What is Medicare, and who is eligible for it?
Medicare is a federal or government-provided health insurance program that began to provide benefits to people roughly 60 years ago. The original Medicare included Part A (hospital insurance) and Part B (medical insurance). Today, these two parts are known as "Original Medicare."
Since its introduction, the government made several changes to include more people in the Medicare database. For example, they started including:
- Younger people with disabilities.
- People aged 65 years or older.
- People with ESRD or End-Stage Renal Disease (a condition that leads to permanent kidney failure and requires dialysis or a transplant).
Over the years, more benefits, such as prescription drug coverage, were also offered under Medicare.
You may be confused between Medicare and Medicaid. Medicaid is also a state—and federal-funded insurance program for individuals with low incomes. Patients can be eligible for both Medicaid and Medicare.
What are the parts of Medicare?
Medicare has several parts that cover different types of services. The coverage depends on Medicare's national coverage decisions, federal and state laws, and local coverage decisions the companies make in every state that processes Medicare claims.
The different parts of Medicare are:
- Medicare Part A: Part A generally includes inpatient care in a hospital facility, home health care, and care in a nursing facility. A patient or spouse who has paid their Social Security taxes while working for a particular period does not have to pay a monthly premium for Part A. If you are not eligible for the "premium-free Part A," you can buy Part A.
- Medicare Part B: Part B includes durable medical equipment, ambulance services, mental health (inpatient, outpatient, intensive outpatient program services, partial hospitalization), and limited outpatient prescription drugs. It also includes medically necessary services or supplies and preventive services like detecting disease early, when treatment is most likely to work best.
- Medicare Part D: Part D helps pay for medications a provider prescribes. To get this coverage, patients must get a Medicare-approved plan that gives drug coverage (including Medicare drug plans and Medicare Advantage Plans with drug coverage). This coverage includes generic and brand-name medicines as well as vaccines or shots.
There is also Plan C. Also known as a Medicare private health plan or Medicare Advantage Plan, these have contracts with the federal government. A fixed amount is paid to provide Medicare benefits.
The most common MA Plan types are:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Private Fee-For-Service (PFFS)
Understanding the costs of Medicare drug coverage
The cost of Medicare drug coverage depends on the specific plan you choose. Here's a breakdown of the main costs:
Premium:
This is the monthly fee you pay for drug coverage, regardless of whether you use prescription drugs. The premium amount varies by plan. If your income is higher, you may pay an additional amount. If you enroll late, you may face a Part D late enrollment penalty, which is added to your monthly premium. To avoid this, it's wise to consider enrolling in a low-premium plan, even if you currently take few or no medications. Every plan must include coverage for a wide variety of commonly used drugs.
Deductible:
This is the amount you pay out-of-pocket each year before your Medicare drug plan starts covering costs. The maximum deductible for 2025 is $590, but some plans have no deductible.
- Copayment: This is a fixed amount you pay for each prescription at the pharmacy.
- Coinsurance: This is a percentage of the drug's cost that you pay when filling a prescription.
Stages of Medicare drug coverage
Medicare drug plans and Medicare Advantage Plans with drug coverage have three stages:
Deductible stage:
If your plan has a deductible, you must pay the full cost of your drugs until you reach that deductible. In 2025, no plan can have a deductible higher than $590. Some plans waive the deductible altogether.
Initial coverage stage:
Once you've paid your deductible (if applicable), you'll enter the initial coverage stage. Here, you'll pay 25% of the cost of both generic and brand-name drugs as coinsurance. This continues until your out-of-pocket spending reaches $2,000 in 2025. This amount includes payments made on your behalf, such as through the Extra Help program. Once you hit this limit, you move into catastrophic coverage.
Catastrophic coverage stage:
In this stage, you won't have to pay out-of-pocket costs for covered Part D drugs for the remainder of the year.
Each month after your pharmacy bills your plan, you'll receive an Explanation of Benefits (EOB). This document details the prescriptions you filled, what your plan and you (or others) paid, your current coverage stage, and the total drug costs counting toward your out-of-pocket expenses.
Who are primary care doctors, and what are their duties?
Primary care is a patient's entry point in the healthcare system. Continual primary care is necessary to address various medical needs, including wellness and preventive care for people of all ages and socioeconomic backgrounds. It also includes the treatment of injuries and a wide range of acute and chronic illnesses, including mental health conditions. There are many types of primary care practitioners. Some primary care professionals include internal medicine doctors, family physicians, nurse practitioners, geriatricians, and OB-GYNs (obstetricians and gynecologists).
A primary care physician (PCP) is a doctor of medicine (M.D.) trained to diagnose and treat several illnesses or injuries in a general population. PCPs have many responsibilities. Some everyday duties include:
- Recording your medical and family history of diseases and assessing your health risk as a part of preventive care.
- Offering wellness and prevention screenings as a part of an annual checkup for conditions like breast cancer, heart disease, sexually transmitted diseases, diabetes, and high blood pressure.
- Managing mental health conditions like depression and helping patients with personal issues like domestic violence.
- Provide wound care for minor injuries and put a splint, cast, or brace on injured limbs.
- Treat minor skin infections, rashes, bites, muscle sprains, strains, and
- PCPs prescribe medications and change or adjust them as needed. They also check drug interactions if patients take multiple medications for different conditions.
- Perform minor procedures such as skin biopsies, toenail removals, and joint injections.
- Order or perform necessary tests like X-rays, spirometry tests, C.T. scans, or EKGs.
- Making sure patients and families have their vaccinations and immunizations up to date.
- Recommend a specialist if a patient has a chronic disease and requires advanced treatment.
- Educate patients about necessary lifestyle changes like a diet and self-care plan to prevent or manage a disease.
What primary care services does Medicare cover?
Medicare covers the following services that your primary care physician may provide:
- Annual wellness visit (AWV): Medicare Part B covers an annual wellness visit with your primary care physician (PCP). During this visit, you and your PCP will discuss or update your preventive care plan based on your overall health and risk factors. It also involves recording your medical and family history, height, weight, and blood pressure. AWVs also cover reviewing your functional ability (for example, checking your ability to perform daily activities and hearing impairment) and screening for cognitive impairment. Note that an AWV is not a head-to-toe physical.
- Preventive screenings: There are many screenings and tests covered under Medicare. Some include bone mass measurements to check the risk of breaking a bone, cardiovascular disease screenings that monitor your cholesterol, lipid, and triglyceride levels, Pap tests and pelvic exams to test for cervical and vaginal cancers, diabetes screenings and self-management training, breast cancer and lung cancer screenings, obesity screenings if your primary care doctor or other primary care practitioner provides it in a primary care setting, and depression screenings.
- Vaccinations: These include Hepatitis B shots if you are at high risk for it, pneumococcal shots (or vaccines) to help protect against different types of pneumonia, and flu shots. Some other vaccines, like tetanus, are also covered when they're related directly to treating an injury or illness. However, these are not covered under preventive services. Further, Medicare also covers the latest 2023–2024 formula of Moderna or Pfizer-BioNTech COVID-19 vaccine for individuals aged five or older.
- Diagnostic non-laboratory tests: Your primary care doctor or any other medical provider may recommend tests like C.T. scans, MRIs, EKGs, X-rays, and PET scans. These are covered by Medicare Part B.
- Chronic pain management: Medicare Part B provides monthly services focused on managing chronic pain for individuals, i.e., persistent or recurring pain lasting longer than three months. Services may include medication management, pain assessment, and care coordination.
Find Medicare primary care doctors near you in Houston, TX
Zocdoc helps patients all over the United States find the best healthcare professionals that match their needs and preferences. With Zocdoc's help, you can book an in-person or video consultation based on your provider's availability.
To book an appointment, visit the Zocdoc website and enter your condition or symptoms, location, and insurance plan. You may select providers based on gender, time of day, hospital affiliation, languages spoken, distance, and whether a provider treats children.
Zocdoc also helps patients find in-network providers. Select your insurance carrier and plan in the drop-down menu to filter the displayed list of PCPs with in-network providers. You may also search for Medicare primary care doctors near you. If you cannot find your specific insurance plan, you can upload an image of your insurance card. Zocdoc will then scan your card and display an insurance plan that matches the scanned image. This service is available only for medical insurance cards, not dental or vision. For more insurance-related information, go through Zocdoc's patient help center. If you need help uploading your medical insurance card or have any other queries, contact Zocdoc's service team, available 365 days a year, to answer your questions via chat or email.
All bookings on Zocdoc are fast, free, and secure!
Insurance-related statistics for Houston and Texas
According to America's Health Rankings, Texas had the highest percentage of uninsured people (about 16.4%) in the United States as of 2023. As per Understanding Houston, for the past ten years, Texas has consistently held the highest percentage of uninsured residents compared to any other U.S. state.
According to American Community Survey (ACS) estimates for 2018-2022, given by the U.S. Census Bureau in December 2023, nearly 1,494,570 people in the City of Houston had at least one type of health insurance coverage, and an estimated 231,558 had two or more types of health insurance. Approximately 552,200 did not have any health insurance coverage. According to ACS 1-year estimates in 2022, among those uninsured in Houston City, roughly 12.6% were aged 65 and older.
As per ACS 1-year estimates in 2022, nearly 262,466 individuals living in Houston City aged 65 and above had Medicare coverage alone or in combination, roughly 4,094 under the age of 19 had Medicare coverage, and nearly 30,477 people aged between 18 and 64 had Medicare coverage.
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