Medicare Advantage Plans in Iowa
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 06, 2021
As most people approach their 65th birthday, they become eligible for Medicare. They are also eligible if they have been receiving Social Security disability benefits, have Amyotrophic Lateral Sclerosis or End-Stage Renal Disease (ESRD).
Most people know about Original Medicare but may not be aware there are other options — they could select a Medicare Advantage plan. These healthcare plans are offered by private insurance companies and are legally required to provide the same benefits as Medicare Part A and Part B. Medicare Advantage plans, however, may include additional benefits, such as dental, vision, or hearing.
- 1 In 2019, there were 42 Medicare Advantage plans available in Iowa.
- 2 19% of the total Medicare population in Iowa is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,807 per beneficiary in Iowa, which is 30% lower than the national average.
- 4 Available Medicare Advantage plans range from three to 21 across Iowa’s 99 counties.
Iowans who decide to enroll in a Medicare Advantage plan may select from four types of plans. Seniors who’ve participated in work-sponsored health insurance programs may be familiar with some of these plans. Some choices require that members only use in-network providers, while others allow members to seek out-of-network service at an added cost. Many of these plans also provide prescription drug coverage, but not all of them do.
During the various Medicare Advantage enrollment periods, Iowans can enroll in Medicare Advantage, move between Medicare Advantage plans, or return to Original Medicare.
Medicare Advantage Plans in Iowa
Types of Medicare Advantage Plans
Before eligible Iowans decide whether they want to enroll in the Iowa Medicare Advantage program, there are several questions they should ask themselves:
- Do I want to see health care providers outside my plan’s network?
- Do I need a plan that includes prescription drug coverage?
- How much of a premium do I want to pay?
- Do I plan to travel or spend time away from my primary care physician?
Iowans can only enroll in a Medicare Advantage plan available in the county in which they live.
Health Maintenance Organizations (HMO)
Most HMOs require members to use in-network health care providers. Members must also select a primary care physician and seek referrals to see specialists. These limitations do not apply to emergencies, out-of-network urgent care, or out-of-network dialysis. Most HMO plans are inexpensive and may not require a premium. And additional benefits may be available, but members may need to pay an additional cost. Most of these plans also pay for prescription drugs, but not all of them do. Iowans who select an HMO may still need to pay Medicare’s Part B premium and, if applicable, Part A.
Preferred Provider Organizations (PPO)
Iowans who select a Medicare Advantage PPO can seek health care outside their plan’s network. In most cases, however, this entails an extra cost. Members of a PPO plan won’t need to select a primary care physician or seek a referral to see a specialist in most cases. Some plans also offer additional benefits, such as vision, dental, and hearing. These benefits may be included in the initial premium, or there may be a separate premium. Most of these plans cover prescription drugs, but not all of them do.
Private Fee-For-Service Plans (PFFS)
PFFS plans are for Iowans who want the most freedom when it comes to their healthcare options. Most PFFS plans contract with a network that provides members with services. However, if a member decides to seek health care outside of their plan’s network, they must first ensure that the provider will accept their plan’s financial terms. Providers have the option to refuse service if they don’t like the payment terms. As with HMOs, exceptions are made for emergencies, out-of-network urgent care, and out-of-network dialysis. Most PFFS plans offer prescription drug coverage.
Special Needs Plans (SNP)
SNP plans are special plans designed to provide health care to Iowans with chronic medical ailments or who reside in a skilled nursing facility. All SNP plans are connected to specialists who treat a member’s specific health care concerns. Members must only use in-network health care providers, choose a primary care physician, and obtain a referral when they need to see a specialist. Emergencies and out-of-network dialysis for End Stage Renal Disease (ESRD) may trigger a coverage exception. All SNPs are legally required to provide prescription medication coverage.
In Iowa, HMOs are by far the most popular plan, with 98.5% of those enrolled in a Medicare Advantage plan in Iowa choosing an HMO. Enrollment in all other plan types was less than 1%.
Enrollment in Eligibility For Medicare Advantage Plans in Iowa
Residents of Iowa who want to enroll in a Medicare Advantage plan must meet certain eligibility criteria:
- Iowans must be aged 65 or older or have been receiving Social Security disability benefits for at least two years.
- They must be American citizens or permanent residents of the United States for the past five years.
- They need to have worked enough hours to qualify for Social Security benefits.
- Before they can roll in a Medicare Advantage plan, Iowans need to be enrolled in Original Medicare Part A and Part B but not enrolled in Medigap.
- Iowans must enroll in a Medicare Advantage program available in the county in which they live.
Once a resident has decided to enroll in an Iowa Medicare Advantage program, they can only do so during certain periods:
- The Initial Enrollment Period encompasses the seven months around a senior’s 65th birthday, including the three months before their birthday, the month of their birthday, and the three months following their birthday.
- The Annual Election Period runs from October 15th to December 7th. During this time, seniors enrolled in Original Medicare can switch to a Medicare Advantage plan, return to Original Medicare, or transfer to a different Medicare Advantage plan.
- The Medicare Advantage Open Enrollment Period takes place from January 1st and March 31st. Members of a Medicare Advantage plan who were not happy with that plan can switch to a different plan or return to Original Medicare.
- A special General Enrollment Period occurs annually from April 1st to June 30th. During that time, anyone who recently signed up for Medicare Part B can enroll in a Medicare Advantage plan.
Prescription Drug Coverage
Prescription drug coverage is an important factor for many seniors. Original Medicare permits its members to purchase separate Part D coverage specifically for prescription drugs. Many Medicare Advantage plans offer drug coverage, but not all of them do. If your monthly medications’ costs are high, you’ll want to make sure your plan provides coverage. There are often special rules that change from plan to plan.
- Most HMOs and PPOs offer prescription drug coverage. The cost of this coverage may or may not require a separate premium.
- HMOs and PPOs that don’t cover medications don’t allow their members to participate in a stand-alone Part D plan. If they attempt to do so, they will lose their membership in the Medicare Advantage plan and revert to Original Medicare coverage.
- PFFS plans have a different approach to prescription drug coverage. While some may not offer coverage for medications, they do allow members to participate in a separate Medicare Part D plan.
- All SNPs are required by law to provide their members with prescription drug coverage.
Medicare Advantage Resources In Iowa
It’s not always easy for Iowa seniors to decide between remaining with Original Medicare and enrolling in a Medicare Advantage plan. While Original Medicare is one basic plan, Medicare Advantage can offer several different types of plans, as well as options within those plans. While friends and family may provide some help, seniors are often left frustrated and concerned about selecting the best choice. Fortunately, there are resources for seniors currently enrolled in Medicare or Medicare Advantage plans and those who are soon becoming eligible. These resources exist to help Iowans navigate their way through these plans to select the best one for their health and their budgets.
Iowa Senior Health Insurance Information Program (SHIIP)
Also known as Iowa’s Medicare Resource, this program provides confidential and free counseling to senior Iowans interested in finding out more about their Medicare options, including Medicare Advantage, Medicaid, and Medigap. Trained, unbiased volunteers can answer questions about Medicare and Medicare Advantage. SHIP counselors are sponsored by various organizations throughout Iowa, and they also put on Medicare seminars and workshops.
Contact Information: Website | 800-351-4664
Iowa Insurance Division
This state department provides services to insurance consumers, including those using government-sponsored health care. Seniors wishing to verify the integrity of the private companies that manage their Medicare Advantage plans can view data and licensing information. The website also has a fraud reporting form that connects to the Senior Medicare Patrol (SMP).
Contact Information: Website | 515-654-6600
Iowa Drug Card
The Iowa Drug Card is available to all Iowans and was specifically designed to help uninsured and under-insured seniors with the costs of prescription drugs. If seniors don’t have a prescription drug plan or have a high deductible plan, the card provides savings as high as 80% on certain brands or generic drugs.
Contact Information: Website | 877-321-6755
- Sources [-]
https://www.medicareadvantage.com/plans-by-state/iowa | Last accessed June 2021
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp | Last accessed June 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 | Last accessed June 2021
https://shiip.iowa.gov/new-medicare | Last accessed June 2021
https://iid.iowa.gov/ | Last accessed June 2021
https://iowadrugcard.com/ | Last accessed June 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.