Franklin County Medicare Advantage Plans
CMS Required Statement for Idaho Franklin County residents interested in a Medicare Advantage plan.
We are licensed with all Idaho Franklin County Medicare Advantage plans listed on the Medicare Plan Finder tool.
We have 2025 Part D licenses with Aetna, United Health Care and Humana.
The remaining 3 companies (Wellcare, Clear Spring, and Cigna) either do not use brokers in 2025, their plans are ‘sanctioned by CMS’, or we chose to not license with them.
Additional information on his subject is documented here.
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When you are finished reading this information, use your ‘browsers back icon’ to return to this page’.
Keep in mind if you would rather talk with us about plan details, just call…but first
Brokers must follow CMS rules before they can discuss plan details.
Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and either text (1-208-867-0296) or email (chuck@getmedicareinsurance.com) the image to us. Upon receipt we will call you and share the details.
2025 Medicare Advantage Plans available for Idaho’s Franklin County residents with chronic health issues.
There are plans for people that 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 and SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.
What Else you need to know.
For 2025, Franklin County has 13 Medicare Advantage plans for residents to consider.
Here is the high level break down:
3 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.
1 are HMO plans;
2 are PPO plans.
8 plans do include prescription drug coverage and services covered by Medicare Part A and B.
4 are HMO plans;
4 are PPO plans.
The remaining plans are reserved for individuals which 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.
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 Franklin 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 prefer these plans because they know they will be paid in a timely manner. Also, there are fewer ‘prior authorizations’ for them 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.
The 2 plans we recommend you consider 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.
What are the differences between the other 8 Franklin County Medicare Advantage plans?
One item is the plan’s Maximum out of pocket limit (MOOP).
This 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.
Be mindful Medicare pays its share of the cost for services you use. You pay the rest. Your share of these costs can vary noticeably between plans.
Think of the MOOP as your limit (or cap) for your share of health care costs for Part A and B services you use during the calendar year. The higher your plan’s MOOP, the more you could end up paying for the services you use.
Medicare sets the maximum figure(s) a plan can have, and they can change it annually.
The insurance company offering your plan sets the plans MOOP where they want it. It must be at or below Medicare’s limit. This figure can change annually.
What are the actual MOOP figures?
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 $6,300.
The range for PPO plans is $5,700 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 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’.
Prior Authorization is an example.
Prior authorization may be required on specific plan covered services. What does this mean? Your insurance company can approve or deny the service request. If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over.
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 (if included in a plan) 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 is 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.
If this is new to you, read this article.
At this writing, 45 hospitals (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?
Would you consider using the services of the top hospitals in Seattle, Salt Lake City, or the Mayo Clinics?
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 (Part A and B). Some do not accept Medicare Advantage plans (Part C). Others prefer you stayed with Original Medicare (Part A and B…and not enrolled in a Medicare Advantage plan). If you have a Medigap plan it will help you pay the left-over costs that Medicare does not completely cover.
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 consider a ‘board certified physician‘.
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’.
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 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 have more flexibility and less hassle 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?
We recommend you consider a Medigap Plan G.
Are there lower premium Medigap plans what have some copays?
Yes.
There are 2 different Medigap plans we like that meet these criteria. They have a Medicare controlled ‘annual deductible’. Yes, it goes up a bit annually.
This ‘deductible’ is similar in concept to the MOOP described above.
The deductible for this year is found here.
Once your share of your costs for the services you use hits this figure, this Medigap plan pays the rest of your Part A and B left over costs for the calendar year.
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.
There are 3 different audiences for Idaho Medicare Advantage plans.
Franklin County Medicare Advantage plans for Veterans.
are entitled to VA health care this is a
great place to get your health care and
prescription medications.
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.
Why the interest by insurance companies in the Veterans Medicare niche?
A couple of obvious reasons could include they want to say thank you to the Veteran for their service.
Another can be 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.
At the current moment, the major insurance companies offering these plans are in Franklin County. There may be more new entrants next (or following) years.
In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.
These plans have different features and costs to the Veteran.
These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.
Why is the Part B ‘buyback’ important?
Many MA plans in Idaho also include the Part B buyback. This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium. In other Idaho Counties, this figure varies from $0 and up.
Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan. Others want access to urgent and emergency care outside of the VA. Others simply want a broader choice of doctors and hospitals.
Another key point is 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.
Medicare Advantage plans for the rest of the Medicare beneficiaries living in Franklin County.
Monthly premiums range from $0 to over $100.
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 the plans offer access to more hospitals beyond Franklin County borders.
What insurance companies offer Medicare Advantage plans in Franklin County, Idaho?
Humana
Select Health
United HealthCare
Other tidbits to be aware of.
Hospitals in your immediate area.
There are 4 hospitals within 25 miles of downtown Preston.
To see these, click here.
When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page.
Hospitals are rated by The Center for Medicaid and Medicare Services (CMS). We recommend people use facilities rated 4 or 5 stars.
If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.
Having resources with these higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.
All of these hospitals listed may not be in every Medicare Advantage plan. They will be available, if you are enrolled in a Medigap plan.
Read the fine print that describes ‘extra’ benefits included in Franklin County 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 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 Membership.
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 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 Medicare Advantage plan 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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