Medicare Advantage Plans in North Dakota
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 06, 2021
The Medicare program in North Dakota offers a wide range of plans for seniors looking for healthcare insurance coverage. Also referred to as Medicare Part C, Medicare Advantage covers the cost of medical treatment and sometimes other services, such as prescription drugs, dental care, vision, and hearing. Where the federal government oversees other Medicare plans, Medicare Advantage is managed by private health insurance agencies and is designed to be an extension of Original Medicare Parts A and B.
- 1 In 2019, there were 19 Medicare Advantage plans available in North Dakota.
- 2 18% of the total Medicare population in North Dakota was enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,825 per beneficiary in North Dakota, which is 13% lower than the national average.
- 4 Available Medicare Advantage plans range from 1 to 22 across North Dakota’s 53 counties.
Each Medicare plan comes with its own set of network rules, benefits, and coverage options. Seniors should carefully compare and consider each plan to find an option that suits their budget and individual healthcare needs. The good news is that local resources offer free advice and support to seniors looking for information about each plan. Health insurance companies can also provide helpful information and recommend a suitable plan. There are currently four Medicare Advantage plans available: Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.
Medicare Advantage Plans in North Dakota
Types of Medicare Advantage Plans
North Dakota’s Medicare Advantage program helps meet the individual needs of seniors living across the state through various plans. The availability of these plans depends on the applicant’s geographical location and the individual health insurance provider. Seniors should have a good understanding of how each plan works and the benefits it offers before making a decision. For example, seniors seeking the most affordable plan might consider a Health Maintenance Organization (HMO) plan, while those looking for maximum freedom when selecting a network might be better suited to a Private Fee-For-Service plan.
Health Maintenance Organizations (HMOs)
HMO plans are the most restrictive of all Medicare Advantage plans and the most affordable and have low or no deductibles. Seniors on this plan are typically required to receive all medical treatments from their HMO network of healthcare providers. They also must confine all visits to their primary care physician unless they receive a referral. The only exception to this rule is if they need to receive emergency or out-of-area urgent care. If plan members receive ordinary, everyday care from out-of-network providers, they’re liable for all medical costs. Many HMO plans include prescription drug coverage in their policy provisions, but not all do.
Planned Provider Organizations (PPOs)
PPO plans have their own network of doctors, hospitals, and healthcare providers, as well, and are managed by private insurance companies. A PPO plan may be the best option for seniors looking for greater freedom as they can choose healthcare providers outside of the plan’s network. However, it should be noted that costs for out-of-network medical treatment are typically higher than care received from a provider within the network. PPO plan members aren’t required to select a primary care doctor or need a referral to see a specialist. A PPO plan may cover prescription drugs.
Private Fee-For-Service Plans (PFFS)
PFFS plans offer seniors even more flexibility to choose out-of-network hospitals, doctors, and specialists. Members are permitted to select a provider outside of their PFFS network as long as the provider accepts the terms of their Medicare Advantage plan. However, costs are usually lower if medical treatment is received from an in-network provider. Each healthcare provider is responsible for determining how much members pay for their services and how much is paid by the plan. Due to the freedom they offer, PFFS plans usually have higher premiums. PFFS plans typically offer coverage for prescription drugs, but if they don’t, members can pick up a stand-alone Medicare D plan.
Special Needs Plans (SNPs)
Special Needs Plans (SNPs) from Medicare are restricted to people who have specific diseases or illnesses. They are also available to people living under special circumstances, such as in a skilled care facility. To meet the particular requirements of the members they serve, SNPs have unique provider rules, benefits, and drug coverage. Participants of a Special Needs Plan must choose a primary care doctor. Special Needs Plans are carefully tailored to the needs of seniors with unique disease conditions — as a result, they may not be widely available. SNPs always include prescription medication coverage.
Enrollment & Eligibility for Medicare Advantage Plans in North Dakota
The Medicare Advantage program in North Dakota is available to Medicare Part A and B participants, as long as the following requirements are met:
- They must be aged 65 or older or have a qualifying disability.
- They can’t be enrolled in a Medigap insurance plan.
- They must live in an area where Medicare Advantage plans are available, a limiting factor in North Dakota.
- They must be a U.S. citizen or permanent resident.
- They can’t have End Stage Renal Disease — SNPs may still be an option.
Medicare Advantage, like other healthcare plans, has specific enrollment periods that run throughout the year. It’s important for seniors to be aware of these enrollment times so they don’t delay applying for their preferred package or transferring to another. When applicants can enroll depends on their individual circumstances. Some enrollment periods are only limited to existing Medicare participants, while others are only open to first-time applicants. The current enrollment periods are as follows:
- Initial coverage election periods are only available to first-time applicants. These enrollment periods start three months before an applicant’s 65th birthday and end three months after.
- Annual election periods start on October 15th and end on December 7th. This enrollment period is limited to existing members looking to change to a Medicare Advantage plan or switch to another.
- Open enrollment periods are only available to existing Medicare Advantage members who want to switch back to Original Medicare or another plan. This enrollment period runs from January 1st and ends on March 31st.
- Special enrollment periods are only available to Medicare Part A members who enrolled in Part B during an open enrollment period and are looking to switch to Medicare Advantage. Other special enrollment periods may be available to seniors who have experienced life-changing events.
Prescription Drug Coverage
Medicare prescription drug coverage, also known as Medicare Part D, is an optional benefit available to all members of Original Medicare. Medicare Advantage plans often include prescription drug coverage. This coverage is often included as part of a bundle known as a Medicare Advantage Prescription Drug (MA-PD) plan. HMO and PPO members may have an MA-PD included in their plan, although in some cases, a separate premium may be required.
If prescription drug coverage is not included in an HMO or PPO plan, members aren’t permitted to enroll in a stand-alone Medicare Part D plan. Some PFFS plans come with prescription drug coverage. If they don’t, PFFS members can enroll in a stand-alone Medicare Part D plan. Prescription drug coverage is always included in a Special Needs Plan.
Medicare Advantage Resources in North Dakota
Seniors in North Dakota should research the Medicare plans and benefits available to them. By learning what each plan has to offer, seniors can choose the one that best suits their needs confidently. However, because each plan has varying rules and eligibility criteria, it can be challenging for seniors to make an informed decision. The good news is that North Dakota is home to several free resources that provide unbiased advice designed to make the decision-making process much easier.
North Dakota State Health Insurance Counseling Program (SHIC)
The North Dakota State Health Insurance Counseling Program (SHIC) provides free help and support on a wide range of Medicare topics. Trained counselors are on hand to answer questions about Medicare, Medicare Advantage, and Medicare Part D plans and help seniors select the right plan to suit their needs.
Contact Information: Website | 1-800-366-6888
North Dakota Senior Medicare Patrol (SMP)
The Senior Medicare Patrol (SMP) in North Dakota helps and empowers Medicare members, their families, and caregivers, helping them detect, prevent, and report cases of healthcare errors, fraud, and abuse. The organization offers counseling services and education through outreach events, groups, and over the phone. From protecting beneficiaries from Medicare scams to helping members save money on their premiums, the North Dakota SMP is a beneficial resource for seniors living throughout the state.
Contact Information: Website | 1-800-233-1737
Family Health Care, Fargo
The Health Resources and Services Administration (HRSA) has designated Family Health Care to provide unbiased and free consumer healthcare advice to North Dakota residents. Based in Fargo, Family Health Care helps consumers understand and enroll in many medical insurance plans, including Medicare.
Contact Information:Website| 1-855-889-4325
- 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://www.insurance.nd.gov/shic-medicare | Last accessed June 2021
http://www.ndcpd.org/smp | Last accessed June 2021
https://www.famhealthcare.org/affordable-care/outreach-and-enrollment/ | 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.