Blaine County Medicare Advantage Plans
What you need to know about 2025 Blaine County Medicare plans!
For 2025, Blaine County has 20 Medicare Advantage plans for residents to consider.
Here is the high level break down:
5 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.
4 of these are PPO;
1 is an HMO plan.
9 plans do include prescription drug coverage and services covered by Medicare Part A and B.
4 are HMO plans;
5 are PPO plans.
The remaining plans are reserved for individuals who qualify for Medicaid special needs plans (I-SNP, C-SNP or D-SNP).
There is another type of Medicare plan you should be aware of.
These are Medigap plans.
Medigap plans open up your access to all physicians/hospitals/other providers (that accept Medicare insurance) in the USA.
They also minimize use of ‘prior authorizations’. Learn what an issue this has created for people enrolled in a Medicare Advantage plan here.
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. Medigap plans have different enrollment qualifications and time periods than Medicare Advantage plans. If you have an interest in this type of plan, please be aware of these rules.
Two of these plans limit your annual out of pocket costs for Part A and B covered services to less than $2,900. 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.
Keep these plans in mind when you review the MOOP discussion below.
Interested in learning more about your plan choices? Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and text it to us (1-208-867-0296). Upon receipt we will call you and share the details.
Call if you have questions.
What are the differences between Medicare Advantage plans?
The plan’s monthly premium. They range from. $0 to over $100. We do not recommend plans with a monthly premium above $70? Why? The above mentioned Medigap plans may offer you better value.
The MOOP (Maximum out of pocket limit) is a key figure you should be aware of. Put plans on your short list that have a lower MOOP. This decision may save you money if you use Medicare covered health care services during the plan year.
Pay attention to your share of the costs for the services you know you will use.
Then look at the cost sharing for the services that would be needed if you were diagnosed with a serious health issue.
What hospital(s) do you want to use if you are diagnosed with a serious health issue?
Would you prefer to have access to one of the major hospitals (and physicians) in the Pacific Northwest (or the entire US)? How do you find them and narrow down the list that excel at treating your specific issue?
What is your cost share for filling/refilling the prescription medications you take? There is typically a 300% +/- annual difference in medication costs between plans for the same set of medications.
What are the extra (non-Medicare covered services) included in plans. What is actually covered? Are the providers you currently use for these services in the plans network? What are the limits your plan will pay for these services?
Idaho based Brokers specializing in Medicare plans are available to you help you navigate your way through this maze.
We have been helping Idaho residents with their Medicare plan choices since 2012. This includes several residents in Blaine County.
If you would like to use our ‘cost-free’ help, complete the ‘scope of appointment’ document mentioned above, send it to us. We will call you for your 1st appointment.
How do brokers get paid for their services?
By the insurance company. Medicare regulates how much a broker gets paid; all/most all insurance companies offering Medicare Advantage plans in Idaho are pay the brokers the same. To us, that means we focus on the people’s needs we are working with and present plans which meet those needs.
If you want to learn more, additional details are below.
What are the actual MOOP figures of Blaine County Medicare plans?
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 $4,500 to $6,000.
The range for PPO plans is $5,900 to $14,000.
Remember, these are the figures you want to compare to the ‘less than $2,900’ for either one of the ‘hi-deductible’ Medigap plans’ mentioned above.
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.
When you subtract these figures 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 service.
This simply means what you pay to see your physician, use hospital services, pay for your MRI/CAT imaging, cancer treatments, skilled nursing care, etc. are often different between plans. When you compare plans annually, you look at these figures and choose the plan that best fits your pocketbook and needs. These figures can change annually.
Cost sharing for services used, the plan’s MOOP, monthly premium, and the financial savings you get when you use the plan’s non-Medicare covered services are some of the differentiators between plans.
Specific plan coverages may have limitations.
Rules may be imposed on specific coverages. You find these rules in your plan’s ‘Evidence of Coverage’. You can find this document on your insurance company’s website or by calling the customer service phone number on your member card.
Prior Authorization is an example.
A ‘prior authorization’ may be required on specific plan covered services. What does this mean? Your insurance company is requesting information from the prescribing physician about the service they wish to perform. The insurance company can approve or deny the service request from your physician. If the service request is denied, your prescribing physician has to go to ‘plan B’ and start the process over. In the meantime, the patient/plan member is waiting.
The article found here information on what has been going on in this industry.
If you use Skilled Nursing Care you may hit your plan’s MOOP!
The number of days ‘skilled nursing care’ has their daily co-pays in place is something you need to pay attention to. Why? Because if you need this service and have the ‘wrong’ plan, it can be the quickest way for you to hit your plan’s MOOP.
Dental coverage is another example where rules are important to know.
For example, dental may exclude certain coverages.
This can be done by dental billing code(s) or by limitations on specific services you need that are in coverage class I, II, and III.
Implants or braces may be covered by some plans, but not others.
There may be limitation on the number of cleanings too (2/year when you may need 4); periodontal services, if covered, may have their own limitations, etc. The dollar value the insurance company offers you for dental coverage can vary widely between plans.
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.
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. It is being used as an alternative to radiation treatments.
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. Learn about examples of these here and here,
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. This article points out further information on this topic.
There are other 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 these 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.
Will you save money and grief by choosing a Medicare Supplement plan?
These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B). Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans.
When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with. You and your physician are making the decision on the ‘next step’ in your health care. You do not have an insurance company standing between you and your physician to get the ‘next step’ in your health care done.
Read the articles supporting the above comments here, here, and here.
Do you want a plan that pays for most all of the left-over cost for Part A and B in the US?
We recommend you consider a Medigap Plan G.
Are there lower premium Medigap plans what have some copay’s?
Yes.
When you work with a Medicare broker that is licensed with all/most all plans available to you, they help you navigate your way through this maze and select the plan which meets your needs and budget.
We have been helping Idaho residents with this task since 2012. Call us if you want help.
Blaine County Medicare Advantage plans for Veterans
Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.
Why would a Veteran consider a Medicare Advantage plan? Because:
- You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care. You can still get services from the VA.
- Take advantage of the Part B buyback offered by some of these plans. This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium. At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho. These figures are determined by the insurance company offering the plan and can change annually.
- Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
- Many of these plans have a $0 monthly premium.
Is an HMO or a PPO plan right for you?
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.
Be aware when plan services are provided by ‘out of network’ providers, the plan members share of the cost for services can be noticeably higher when compared to using ‘in network doctors/hospitals/etc. Getting ‘out of network’ services may greatly increase the Veterans probability of hitting their ‘out of network’ maximum out of pocket limit. Check out this figure if you are interested in a PPO plan. Call us if you want help thinking this through. A hi-deductible Medigap plan may save you money and grief.
An HMO plan may fit a veteran that wants coverage outside the VA for regular health care OR just want access urgent and emergent care when it is needed.
Some Veterans choose a $0 premium plan so they can get the low/no-cost ‘extra’ benefits which can come with these plans. We noticed some plan(s) with a high Part B giveback also come with high cost sharing when plan health care service is used. Call us if you want help thinking this through.
If a Veteran plans to get health care from an HMO plan, we need to pay attention to the plan’s network. Participating hospitals and doctors can vary by plan and this can change annually.
Why the interest by insurance companies in the Veterans niche?
A couple of obvious reasons could include they want to say thank you to the Veteran for their service.
Another can be is these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.
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. Look at the ‘extra’ services not covered by Medicare for each plan you are considering. Do you see any differences?
These companies may improve their offerings annually. They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.
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.
Blaine County residents on Medicaid and enrolled in Medicare.
There are several satellite offices spread around the State.
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.
Medicare Advantage plans for the rest of the Medicare beneficiaries living in Blaine County
Check out the hospitals in each plan’s network and where they are located.
There is one major hospital in Blaine County.
Check out the other facilities within 50 miles of zip code 83353 by clicking here.
Be sure and enter your zip code (83353) and adjust the radius to 50-miles.
If you raise the radius to 100 miles, there are 15 hospitals available. These include a hospital in Rupert, Twin Falls, a few other nearby Counties, and in Boise.
Notice some hospitals on this list have a Star rating (range is 1 – 5) and some do not.
Hospital(s) without a rating may have not reported their results or did not meet the minimum number of procedures to be measured and rated for the current period.
We recommend Idaho residents consider any hospital with either 4 or 5 star rating.
When selecting a health plan…
Be sure the hospitals and doctors you want to take care of you no matter the health issue is available to you.
The CMS hospital rating system is a guideline to consider using.
You can also use another tool that identifies the top 100 hospitals in the US. This information rates hospitals by type of surgery within hospital too. Learn more here. You can consider these resources if you have a plan which opens up these facilities to you.
Additional information on Blaine County plans in just a moment.
What insurance companies offer Medicare Advantage plans in Blaine County?
American Health Advantage of Idaho
Blue Cross of Idaho
Humana
Pacific Source
United Healthcare
Other tidbits to be aware of
Additional details about the plans available in Blaine County
Monthly premiums of Medicare Advantage plans range from $0 to $116.
The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans.
Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’.
Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’.
Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory). Reference this note for details.
Some of these plans specialize in the St Lukes hospitals in Idaho.
Some of the plans offer access to more hospitals beyond Blaine County borders.
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 TV commercials, this is 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 preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.). The plan may cover certain periodontal services. If covered, the plan may limit the number of times specific service(s) can be used during the year. 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 co
Do you need to use the plans network of dentists?
Plans may have a network of dentists you can use; some let you use any dentist. Please read your plan’s ‘Evidence of Coverage’ for specific details.
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 plans 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.
Visiting the Costco hearing department may provide the education you need to understand product differences.
Plans can be different depending 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 ad’s include this service for you?
Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.
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