For Texas retirees, Medicare Open Enrollment is an annual opportunity to review whether current coverage still fits the year ahead. The enrollment period for 2027 coverage runs from October 15 through December 7, 2026. Changes made during this window generally take effect on January 1, 2027, provided the plan receives the enrollment request by December 7, according to Medicare.gov.
“Open Enrollment happens from October 15 – December 7 and is the time each year when you can make changes to your coverage.” : Medicare.gov
The best choice is not always the plan with the lowest advertised premium. A plan that looks inexpensive at first glance may have a narrower provider network, higher prescription costs, or rules that make it difficult to access care.
Before renewing automatically, ask these seven questions.
1. What will this plan realistically cost me next year?
Start with the full picture rather than the monthly premium alone. Review:
- The plan’s monthly premium
- Any applicable Medicare Part B premium
- Medical and prescription deductibles
- Copayments and coinsurance
- Estimated yearly prescription costs
- Costs for specialist visits, hospital care, imaging, and urgent care
- Charges for out-of-network services
Medicare’s Plan Compare tool allows you to enter your prescriptions and preferred pharmacies to estimate monthly and yearly drug costs. This can be more useful than comparing premiums in isolation.
A retiree who takes only a few generic medications may prioritize a different cost structure than someone who regularly uses specialty prescriptions or sees multiple specialists. Similarly, someone who spends part of the year outside Texas may need to pay closer attention to travel and out-of-area care.
As you compare plans, consider both a typical year and a difficult year. What would you pay if you needed several specialist visits, an outpatient procedure, or an extended course of treatment?
2. Are my doctors, hospitals, and pharmacies covered?
Network coverage can be especially important in Texas, where retirees may live in a smaller Hill Country community but travel to Austin, San Antonio, or another regional center for specialized care.
Ask whether the plan includes:
- Your primary-care physician
- Your preferred specialists
- The hospital system you would use for serious care
- Nearby urgent-care facilities
- Your preferred pharmacy
- A convenient mail-order pharmacy, if applicable
- Providers in any location where you spend significant time
Do not rely only on an online directory. Provider information can change, and directories may not always reflect the latest participation status. Medicare recommends asking doctors and pharmacies directly whether they participate in a specific plan.
For Medicare Advantage plans, also determine whether the plan is an HMO, PPO, or another structure. Find out whether referrals are required for specialists and what happens if you seek care outside the network.
3. How are my prescriptions covered, and which drug tiers apply?
A plan’s drug list, or formulary, shows which medications it covers and how much you may pay for them. Plans commonly group medications into tiers, such as:
- Preferred generic drugs
- Other generic drugs
- Preferred brand-name drugs
- Non-preferred brand-name drugs
- Specialty medications
The exact tier structure varies by plan. Two plans may cover the same prescription but place it in different tiers, creating very different costs.
For every medication you take, check:
- Is the drug covered?
- Which tier is it assigned to?
- What will you pay at your preferred pharmacy?
- Is a lower-cost pharmacy available?
- Does the plan require prior authorization?
- Are there quantity limits?
- Does the plan require step therapy before approving the medication?
It is also important to review whether your prescriptions are likely to remain covered for the entire plan year. A plan’s published formulary and pharmacy terms provide the most reliable starting point.
Bring an up-to-date medication list when comparing plans. Include the exact name, dosage, frequency, and whether each prescription is filled at a retail pharmacy or through mail order.
4. What is the plan’s maximum out-of-pocket limit?
If you are considering Medicare Advantage, ask for the plan’s annual maximum out-of-pocket limit for covered Part A and Part B services. This is the most you would pay through deductibles, copayments, and coinsurance for covered medical services during the plan year.
After reaching the plan’s limit, the plan generally pays 100% of covered Part A and Part B services for the remainder of the year. However, the exact limit varies by plan.
Pay attention to what does: and does not: count toward the limit. Prescription drug costs are generally tracked separately from the medical maximum. Premiums and services the plan does not cover may also be treated differently.
If you use Original Medicare, remember that Original Medicare itself does not include an annual out-of-pocket maximum. Supplemental coverage can change how costs are handled, but the details depend on the coverage you have. Medicare.gov explains the differences between coverage options.
The goal is not simply to find the lowest maximum. Look at the limit alongside the plan’s everyday copayments, provider network, and coverage rules.
5. How easy will it be to get the care I need?
A provider can technically be in a network and still be difficult to reach. Ask practical questions about access:
- How long does it typically take to see a specialist?
- Do I need a referral?
- Which services require prior authorization?
- Can I receive care at a nearby hospital?
- Are telehealth visits available?
- What happens if I need care while traveling?
- Can I receive routine care if I spend part of the year elsewhere?
- Are transportation or other support services available if mobility becomes an issue?
This question matters for retirees in rural or semirural parts of Texas. A plan may work well for routine appointments but become inconvenient if specialty care requires a long drive.
Consider your current health needs as well as the care you may reasonably need in the next year. A plan should be evaluated based on how it functions in real life: not only on its benefits summary.
6. What does the plan’s Medicare Star Rating tell me?
Medicare uses a one-to-five-star rating system to help consumers compare the quality and performance of Medicare Advantage and Part D plans. Ratings may reflect areas such as:
- Member experience
- Preventive care
- Care coordination
- Management of chronic conditions
- Customer service
- Complaints and appeals
- Prescription drug safety
Five stars is the highest rating. You can review ratings through Medicare’s Plan Compare tool.
A star rating is useful, but it should not be the only factor in your decision. A highly rated plan may not include your preferred doctor, hospital, or prescriptions. Conversely, a plan with a lower overall rating may fit your specific circumstances better.
Use the rating as one signal among several. Compare it with costs, provider access, drug coverage, and the plan’s rules for receiving care.
7. When should I switch plans?
You may want to consider changing plans during Open Enrollment if:
- Your premium or cost-sharing is changing
- Your medications moved to more expensive tiers
- A doctor, hospital, or pharmacy is leaving the network
- Your plan added prior-authorization requirements
- Your preferred specialists are no longer available
- You expect a change in your healthcare needs
- Your plan’s customer service or quality rating concerns you
- You are moving or spending more time outside the plan’s service area
Do not wait until December 7 if you are seriously considering a change. Give yourself time to compare plan documents, call providers, verify prescriptions, and save confirmation details.
If you are already enrolled in Medicare Advantage, the Medicare Advantage Open Enrollment Period runs from January 1 through March 31. During that period, you may generally make one change, such as switching to another Medicare Advantage plan or returning to Original Medicare with a separate drug plan. Rules can be situation-specific, so review Medicare’s enrollment guidance before acting.
Also be careful when moving from Medicare Advantage to Original Medicare. Supplemental coverage rules can be time-sensitive, so verify your options before canceling existing coverage.
A simple Texas Medicare review checklist
Before making a decision, gather:
- Your Medicare card
- A current list of prescriptions
- Your doctors’ names and locations
- Preferred hospitals and pharmacies
- Any upcoming procedures or specialist visits
- Your current plan’s Annual Notice of Change
- Your preferred ZIP code or service area information
Then compare plans through Medicare.gov or contact Medicare at 1-800-MEDICARE (1-800-633-4227). Texas residents can also seek free, personalized health insurance counseling through the State Health Insurance Assistance Program.
Open Enrollment is not about changing plans simply because a new advertisement looks attractive. It is about checking whether your coverage still supports the doctors, medications, budget, and lifestyle you expect for the coming year.
Schedule a private meeting with a fiduciary financial advisor today by calling (512) 593-8380 or by visiting: https://calendly.com/portafoliocapital/15min
Portafolio Capital Management dba Mau Sanchez Capital is a Registered Investment Adviser. This content is for informational purposes only and does not constitute investment advice or a solicitation to buy or sell any security. Advisory services are provided only pursuant to a written advisory agreement.
Texas Retirement Journal is an educational publication focused on retirement living, financial preparedness, wealth preservation, and lifestyle opportunities across Texas. To learn more about retirement planning and investment management services, visit Mau Sanchez Capital.
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