Medicare Advantage Plans in Montana
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 06, 2021
Medicare Advantage is a Medicare program available to Montana seniors who are eligible for Original Medicare Parts A and B. Also known as Medicare Part C, Medicare Advantage includes all hospital and medical coverage available with Parts A and B but also may pay for extra services, such as prescription drugs, dental, vision, and hearing care. Where other Medicare plans are managed by the federal government, Medicare Part C is overseen by private insurance companies that Medicare has preapproved.
- 1 In 2019, there were 14 Medicare Advantage plans available in Montana.
- 2 18% of the total Medicare population in Montana was enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,044 per beneficiary in Montana, which is 20% lower than the national average.
- 4 Available Medicare Advantage plans range from one to 9 across Montana’s 56 counties.
Montana’s Medicare Advantage plans can differ quite significantly in both cost and coverage. Seniors should spend time comparing plans carefully before making a decision. By having a thorough understanding of costs, coverage, and eligibility criteria, they can choose a plan that best suits their needs and budget. The availability of Medicare plans depends on the individual healthcare provider and the applicant’s geographic location. All plans must correspond with Medicare’s terms of coverage and offer the same rights, benefits and protection as the Original Medicare program
Medicare Advantage Plans in Montana
Types of Medicare Advantage Plans
The Medicare Advantage program in Montana offers a variety of plans to seniors, and the availability of specific plans may vary across the state. Standard options include Health Maintenance Organizations (HMO), Planned Provider Organizations (PPO), and Private Fee for Service (PFFS). Special Needs Plans (SNP) are also available to people with specific illnesses and conditions. Each plan is governed by its own set of eligibility criteria and rules. Understanding these rules is key to making the right plan choice. The good news is that Montana is home to several resources that provide free and unbiased Medicare counseling services.
Health Maintenance Organization (HMO)
Seniors enrolled in an HMO plan must receive all treatment from a network of specific healthcare providers. The only exception to this rule is if the participant requires emergency medical treatment. If general medical treatment is received from a provider outside of this network, the participant is responsible for all costs. Enrollees must also choose a primary care physician who will be responsible for all medical decisions and specialist referrals if required. HMO plans are the most restrictive Medicare Advantage plans available in Montana, but they’re also one of the most affordable and always come with low or no deductibles.
Planned Provider Organizations (PPO)
PPO plans typically cost more than HMO plans and always include deductibles, but these plans provide members with more flexibility when it comes to network rules. Like HMOs, PPO plans have a preferred network of healthcare providers. However, the list of providers is more extensive and offers members more choice. Members of a PPO will usually receive at least a fraction of the cost of any healthcare services they receive from an out-of-network provider. However, in-network providers offer reduced rates to PPO members and also the lowest coinsurance and copay rates. When enrolled in a PPO plan, seniors don’t need to select a primary care provider or require a referral to see a specialist.
Private Fee-For-Service Plans (PFFS)
When it comes to flexibility with choosing healthcare providers, PFFS plans offer the most freedom. A Private Fee-For-Service plan may use a partial or full network of providers and sometimes no network at all. Participants are free to choose out-of-network hospitals, doctors, and other healthcare providers who accept the plan’s terms. However, members will usually pay less if they choose a provider within their network. With this type of plan, providers receive payments on a fee-for-service basis and the insurance company determines how much participants pay for each service and how much the plan pays. PFFS plans usually have higher premiums than other Medicare Advantage plans.
Special Needs Plans (SNP)
Special Needs Plans (SNP) provide tailored benefits to individuals with certain disabling or chronic conditions. These plans come with stricter rules and eligibility criteria than other Medicare Advantage plans, as well as their own network of carefully targeted healthcare providers. Participants on an SNP must receive all care from within this network. Due to their specialized nature, SNPs typically have higher premiums and are often limited in geographic coverage. This means that it may be harder for seniors to find a plan of this type in their area.
Enrollment & Eligibility for Medicare Advantage Plans in Montana
Seniors enrolled in Medicare Parts A and B are also eligible to enroll in Montana’s Medicare Advantage program as long as they meet the following eligibility criteria:
- Are at least 65 years old or have a qualifying disability
- Aren’t enrolled in a Medigap insurance plan
- Live in an area where Medicare Advantage plans are available
- Are a U.S. citizen or permanent resident
- Don’t have End-Stage Renal Disease, but SNPs may still be an option
Medicare Advantage enrollment periods can differ depending on certain qualifying criteria. Some enrollment periods may only be accessible to first-time applicants, while others require applicants to already be enrolled in a Medicare plan. Enrollment periods are as follows:
- Initial coverage election periods allow first-time members to register. This period runs for seven months and includes the three months before an applicant’s 65th birthday and the three months following.
- Annual election periods are limited to existing Medicare members who wish to switch to Medicare Advantage for the first time or Medicare Advantage members who want to change plans. This period starts on October 15th and ends on December 7th.
- Open enrollment periods are only available to existing members of Medicare Advantage who are switching plans or going back to Original Medicare. This enrollment period runs from January 1st to March 31st.
- Special enrollment periods include one that runs from April 1st to June 30th. This enrollment period is only available to Medicare Part A members who enrolled in Part B during open enrollment and want to change to Medicare Advantage. Seniors who have life-altering events, such as losing an employer-sponsored plan, may have additional enrollment options.
Prescription Drug Coverage
Also referred to as Medicare Part D, Medicare prescription drug coverage is an optional benefit available to individuals enrolled in Original Medicare and some Medicare Advantage plans. Often, prescription drug coverage comes as part of a package known as a Medicare Advantage Prescription Drug or MA-PD plan. Medicare Advantage members enrolled in an HMO or PPO plan that doesn’t include drug coverage aren’t permitted to obtain a stand-alone Medicare Part D plan. Members of a PFFS plan may have prescription drug coverage included in their plan or be permitted to enroll in a stand-alone Medicare Part D plan. Special Needs Plans are legally required to include prescription drug coverage.
Medicare Advantage Resources in Montana
It’s vital that Montana seniors have access to quality healthcare services, and Medicare Advantage includes a wide variety of plans that can provide comprehensive coverage. Montana’s Medicare Advantage program offers a number of options throughout the state, allowing seniors to choose a plan to best suit their needs and budget. However, understanding the eligibility criteria and benefits of each plan can be quite daunting to first-time applicants or members looking to switch plans. Fortunately, help is on hand from government- and nonprofit-sponsored unbiased resources across Montana. From toll-free hotlines to website resources and seminars, seniors in Montana have access to a wide range of free assistance that can help them understand their options and make the right decision.
State Health and Insurance Assistance Program (SHIP)
The State Health Insurance Assistance Program (SHIP) offers health-benefits counseling and advocacy services to Montana seniors. This free service is designed to educate, counsel, advocate for, and empower Medicare beneficiaries and their families or caregivers to make informed decisions about healthcare benefits.
Contact Information: Website | 1-800-551-3191
Montana Senior Medicare Patrol (SMP)
The Montana Senior Medicare Patrol (SMP) is a voluntary service designed to protect seniors from Medicare billing mistakes, fraud, and abuse. The program is available statewide and is run by experienced and highly trained senior volunteers. From teaching seniors how to understand Medicare Summary Notices to recognizing potential scams, Montana’s SMP is a valuable free resource that helps seniors to get the best from their health insurance plan.
Contact Information: Website | 1-800-551-3191
The Office of the Montana State Auditor, Commissioner of Securities and Insurance (CSI)
The Office of the Montana State Auditor, Commissioner of Securities and Insurance (CSI) is a state government regulator of the insurance and securities industries and advocates for Montana citizens. The agency helps ensure transparency and fairness to Medicare participants and offers a number of resources on its website. Seniors experiencing problems with their insurance can use this service free of charge.
Contact Information: Website | 1-800 332 6148
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans | Last accessed June 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 | Last accessed June 2021
https://www.medicare.gov/drug-coverage-part-d | Last accessed June 2021
https://dphhs.mt.gov/sltc/aging/ship | Last accessed June 2021
https://missoulaagingservices.org/get-help/medicare-finances/senior-medicare-patrol.html | Last accessed June 2021
https://csimt.gov/your-insurance/medicare/ | 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.