Medicare Advantage Plans in Idaho
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: March 3, 2021
Medicare Advantage plans in Idaho are also referred to as Medicare Part C. This program extends the benefits of Original Medicare Parts A and B by contracting with private insurance companies. The advantages of selecting a Medicare-approved carrier to manage the plans include the ability to add supplemental coverage beyond hospital and medical for prescription drugs, dental, hearing, and vision. One of the more significant differences between the two types of Medicare plans is that Medicare Advantage offers out-of-pocket maximum payments, whereas Original Medicare does not.
- 1 In 2019, there were 44 Medicare Advantage plans available in Idaho.
- 2 32% of the total Medicare population in Idaho is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,467 per beneficiary in Idaho, which is 16% lower than the national average.
- 4 Available Medicare Advantage plans range from one to 43 across Idaho’s 44 counties.
There are a number of Medicare Advantage plans in Idaho from which to choose. Seniors have the opportunity to compare coverage options and costs before determining which plan best meets their needs. Those who opt for Medicare Advantage enjoy the same agency protections as Original Medicare members. Specific plans may vary depending on the enrollee’s location and the carrier; however, options include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service selections, and Special Needs Plans.
Medicare Advantage Plans in Idaho
Types of Medicare Advantage Plans
Idaho’s Medicare Advantage program offers a variety of insurance options provided through private insurance companies, including HMO, PPO, PFFS, and SNP selections. Each has specific requirements regarding enrollment and eligibility, and all plans must adhere to Medicare’s guidelines. Seniors may receive help with navigating the Original Medicare and Medicare Advantage systems as well as with choosing the right coverage for their needs through local resources, including Senior Health Insurance Benefits Advisors (SHIBA).
Health Maintenance Organizations (HMO)
HMO plans typically require its members to receive care through their network of providers and healthcare facilities. While each plan is different, the basic structure of HMOs requires beneficiaries to choose a primary care physician who manages the patient’s day-to-day care as well as specialist referrals. With the exception of some emergency situations, the insured is required to seek medical care within the network to receive coverage. Although it’s more expensive, some carriers allow enrollees to receive care for specific out-of-network services, including emergency care, out-of-area urgent care, and out-of-area dialysis. Although HMOs are the most restrictive plans, their benefits include low and no deductibles.
Preferred Provider Organizations (PPO)
While the PPO plans’ premiums and other related costs may run more than HMOs, they also offer more flexibility. For one thing, beneficiaries can see a general practitioner or specialist without choosing a primary care physician and asking for referrals. However, PPO plans do save their members money if they choose in-network care. Most Medicare Advantage PPOs offer prescription drug coverage. One caveat is that beneficiaries must opt for a plan that includes prescription drugs if they require such coverage, as they cannot also enroll in the Medicare Part D drug plan.
Private Fee-For-Service Plans (PFFS)
PFFS plans allow beneficiaries the option of seeing any Medicare-approved physician or healthcare facility that accepts the plan. Members are not required to choose a primary care doctor, and they do not need referrals to see specialists. While some plans offer a network of providers and facilities, not all of them do. If the enrollee does join a network, the option is also available to seek out-of-network care and typically pay higher costs. PFFS plans may offer prescription drug coverage, and members can join a Medicare D Plan if their plan does not.
Special Needs Plans (SNP)
SNPs are limited to individuals with specific circumstances, such as those living in nursing homes, beneficiaries who are eligible for Medicaid and Medicare, and people with chronic conditions, including dementia, heart failure, End Stage Renal Disease (ESRD), and HIV/AIDS. All SNPs provide prescription drug coverage. They also usually require members to choose a primary care physician and obtain a referral for specialist care. In order to receive coverage, healthcare must be performed by an in-network provider. There are some exceptions, including the necessity of receiving out-of-network emergency care, and ESRD patients who need out-of-area dialysis. Although SNPs are designed to cover individuals with unique situations, their premiums are also higher than other plans. They may also be challenging to locate, as they are limited to certain geographic areas.
Enrollment & Eligibility for Medicare Advantage Plans in Idaho
Idaho’s Medicare Advantage plans are available to seniors and select others who meet the following eligibility qualifications:
- Seniors who are at least 65 years of age as well as younger individuals with qualifying disabilities
- Enrollees entitled to receive Medicare Parts A and B
- Individuals who are not enrolled in a Medigap plan
- American citizens and permanent residents with a minimum of five consecutive years of residency
- Persons living within a designated service area
Idaho seniors receiving Railroad Retirement or Social Security benefits are systematically enrolled in Medicare Parts A and B upon turning 65. Beneficiaries may change plans or enroll in Medicare Advantage during open enrollment periods.
Eligible seniors who adhere to Medicare’s enrollment periods reap the greatest benefits of what the Medicare Advantage programs have to offer, especially those who require special needs. Enrolling during the appropriate designated times also avoids having to pay penalties.
- During the initial enrollment period, seniors signing up for first-time benefits are allowed a three-month window before and after their 65th birthday.
- Current Medicare recipients may enroll in a Medicare Advantage plan for the first time, and current Medicare Advantage beneficiaries can switch plans during the annual election periods. The time frame is between October 15th and December 7th each year.
- January 1st to March 31st is designated as the annual open enrollment period. Individuals currently covered by a Medicare Advantage plan may change plans or return to Original Medicare during this interval.
- The general enrollment period begins April 1st and ends June 30th annually. It is limited to seniors who want to switch to a Medicare Advantage plan. They must be currently covered under Medicare Part A and have completed Part B registration during open enrollment.
Prescription Drug Coverage
Medicare-approved private insurance companies operate Idaho’s Medicare Part D or prescription drug plans. The exact coverage and cost depend on the plan the individual chooses. One option for seniors who take prescription medication is to add supplemental drug coverage to an Original Medicare package. Another alternative is to enroll in a Medicare Advantage program, such as an HMO, PPO, PFFS, or SNP that includes drug coverage. Medicare Advantage plans that include prescription drugs are called MA-PDs. These comprehensive plans encompass Medicare Parts A, B, and D. Individuals interested in receiving prescription coverage with their Medicare Advantage HMO or PPO plans must choose a policy that includes it. Those who want to add prescription coverage by enrolling in Part D are automatically dropped from their Medicare Advantage plan and enrolled in Original Medicare. PFFS plans permit you to add a stand-alone Medicare D plan, and SNPs are required by law to cover medications.
Medicare Advantage Resources in Idaho
Trying to navigate through the range of choices offered by Idaho’s Medicare Advantage programs can be overwhelming. There are a number of free resources throughout the state with qualified individuals who can help enrollees determine which plan is the most beneficial for their unique circumstances.
Senior Health Insurance Benefits Advisors (SHIBA)
As a division of the Idaho Department of Insurance, SHIBA offers Idaho seniors on Medicare a variety of resources to assist them with understanding the programs’ requirements and benefits. SHIBA’s volunteers are certified Medicare counselors and provide unbiased advice about how Original Medicare or Medicare Advantage can best serve individual needs. SHIBA’s offices are located in Coeur d’Alene, Boise, and Pocatello. The program also offers services via telephone and through internet webinars. Individuals may receive personal assistance with a counselor or have questions answered through workshops presented at one of the facilities or remotely.
Contact Information: Website | 800-247-4422
Southwest Idaho Area Agency on Aging
Seniors who contact the Information and Assistance Program office are connected to a Senior Services Specialist who offers the most current information regarding available assistance. Specialists also introduce individuals to the appropriate support services available within their communities, such as assistance with the Medicare Advantage program.
Contact Information: Website | 208-898-7060
Idaho Legal Aid Services Inc.
This nonprofit law firm offers seven regional and two satellite offices in addition to three toll-free legal advice lines and a website to obtain more information and download forms. Idaho Legal Aid is committed to providing services to vulnerable members of society. Its elder lawyers help seniors understand their health benefits, including those offered by Medicare Advantage, to receive the coverage that best suits their needs. Idaho’s Legal Aid Services’ ability to work with individual seniors is based on available staffing at its local offices.
Contact Information: Website | 208-664-0931
- Sources [-]
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp Last accessed April 2021
https://www.medicare.gov/drug-coverage-part-d Last accessed April 2021
https://doi.idaho.gov/shiba/AboutUs Last accessed April 2021
https://www.a3ssa.com/programs_and_services/stay-informed/ Last accessed April 2021
https://www.idaholegalaid.org/node/2178/seniors Last accessed April 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.