Adams County Medicare Advantage Plans
Several 2025 Adams County Medicare Advantage plans caught our attention.
The first one a plan will credit back over $100 of your Part B Monthly premium. This plan also includes prescription drug coverage too. If you are a veteran and get your prescription meds and other health care from the VA, you should consider this plan too.
If you have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder) call us. There is a unique plan that specializes in helping Medicare beneficiaries with these health issues. We will help you understand these plans and how they can help.
If you have a Medicaid status of QMB and SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.
There are other Adams County Medicare HMO and PPO plans on our recommend list. Which medications, hospital preferences, and health issues a person has/does not have are determining factors on which are appropriate.
Don’t forget, if you are enrolled in a Medicare Advantage plan now, and the your plan no longer meets your needs, you can switch to a different plan between January 1 and March 31.
What Else you need to know.
For 2025, Adams County has 24 Medicare Advantage plans for residents to consider.
Here is the high level break down:
6 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.
3 of these are PPO;
3 are HMO plans.
12 plans do include prescription drug coverage and services covered by Medicare Part A and B.
8 are HMO plans;
4 are PPO plans.
The remaining plans are reserved for individuals which qualify for Medicaid special needs plans (C-SNP or D-SNP).
There is another type of Medicare plan you should be aware of.
These are Medigap plans.
Two of these limit your annual out of pocket costs for Part A and B covered services to less than $2,900. Keep this figure in mind when you look at any Adams County Medicare Advantage plan’s Maximum out of pocket limit (MOOP). They are typically noticeably higher than this figure.
This figure is controlled by Medicare and typically goes up a bit annually. If your cost share for Medicare Part A and B used services for the calendar year hits this figure, your Medigap plan pays the rest of your left-over health care costs.
When you choose this Medigap plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you. This means you do not have the network restrictions/rules found in Adams County Medicare Advantage plans.
Also, you do not have an insurance company standing between your physician to get permission to move forward with your treatment plan. Physicians/hospitals may prefer these plans because they know they will be paid in a timely manner.
You will have fewer ‘prior authorizations’ to deal with.
Medicare published a document that provides the rest of the details you need to know about Medigap plans. You can download this PDF document by clicking here.
What are the some of the differences between Adams County Medicare Advantage plans?
One item is the plan’s Maximum out of pocket limit (MOOP).
Medicare’s maximum MOOP for this year’s HMO is $9,350.
The MOOP maximum for PPO plans cannot exceed $14,000.
Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals.
Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.
The range of MOOP for your County’s HMO Medicare Advantage plans is $4,800 to $6,900.
The range for PPO plans is $6,100 to $14,000.
The example below will help you understand how your plan’s MOOP works.
Let’s say your plan’s MOOP is $7,000 for the year.
In January you are admitted to the hospital for surgery. Your bill for the 5-day hospital stay is $1,750. Your post-op visits to your physician and physical therapist(s) are $475.
After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP. When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A & B services.
If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket.
The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B covered service too.
This simply means that you pay your share of the costs for services provided by your physician, use specific hospital services like MRI or CAT imaging, cancer treatments, services provided in the surgical suite, etc.. The insurance company behind each plan sets their own cost sharing for that plan. You find these figures in each plan’s ‘Evidence of Coverage’ (EOC).
The EOC also identifies which services must be approved by the insurance company before they can be performed. Be aware approval requests can be denied by the insurance company.
Prior Authorizations.
Services covered by any Medicare Advantage plan may have a ‘prior authorization’ tag on a service. These are found in the plan’s EOC. The insurance company can approve or deny the prior authorization request. Learn more about what is going when these requests by reading this article, this article, and this article. CMS is in the process of implementing new procedures to improve this situation.
When you stay with Original Medicare (Part A and B….not enrolled in a Medicare Advantage plan) these are the Medicare covered services which have prior authorizations. This list is considerably smaller than what you typically find in a Medicare Advantage plan.
Doctors/hospitals/other providers.
Availability of physicians, hospitals, physical therapists, skilled nursing facilities, durable medical equipment providers and all other provider types vary by plan. Read this article to learn more.
The insurance companies offering Medicare Advantage plans put together their networks of these people/facilities for their plan members. Medicare requires insurance meet a minimum adequacy requirement when they put their networks together. This means there is a good probability not all of the physicians/providers that ‘accept Medicare’ insurance are not in your plan’s network.
If, during your plan research, you wish to find out how many of a certain type of specialists are in the plan’s network vs how many that ‘accept Medicare’ are in the same area, you have tools available to figure this out. It may be useful knowing which plans have the higher percentage of cardiologists, oncologists, etc. are in their network. We can show you how to get the answer to this question.
The above can change during the calendar year. This announcement is an example of why networks can change during the year. Another example is found here and here.
Some plans in your county specialize in St. Alphonsus hospital(s) and their providers. Other plans include both major hospitals systems. Some may include, at their option, specific 2nd tier facilities (like Treasure Valley Hospital, etc.).
Be aware hospitals may/may not be using current technologies/techniques to treat patients. Why? Because of the cost for new technologies are competing for other financial needs of the hospital.
Proton Therapy is an example of newer technology for treating cancer.
Read this article if you are unfamiliar with this. At this writing, 45 hospitals (out of over 4500) offer this solution. Facilities near Idaho include:
Huntsman Cancer Institute (Salt Lake City) (began offering this service in 2021)
The Mayo Clinic Cancer Center (Phoenix…rolled out this service on 2016)
Loma Linda University Cancer Center (began offering this service in 1990)
California Protons Cancer Therapy Center (San Diego) (began offering this service in 2017).
If you are interested in this service, you might check where each of the above facilities are ranked in the top 250 hospitals.
Do you want access to the top 250 hospitals in the country?
The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them. These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.
Does Medicare rate hospitals for us?
Yes.
Hospitals are assigned a ‘star rating’ by Medicare. We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.
There are physician rating services too. One is available here. We focus on physicians with a 4 or 5 star rating and have at least 10-ratings. You can use this same tool to find physicians that ‘accept Medicare insurance’.
We also recommend you use a ‘board certified physician‘.
Medications covered by each plan.
According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of the Idaho plans include 100% of the medications covered by Medicare.
This same resource documents the number of medications each plan has in each of the 5 (or 6) drug tiers AND the fill/refill cost by these same drug tiers. These figures can vary noticeably between plans.
Given the wide variance between plans on the above, it is easy to understand why there can be a 300% +/- variance in your projected annual out of pocket cost between your plan choices for the medications you take.
This is a key reason you should not enroll in any Medicare Advantage plan until you understand your cost for your prescription medications. If you are working with a broker/agent that just tells you your medications are covered, we suggest you work with someone else that will share the whole picture.
Are medications that treat serious health issues (cancer, etc.) covered by my plan?
The Centers for Medicare and Medicaid Services (CMS) has requirements insurance company(s) offering Medicare plan(s) must meet when they put together their list of covered medications.
Below is a cut/paste from (Section 30.2.5) the current Medicare Prescription Drug Benefit Manual.
“Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant(for prophylaxis of organ transplant rejection), antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes. CMS instituted this policy because it was necessary to ensure that Medicare beneficiaries reliant upon these drugs would not be substantially discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“
We feel this is an important statement everyone enrolled/wishing to enroll in a Medicare prescription drug plan should be aware of.
There are 3 different audiences for Adams County Medicare Advantage plans.
There are Medicare Advantage plans for Veterans, people enrolled in Medicaid and Medicare, and several plans for the rest of us.
Let’s take a closer look at each.
Adams County Medicare Advantage plans for Veterans.
Veterans have 6 Medicare Advantage plans that do not include prescription drug coverage.
There are also other $0/low premium plans that include prescription drug coverage which should be considered. Why? Because the ‘extra benefits’ in these plans can be more attractive than the plans without drug coverage.
Many of these plans include a ‘giveback’ for the member’s Part B monthly premium.
This benefit varies between $0 to OVER $100/month. These figures can change annually.
The amount of the Veterans out of pocket costs for plan covered health care services can vary widely between these plans. This is also true for the ‘non-Medicare’ covered benefits that are often found in these plans (gym membership, dental coverage, etc.). Which hospitals and physicians are available to the plan member can also vary by plan.
Should you choose an HMO or a PPO plan?
A veteran may prefer a PPO plan if they want to open their choice of hospitals and doctors to include those beyond Idaho’s borders. An HMO plan may fit a veteran that wants health care outside the VA and/or urgent and emergent care.
We do need to pay attention to the HMO plan’s network of hospitals and doctors, as they can vary.
We recommend Veterans review their Medicare Advantage plans at least every 2-3 years.
This market niche has become quite competitive between the insurance companies.
Some of these companies want to increase their market share by offering more attractive features than their competitors. These companies are changing their offerings annually to attract more potential new members.
We suggest veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.
We can help you with this when you are ready. Learn more about us here.
Adams County residents on Medicaid and enrolled in Medicare.
Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025.
Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here. Answers to ‘frequently asked questions’ is available here.
If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.
UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026.
Molina continues to serve Idaho residents with these important products.
If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help. We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022.
Additional pertinent information about Idaho Medicaid and your plan choices.
There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).
If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider.
Click here to learn more about your options.
We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP).
Explaining plan differences and helping you with enrollment are other services we help you with.
Adams County Medicare Advantage plans with low/no premium and are rich in non-Medicare benefits.
When you look at the Summary of Benefits’ document, you may notice some plan(s) have $0/low premiums and include attractive extra no cost benefits. These plan(s) may separate themselves from other plans because of this. If you are attracted to these plan(s) be sure and consider your financial exposure if you will use plan(s) health care services. The plan’s ‘out of network limit’ may be higher than other plans. The ‘cost sharing’, when plan health care services are used, may also be higher than other plans.
Adams County Medicare residents who seldom use health care services and prescription drug medications may be attracted to these plan(s). If the insurance company is successful in attracting this type of consumer, their expenses may be lower (and be more profitable).
Medicare Advantage plans with only one of the major hospital systems in their network.
We like these plans from a feature and out of pocket cost standpoint.
They can have lower costs for services covered by other plans AND for prescription drug fills/refills.
A potential downside of any plan with a narrow network is the narrow network. Each of us is one doctor visit or one heartbeat away from needing medical care. If you prefer to research the background and skill set of hospital(s) and other providers before deciding on whom to do business with, a single hospital plan may or may not end up being the right plan. This is for you to decide. There are tools available that identify the top hospitals (and often the top specialists) in the US.
We are here to help you think this through.
Adams County Medicare Advantage plans with most/all of the major and 2nd tier hospitals located in Ada and Canyon County in their network.
Plans in this category may be a good fit for people that want more flexibility on where they get their health care (when compared to single hospital plans).
Monthly premiums for these plans range from $0 to over $135.
If you are interested in a Medicare Advantage plan with a premium above $65/month, an Out-of-Pocket Limit above $6,000 or have copays for stays in a Skilled Nursing Facility after day 60, be sure you understand your other choices. These include the other lower premium Medicare Advantage plans as well as Medigap plans. Learn more about your Medigap options here.
We can help you think this through.
What insurance companies offer Medicare Advantage plans in Adams County?
Blue Cross of Idaho
Humana
Molina
Saint Alphonsus Health Plan
United Healthcare
Other tidbits to be aware of
Hospitals in your immediate area
There are no hospitals in Adams County. There are 2 relatively close by. One in McCall and the other in Cascade.
The plans available to Adams County residents are also available to residents of both Ada and Canyon County.
There are 20 hospitals within 100 miles of downtown New Meadows. Get a visual of their location by clicking here. Be sure and click on ‘hospitals’, then enter zip code 83654; adjust the ‘radius’ to 100 miles.
Be sure and check out the CMS hospital star rating of these facilities.
Having resources with a ‘4 or 5’ Star rating can be important to you when you get regular care, emergency and scheduled surgical procedures.
Read the fine print on extra Benefits included in Medicare Advantage plans.
Dental Coverage.
Please review the verbiage on dental care found in the Evidence of Coverage.
If you listen to the TV commercials, this sounds like a great and often needed ‘extra’.
You really need to pay attention to the details as they can vary widely between the plans that include this feature.
For example, some plans restrict coverage to periodontal preventative care. Some may limit the number of annual cleanings you can get, etc.
Some plans include class II and III services. If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes. Please read your plan’s ‘Evidence of Coverage’ for specific details.
Do you need to use the plans network of dentists?
Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services.
Plans may state cosmetic services are not covered.
It you use an ‘out of network dentist, you may pay for all services. Or services you use may cost you more when compared to your cost if you use an in-network dentist.
We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.
Your plan may not pay for services you use which are excluded from your plan.
If you have any question about whether a service is covered, call your plan’s customer service. You may have to get specific billing codes from your dentist just to be sure you get the right answer.
We like plans that let you use any licensed dentist in the US and cover all non-cosmetic dental services.
Vision Coverage.
The depth of this coverage varies by plan. The same issues pointed out for dental coverage can apply to this service too. Be sure and look at the cost for an annual checkup, network restrictions, how much the plan will pay for glasses, frames, contacts, etc.
Over The Counter benefit.
Some plans have a catalog of ‘drug store‘ items you can order from and they are delivered to you at no cost. It is possible the items you want will not be included in the plan’s catalog of covered items. Plan’s have a quarterly limit on how much it gives you to spend on these items. The amount of the quarterly limit can vary widely between plans.
Gym Memberships.
You need to pay attention to the depth/variety of facilities that are available and close to you. Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’, a membership with their own network of facilities. Some plans may charge ‘extra’ for this feature. Read the plan’s rules for this service…and which facilities in your area are available to you.
Hearing Aids.
Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit. This means you are using that vendor to spend your hearing allowance.
If you are unfamiliar with these products visiting the Costco hearing department may provide a good education.
What you learn about product differences may help you better understand the differences of the product(s) available from your insurance plans choices.
Plans can be different on what specific products (and services) are available to you.
Would a Medicare coach be helpful?
A coach can answer your question(s), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process. They will also be there year after year to help you.
Will the people behind the TV ads include this service for you?
Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.
We started this business in 2012 explicitly to help Idaho residents work their way through this maze.
This page was updated on