Gem County Medicare Advantage Plans
Several 2025 Gem County Medicare Advantage plans caught our attention.
The first plan has key 5-star hospitals in Oregon, Washington, Utah and Idaho in their network!
This means you have a broader choice of resources to consider on where you get your health care. When you use these resources, you pay in-network cost sharing. This same plan opens up access to other hospitals/physicians in the US that ‘accept Medicare’ too. This can be useful for ‘snowbirds’.
The second plan has all the of the boxes checked (attractive network, formulary, out of pocket costs, competitive ‘extras’, and MOOP). If you presently have an HMO plan (or are considering one for 2025) and live in Southwest Idaho we encourage you to add this to your short list.
The 3rd plan puts OVER $100 a month for the rest of 2025 back in your pocket. This plan includes prescription drug coverage too! Veterans should also consider this this plan!
If you have been 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) you should look at these plans. They were developed for individuals with these specific health issues.
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 Gem County Medicare plans on our recommend list. Which medications, health issues, and hospital preference(s) a person has/does not have are determining factors on which are appropriate.
Call us with your questions.
What else you need to know!
For 2025, Gem County has 36 Medicare Advantage plans for residents to consider.
Here is the high level breakdown:
8 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.
5 of these are PPO;
3 are HMO plans.
Veterans should also consider the HMO plan with a buy back of over $100 too. Why? It’s Part B but back is higher than any of the Medicare Advantage plans which do not include prescription drug coverage.
21 plans do include prescription drug coverage and services covered by Medicare Part A and B.
14 are HMO plans;
7 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 (also known as Medicare Supplement) 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 Gem County Medicare Advantage plans.
Also, you do not have an insurance company standing between your physicians 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.
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 figures in mind when you review the MOOP discussion below.
What are the differences between Gem County Medicare Advantage plans?
The result of annual negotiation between physicians, hospitals and insurance companies offering Medicare Advantage plans. This issue affected Idaho residents in 2025. Read this article for details.
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.
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.
The information below is for people that want to know more. You might scan the bold headings to see if the topic is of interest to you.
What are the actual MOOP figures?
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 $3,000 to $13,300. The range for PPO plans is $4,100 to $14,000.
We prefer plans that meet a person’s needs AND have a low MOOP.
You can check out the above figures by using the resource found here.
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 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 coverage. 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, your plan may exclude certain services.
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 limitations on the number of cleanings too (2 per 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.
When reviewing 2025 dental coverage for some plans we noticed something we have not seen before. It reads ‘Submitted claims are subject to a review process which may include a clinical review and dental history to approve coverage’. To us, this is an example of why people interested in dental coverage included in a Medicare Advantage plan need to read the fine print before choosing a 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 that 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. 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.
Are you interested in 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.
Hospitals are assigned a ‘star rating’ by Medicare. We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities. Be aware the CMS hospital ratings do not include surgical results by type of surgery. This is why we also look at the other ‘hospital rating’ services that include these measurements.
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 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) have requirements insurance companies 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 Gem 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.
Gem County 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 with each other for your business.
Some of these plans help you pay for your monthly Part B premium (the plan’s call this feature a Part B giveback). Each plan sets their ‘giveback’ for the member’s Part B monthly premium.
This year your County’s plans have a giveback between $0 to $100/month.
The Part B payback figures can change annually and are controlled by the insurance company offering the plan.
The Veterans out of pocket costs for plan covered health care services can vary widely between 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.
Which plan is right for you?
Do you want access to doctors/hospitals anywhere in the US?
A veteran may prefer a PPO plan if you want to open your 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 MOOP.
You may want to include PPO plans which include prescription drug coverage too. They may offer better value to you than the PPO plans which do not.
Call us if you want help thinking this through.
Do you want a plan that is a backup for the health care services available through the VA?
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.
If a Veteran selects 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.
Are you getting a plan to take advantage of the Part B give back and/or the ‘extras’ that come with some of these plans?
Some Veterans may have no intention of getting health care from one of these plans. They just enroll in a 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.
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 insurance company if the Veteran continues to get their health care from the VA.
If you want help with plan selection…
Call us. I am a veteran (Vietnam) and have been helping others with Medicare, plan selection, and enrollment since 2012.
Gem 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.
Gem County Medicare Advantage plans with low/no premium and are rich in non-Medicare benefits.
When you look 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 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 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 the plan AND for prescription drug plan 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.
Gem 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 a bit more flexibility on where they get their health care (when compared to single hospital plans).
Monthly premiums range from $0 to over $150.
If you are interested in a Medicare Advantage plan with a premium above $70/month, an Out of Pocket Limit above of $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 Gem County?
Blue Cross of Idaho
Humana
Pacific Source
Regence Blue Shield of Idaho
Saint Alphonsus Health Plan
United Healthcare
Other tidbits to be aware of
Hospitals in your immediate area.
Gem County has 1 hospital within its borders. There are several others relatively close by (Ada and Canyon County).
The plans available to Gem County residents are also available to residents of both Ada and Canyon County.
There are 14 hospitals within 50 miles of downtown Emmett. Get a visual of their location by clicking here. Be sure and enter zip code 83617; adjust the ‘radius’ to 50.
1 of these hospitals is not in Idaho and may not be available in the network of Medicare Advantage plans in Gem County.
Always pay attention to the CMS star rating of any hospital you would consider using.
Having resources with a ‘4 or 5’ Star rating can be important to you when you get regular care, emergency and scheduled surgical procedures.
All the hospitals listed in the above search may not be in every plan.
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 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. Some plans may not.
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 and are a member of Costco, you might visit them. They can provide you the foundation you need to understand product differences.
Plans can be different regarding what specific products (and services) are available to you.
Would a Medicare coach be helpful?
A coach can answer your questions, help firm up your understanding of Medicare, and explain the differences between your choices. When you are ready we will help you through the enrollment process. They will also be there year after year to help you review your options.
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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