Clearwater County Medicare plans
2026 Clearwater County Medicare Advantage plans.
There is a synopsis of changes to the Idaho Medicare Advantage marketplace here. If you are not aware of these changes, please take a few minutes and read this material.
An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15-25/2026. Be sure and check back for this important information.
What are we waiting for? Provider directories which include which hospitals are in the plan’s network. We have most of the Evidence of Coverage documents now.
Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices. This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.
What you need to know about 2025 Clearwater County Medicare Advantage plans!
For 2025, Clearwater County has 9 Medicare Advantage plans for residents to consider.A plan targeted for Veterans.
1 plan is targeted for Veterans that gets their prescription med’s from the VA. Veterans may find this plan attractive as it is a back up for health care services you get from the VA. All health care services offered by Medicare are included in this plan including ‘Emergency services’. The plan may contain other non-Medicare covered benefits.Plans for people with specific chronic health issues.
2 plans are unique and reserved for residents which 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). If you have a Medicaid status of QMB+, QMB or SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.Plans for people with Medicaid status of ‘enhanced’ or ‘QMB’.
3 other plans are reserved for people classified as ‘Enhanced’ Medicaid. If you have this qualification, we suggest you consider these plans. Why? Because you get a ‘care coordinator’ that helps pave the way for you to get the medical appoints you need AND these plans may have ‘extra’ benefits that go beyond what either Medicare OR Medicaid offers. These plans are also called a ‘Medicare Medicaid Coordinated plan’. The next plan is for people assigned a ‘QMB’ Medicaid status. If this includes you, we encourage you to focus on this plan. Why? The care coordination covered by either Medicaid or Medicare is taken care of by the plan. The plan may also include ‘extra benefits’ at little/no cost.Plans for the rest of Clearwater County residents.
2 plans are available for the rest of Clearwater County residents. Both of these are HMO plans. We help you understand their differences and enroll in the play you choose. We recommend veterans also consider these plans.Clearwater County has another type of Medicare plan you should be aware of.
These plans are called Medigap (also called Medicare Supplement) plans.
When you choose this type of plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you.Two of these plans limit your annual out of pocket costs for Part A and B covered services to less than $2,900.
What are the differences between the two Clearwater County Medicare Advantage plans for residents not enrolled in Medicaid?
One item is the plan’s Maximum out of pocket limit (MOOP). Read the information below to learn why this is a key differentiator between plans.What are the actual MOOP figures?
Medicare’s maximum MOOP for this year’s HMO plans is $9,350. 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. According to this source, the range of MOOP for your County’s HMO Medicare Advantage plans is $4,900 to $6,300.We prefer plans that meet a person’s needs, have a low MOOP, AND plans with a monthly premium below $70.
Why $70? You can get a Medigap plan described above for a lower premium AND you will not have an insurance company standing between you and your doctor to get the ‘next step’ in your health care accomplished. There are far fewer ‘prior authorizations’ that your physician/hospital have to contend with.If you understand how the math works when calculating your MOOP after you use plan services, skip the paragraph below.
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 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(s) offering Clearwater County Medicare Advantage plans 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 plans may have prior authorizations on certain covered services.
You find this information in your plan’s ‘Evidence of Coverage’ document. This is available on the insurance company’s web site and can be downloaded. Your insurance company can approve or deny the service requested by the ‘prior authorization’. If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over. This is one of the reasons we prefer plans that do not have insurance companies standing between you/your physician to get to the ‘next step’ in your health care. The article found here brings this point to life. 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.Hospitals in your immediate area
There is 1 hospitals within 25 miles of downtown Orofino (zip code 83554). Get a visual of its location by clicking here. Change the search area radius to 50 miles to check out your other options.Some of these hospitals are rated by The Center for Medicaid and Medicare Services (CMS) as 3 stars. We recommend hospitals with at least a 4-star rating.Having resources with higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.All of these hospitals may not be in-network for the Medicare Advantage plans available to you.If you have a Medigap plan, they will be.
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 physicians/providers in your geographic area that ‘accept Medicare’ insurance are not in your plan’s network.
You have the tools available 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 .
If you have existing health issues, would it be important for you to know how many specialists which treat this for you are in the plan you select? We can show you the tools to do this. 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 is competing for other financial needs of the hospital.
Proton Therapy is an example of newer technology to treat 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.
Are you interested in the top 250 hospitals in the country?
Would you consider using the services of the top hospitals in the Seattle area…or the Mayo Clinics?Medications covered by Clearwater County Medicare Advantage plans.
According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you.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.Clearwater County Medicare Advantage plans for Veterans
Veterans have several Medicare Advantage plans to consider. These plans do not include prescription drug coverage and are offered by private insurance companies which compete each other for your business. Each plan sets their ‘giveback’ for the member’s Part B monthly premium. This year this figure varies between $0 to $75/month for this year. 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 available to the plan member can also vary by plan.
A veteran may prefer a PPO plan if they want to open up 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 Clearwater County Veteran Medicare Advantage plans at least every 2-3 years.
This market niche is becoming more competitive between the insurance companies offering these plans. 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 of these plans.
We can help you with this when you are ready. Learn more about us here.
Clearwater 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.
Clearwater County Medicare Advantage plans available to the rest of the Medicare beneficiaries.
When you look the plan’s 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 their self 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.
Insurance companies may offer Medicare Advantage plans in a market niche designed for people which seldom need health care services. If the company is successful attracting this type of consumer, their expenses may be lower (and also be more profitable).
Would a Medicare coach be helpful?
A coach can answer your question(s) and firm up your understanding of Medicare. Once this is done, they will 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.
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