Medicare Advantage Plans in South Dakota
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 06, 2021
Medicare combines hospital and emergency care (Part A) and general health and wellness services (Part B) under the umbrella of Original Medicare. Since Original Medicare doesn't include ancillary health services such as hearing, vision, dental, or prescription medication coverage, Medicare Advantage plans are offered as a solution to help fill the gap. Medicare Advantage plans, also known as Part C, meet the minimum benefits offered under Original Medicare and often include extras. These plans are approved by Medicare but managed by private insurance companies. Out-of-pocket costs vary between plans depending on deductibles, premiums, and other factors.
- 1 In 2019, there were 23 Medicare Advantage plans available in South Dakota.
- 2 19% of the total Medicare population in South Dakota is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,782 per beneficiary in South Dakota, which is 13% lower than the national average.
- 4 Available Medicare Advantage plans range from seven to 22 across South Dakota’s 66 counties.
The cost of Medicare Advantage plans can vary dramatically based on the type of plan and expected out-of-pocket costs. All Advantage plans must meet minimum coverage requirements, but the expanded plan benefits can affect the cost and availability. Advantage plans are offered in specific geographic regions, so a senior’s address also determines which plans are available to them. Some of the most common types of Advantage plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.
Medicare Advantage Plans in South Dakota
Types of Medicare Advantage Plans
South Dakota’s Medicare Advantage program includes a full range of HMOs and PPOs, along with limited availability for PFFS and SNP plans. There are many insurance providers licensed to offer Advantage plans throughout the state, providing seniors with several options for each type of plan, although SNP and PFFS plans may not be available in all areas. State and local resources can help seniors identify the plans available to them and answer questions about coverage options and estimated out-of-pocket costs.
Health Maintenance Organizations (HMO)
HMOs are a fairly common approach to health insurance, and many may have experienced this type of plan with their employee healthcare coverage. Through an HMO, enrollees work with a network of healthcare providers that have agreements in place with the insurance company. Out-of-network care, excluding emergency situations, may be entirely uncovered when insured through an HMO. To access doctors and other providers, seniors must first choose a primary care physician to provide maintenance care and any needed referrals. Members generally need a referral to seek out specialist care. HMOs are typically the most restrictive about provider choice but are affordable plans with low or no deductibles.
Preferred Provider Organizations (PPO)
PPO plans may also be familiar to those who’ve received healthcare coverage through an employer. These plans often have higher premiums than HMOs but offer significantly more flexibility when it comes to selecting healthcare providers. PPOs have a network of doctors and hospitals that enrollees can use to get care at the lowest out-of-pocket cost. However, selecting an out-of-network provider usually still means the PPO insurance will cover some of the costs. One of the benefits of PPOs is the ability to avoid designating a primary care physician. Additionally, members usually don’t need a referral to see a specialist, although they may want to seek out in-network providers to keep costs low.
Private Fee-For-Service Plans (PFFS)
PFFS plans tend to have higher premiums than HMOs and PPOs, but these plans also offer total flexibility when selecting healthcare providers. There’s no need to seek out in-network hospitals or doctors. Instead, with a PFFS plan, members can use any provider that agrees to accept the payment terms. The insurer may limit the amount of reimbursement offered for services rendered and include the co-pay owed by the patient. There’s no guarantee that a location will accept PFFS insurance plans, so enrollees should check at the time of service. To ensure coverage is available, some PFFS plans offer networks of guaranteed providers.
Special Needs Plans (SNP)
Seniors with certain conditions may benefit from enrollment in an SNP. Special Needs Plans are only available to members with qualifying diagnoses or living circumstances and typically have the highest premiums. These plans offer coverage that’s customized for their members, and those with End Stage Renal Disease may only be eligible for an SNP. When enrolled in an SNP, seniors benefit from pharmacy formularies tailored to their illnesses and a network of service providers who offer needed specialist care. SNPs aren’t offered in every area and may have geographic limitations on where service is available.
Enrollment & Eligibility for Medicare Advantage Plans in South Dakota
South Dakota seniors aged 65 or younger individuals with a qualifying disability are eligible for Medicare. To enroll in an Advantage plan, seniors must select a plan that’s offered in their area and avoid enrolling in Medigap insurance. An enrollee must also be a U.S. citizen or permanent resident and have a diagnosis that doesn’t include End Stage Renal Disease. For individuals with End Stage Renal Disease, SNPs may be an option if available.
While South Dakota seniors receiving Social Security or Railroad Retirement benefits are usually automatically enrolled in Medicare Parts A and B, enrollment in a Medicare Advantage plan requires seniors to select a plan prior to their automated enrollment or to switch to an Advantage plan during an appropriate enrollment period.
There are three annual periods during which seniors may be eligible to make changes to their Medicare coverage and enroll in a Medicare Advantage plan, in addition to the initial coverage period, which occurs during their 65th year. Here’s a look at the enrollment periods and who can use them.
- Initial enrollment period. During the initial enrollment period, seniors can select either Original Medicare or an Advantage plan, or opt to stay with an employer-provided plan if they haven’t yet retired. This period runs for three months prior to their birthday month, during their birthday month, and for three months after for a total of seven months.
- Annual election period. Starting on October 15th and running until December 7th, seniors currently enrolled in Original Medicare or an Advantage plan can make changes to their plans. Members can make a first-time switch to an Advantage plan or change their current plan for a different option.
- Open enrollment period. During the open enrollment period, current Advantage plan members can change their plan or switch back to Original Medicare. This period starts on January 1st and runs until March 31st.
- General enrollment period. Starting on April 1st, seniors enrolled in Medicare Part A who opted into Part B for the first time during the prior open enrollment period are eligible to switch to a Medicare Advantage plan. Seniors have until June 30th to make this decision.
Prescription Drug Coverage
In South Dakota, many Medicare Advantage plans also include prescription drug coverage. Plans with bundled prescription coverage are listed at MA-PDs. With some plans, drug coverage is included in the standard premium, while others have a separate premium for prescriptions. When shopping for an Advantage plan, it’s important to note that HMOs and PPOs without prescription drug coverage prevent seniors from opting into Medicare Part D, the standalone prescription coverage offered by Original Medicare. PFFS plans that don’t have prescription coverage do allow enrollment in Part D, while all SNPs include prescription coverage.
Medicare Advantage Resources in South Dakota
As seniors age, health care becomes a critically important issue. Medicare Advantage plans are options to consider when shopping for comprehensive coverage. In South Dakota, several types of plans are available, but each has highly specific limitations and out-of-pocket expenses, which can make selecting the best option confusing. To help first-time Medicare beneficiaries and those seeking a change to their coverage, South Dakota offers numerous counseling and information services to assist with the process.
Offered in partnership with the State Health Insurance Assistance Programs (SHIP), SHINE administers a network of volunteer counselors who offer unbiased, free assistance to seniors seeking information about Medicare. SHINE operates three locations throughout South Dakota and provides counseling over the phone for those who can’t easily make an office visit. In addition to one-on-one counseling sessions to help South Dakota seniors explore their healthcare options, SHINE also publishes annual guides to the various types of Medicare Advantage plans offered in the state. These guides provide an overview of the types of plans offered in each major metropolitan area and their expected out-of-pocket costs.
Contact Information: Website | 800-536-8197
South Dakota Office of the Attorney General
The South Dakota Office of the Attorney General provides some basic information about Medicare Advantage plans, Medigap insurance, and the legal requirements for each type of plan. In addition to information about health insurance coverage, the Office of the Attorney General also provides a list of resources that may help seniors with other issues, including abuse reporting, legal aid, estate planning, and other benefits and services.
Contact Information: Website | 605-773-3215
The Community HealthCare Association of the Dakotas (CHAD), offers a wealth of resources specific to health care and shopping for coverage. CHAD is a nonprofit organization that works with community health centers to ensure that every South Dakota resident has access to high-quality health care. Seniors considering different healthcare models can get help understanding their options and make arrangements for wellness checks and other healthcare needs while waiting for Medicare coverage. To date, CHAD has assisted more than 120,000 residents at 62 sites throughout North and South Dakota.
Contact Information: Website | 605-275-2423
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans | Last accessed June 2021
https://www.medicare.gov/Pubs/pdf/11135-prescription-drug-coverage-with-ma-mcp.pdf | Last accessed June 2021
http://shiine.net/ | Last accessed June 2021
https://atg.sd.gov/victim/seniors/supplemental.aspx | Last accessed June 2021
https://communityhealthcare.net | 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.