 31 each year. If you're in a Medicare Advantage plan, you can switch to another one or go back to Original Medicare (and join a Part D plan) once during this time. People new to Medicare Advantage also get it during their first three months of Medicare.
Medicare Advantage (Part C)
Plans from private companies approved by Medicare that provide your Part A and Part B coverage, usually with drug coverage, through a network. Plans are approved county by county; for 2027, 21 companies offer 214 Medicare Advantage plans open to everyone with Medicare in Texas (CMS plan data). See Medicare Advantage in Texas.
Medicare-approved amount
The amount Medicare sets as payment for a covered service. Your coinsurance is figured from it. A provider who accepts assignment takes it as full payment.
Medicare Prescription Payment Plan
An option in every Medicare drug plan that lets you pay your Part D out-of-pocket costs in monthly bills from your plan instead of all at once at the pharmacy. It doesn't lower what you owe; it spreads it over the year. See the drug cap estimator.
Medicare Summary Notice (MSN)
A statement Original Medicare mails every four months if you had services, listing what providers billed, what Medicare paid and the most you may owe. It's not a bill, and it explains how to appeal. You can also see claims in your Medicare.gov account.
Medigap (Medicare Supplement Insurance)
Private insurance that works with Original Medicare to pay some of what it leaves, such as deductibles and the 20% coinsurance. Plans are standardized by letter (A, B, C, D, F, G, K, L, M, N), so the same letter has the same benefits from every company; prices differ. TDI regulates Medigap in Texas. See Medigap in Texas.
Medigap open enrollment period
Six months that start the first month you're both 65 or older and enrolled in Part B. During it, a Medigap company must sell you any policy it offers in Texas, regardless of your health.
MEPD (Medicaid for the Elderly and People with Disabilities)
HHSC's name for the Texas Medicaid programs for people 65 and older and people with disabilities, and for the handbook that sets their rules. The Medicare Savings Programs (QMB, SLMB, QI-1) are MEPD programs, and the handbook sets their income and resource limits.
MOOP (maximum out-of-pocket limit)
The most you pay in a year for covered Part A and Part B services in a Medicare Advantage plan. CMS sets the highest limit plans may use ($9,250 for in-network services in 2026); each plan sets its own. Original Medicare has no such limit.
MSP (Medicare Savings Programs)
State programs that pay Medicare premiums, and for some people deductibles and coinsurance. In Texas, HHSC runs three through Texas Medicaid: QMB, SLMB and QI-1. Texas checks both income and resources; in 2026 the resource limit is $9,950 for one person and $14,910 for a couple. See Medicare Savings Programs in Texas.
Network
The doctors, hospitals, pharmacies and other providers a plan contracts with. Medicare Advantage networks are local, which matters if you split the year between Texas and another state, or live in a rural county with few providers nearby.
Observation status
Hospital care as an outpatient while doctors decide whether to admit you. It's billed under Part B, and days under observation don't count toward the three inpatient days needed for Original Medicare to cover skilled nursing care. If you're under observation more than 24 hours, the hospital must give you a Medicare Outpatient Observation Notice (MOON).
Original Medicare
Part A and Part B, run by the federal government. You can use any doctor or hospital in the U.S. that accepts Medicare, and you can add a Medigap policy and a Part D plan.
PACE (Program of All-Inclusive Care for the Elderly)
A Medicare and Medicaid program that provides medical care and long-term services through one local organization, for people 55 and older who need a nursing-home level of care but can live safely at home. PACE is offered only where a PACE organization operates, which in Texas is a limited number of areas; check Medicare.gov or HHSC for whether one serves your ZIP code.
Part A (hospital insurance)
Covers inpatient hospital stays, skilled nursing care after a qualifying stay, hospice and some home health care. Most people pay no premium for Part A because they or a spouse paid Medicare taxes for at least 10 years. See Part A.
Part B (medical insurance)
Covers doctor visits, outpatient care, lab tests, durable medical equipment and preventive services. The standard premium is $202.90 a month in 2026. See Part B.
Part D (prescription drug coverage)
Drug coverage from private plans, either a stand-alone Part D plan with Original Medicare or as part of a Medicare Advantage plan. In 2026 your out-of-pocket costs for covered drugs are capped at $2,100 for the year, and covered insulin costs no more than $35 for a month's supply. See Part D in Texas.
PFFS (Private Fee-for-Service plan)
A type of Medicare Advantage plan that sets how much it pays providers. Some PFFS plans have networks; with others you can see any Medicare provider who agrees to the plan's terms before each visit.
PPO (Preferred Provider Organization)
A type of Medicare Advantage plan with a network that also pays for covered care outside the network, usually at a higher cost to you.
Premium
The amount you pay each month for coverage, such as the Part B premium or a plan's premium. If you have a Medicare Advantage plan, you keep paying your Part B premium.
Preventive services
Care to prevent illness or find it early, such as flu shots, screenings and the yearly wellness visit. Many are covered by Part B with no cost to you when the provider accepts assignment.
Prior authorization
Approval you or your provider must get from a plan before it will cover a service or drug. Medicare Advantage and Part D plans use it; Original Medicare uses it only for a few services.
QI-1 (Qualifying Individual)
A Medicare Savings Program that pays your Part B premium, for incomes above 120% and up to 135% of the federal poverty level, within the Texas resource limit. You can't get QI-1 if you already receive Texas Medicaid.
QMB (Qualified Medicare Beneficiary)
A Medicare Savings Program that pays Part A premiums (if you owe one), Part B premiums, and Medicare deductibles, coinsurance and copays, for incomes up to 100% of the federal poverty level within the Texas resource limit. Providers may not bill people in QMB for Medicare-covered cost sharing.
Referral
An order from your primary care doctor for specialty care, such as a visit to a cardiologist. Some Medicare Advantage HMOs require one; Original Medicare doesn't.
SEP (Special Enrollment Period)
A chance to sign up for or change coverage outside the usual windows because of a life event, such as moving, losing job-based coverage, your plan leaving your area, a disaster declaration, or getting Texas Medicaid or Extra Help. If your plan is ending in 2027, your SEP runs through February 28, 2027; choose by December 31 to avoid a gap. See enrollment periods.
Service area
The counties where a Medicare Advantage or Part D plan is offered. You must live in the service area to join, and a plan can disenroll you if you're away more than six months.
Skilled nursing facility (SNF)
A facility with skilled nursing or rehab staff. Original Medicare covers up to 100 days per benefit period after a qualifying inpatient stay of at least three days; in 2026 you pay $217 a day for days 21 to 100. Medicare doesn't cover long-term custodial care; in Texas, Medicaid may for people who qualify.
SLMB (Specified Low-Income Medicare Beneficiary)
A Medicare Savings Program that pays your Part B premium, for incomes above 100% and up to 120% of the federal poverty level, within the Texas resource limit.
SNP (Special Needs Plan)
A Medicare Advantage plan limited to people with certain needs: both Medicare and Medicaid (D-SNP), certain chronic conditions (C-SNP), or living in an institution (I-SNP). For 2027 there are 173 special needs plans in Texas (CMS plan data).
STAR+PLUS
The Texas Medicaid managed care program for adults 65 and older and adults with disabilities who have Medicaid. Members get a service coordinator and Medicaid services that can include help at home with daily activities, home changes for safety and short breaks for caregivers. For members who also have Medicare, HHSC says STAR+PLUS doesn't change the way you get Medicare services.
STEAR (State of Texas Emergency Assistance Registry)
A voluntary registry run by the Texas Division of Emergency Management that gives local emergency planners and responders information about people who may need extra help in a disaster, such as people with disabilities, medical needs or limited mobility. You can register at stear.texas.gov or by calling 2-1-1, and you re-register each year. Registering doesn't guarantee a specific service. See hurricanes, floods and Medicare.
Step therapy
A plan rule that you try a lower-cost drug first before it covers a similar, higher-cost drug. You or your prescriber can ask for an exception.
Summary of Benefits
A short document showing a Medicare Advantage or Part D plan's main costs and covered services. Read it with the Evidence of Coverage before you choose.
TDI (Texas Department of Insurance)
The state agency that licenses insurance companies and agents in Texas and regulates Medigap policies sold here. You can check an agent's license or file a complaint about an insurance company or agent with TDI.
Texas Senior Medicare Patrol
The Texas part of the national Senior Medicare Patrol program, funded by the federal Administration for Community Living, that helps people with Medicare spot and report fraud, errors and abuse, such as charges for care you never got. See Medicare fraud in Texas.
Tier
A level on a plan's formulary. Drugs on lower tiers usually cost you less than drugs on higher tiers.
TPMO (third-party marketing organization)
CMS's term for agents, agencies and companies that sell Medicare plans for insurance companies. Benefits Life, the publisher of this site, is a TPMO, which is why plan pages and calculators show the CMS disclaimer about the plans we represent.
TRICARE For Life
Coverage for military retirees and eligible family members with Medicare that pays after Medicare. You must have Part A and Part B to keep it. See veterans, TRICARE and military retirees.
TRS-Care
The health plan of the Teacher Retirement System of Texas (TRS) for retired public school employees. Participants with Medicare are enrolled in TRS-Care's Medicare Advantage medical plan and its Medicare drug plan, and starting January 1, 2026, everyone eligible for Medicare must enroll in and pay for Part B to keep TRS-Care. See TRS-Care, ERS retirees and Medicare.
Urgently needed care
Care for a sudden illness or injury that isn't an emergency but can't wait. Medicare Advantage plans must cover it when you're temporarily outside the plan's service area, in the U.S.
VA health care
Care from the Department of Veterans Affairs at VA medical centers and clinics across Texas. VA and Medicare don't coordinate payment: VA pays for care at VA facilities, Medicare for care elsewhere. VA drug coverage is creditable for Part D.
Visitor/traveler program
An option some Medicare Advantage plans offer that lets you stay enrolled while you're out of the service area within the U.S. for more than six months, up to 12. See Winter Texans and Medicare.
Winter Texan
The name Texans use for seasonal residents, many of them retirees from colder states, who spend the winter months in Texas, especially in the Rio Grande Valley. For Medicare, the question is where your permanent home is: Medicare Advantage and Part D plans are tied to the service area where you live, and Original Medicare works in every state. See Winter Texans and Medicare.
Your Texas Benefits
HHSC's website, YourTexasBenefits.com, where Texans apply for, renew and manage benefits such as Texas Medicaid and the Medicare Savings Programs. HHSC's paper application, Form H1200, carries the same name, and Form H1200-EZ is the version for Medicare Savings Programs.
Sources
- Medicare.gov — Get started with Medicare
- Medicare.gov — Special Enrollment Periods
- Medicare.gov — When can I buy Medigap?
- Medicare.gov — Creditable drug coverage
- Medicare.gov — Medicare Prescription Payment Plan
- Medicare.gov — PACE
- Medicare.gov — Special Needs Plans
- 42 CFR 422.74 — Disenrollment by the MA organization (temporary absence, visitor/traveler)
- 42 CFR 422.107 — Special needs plans for dual-eligible individuals: contract with state Medicaid agency
- HHSC — STAR+PLUS
- HHSC MEPD Handbook — Appendix IX, Medicare Savings Program information
- HHSC — Form H1200, Application for Assistance – Your Texas Benefits
- Texas Department of Insurance
- TRS — 2026 FAQs for TRS-Care participants with Medicare (PDF)
- ERS — Medicare Advantage coverage for retirees (eligibility)
- Texas Division of Emergency Management — State of Texas Emergency Assistance Registry
- Texas Secretary of State — Border and Mexican affairs initiatives (Colonia Initiatives Program)
- Administration for Community Living — Senior Medicare Patrol
- CMS — Medicare Advantage and Part D plan data (2027 Landscape files)
Frequently asked questions
What is the difference between Texas Medicaid and Medicare?
Medicare is the federal health insurance program for people 65 and older and some younger people with disabilities. Texas Medicaid, run by the Texas Health and Human Services Commission (HHSC), is based on income, resources and other rules. Some Texans have both; Medicare then pays first, and Texas Medicaid can help with premiums, costs Medicare leaves and long-term services.
What is STAR+PLUS?
STAR+PLUS is the Texas Medicaid managed care program for adults 65 and older and adults with disabilities. Members get service coordination and Medicaid services such as help at home. If you also have Medicare, HHSC says STAR+PLUS doesn't change the way you get your Medicare services.
Who regulates Medigap and insurance agents in Texas?
The Texas Department of Insurance (TDI). It licenses insurance companies and agents, regulates Medigap policies sold in Texas, and takes complaints. You can look up an agent's license on TDI's website.
Where can I look up a Medicare term that isn't on this page?
Medicare.gov has a full glossary, and 1-800-MEDICARE can explain any term on a Medicare notice. A licensed insurance agent with Benefits Life can also help you read plan documents, at no cost to you: (512) 265-6565, TTY 711.
Medicare in your Texas county
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