Jefferson County Medicare Advantage Plans

CMS Required Statement for Jefferson County residents interested in a Medicare Advantage plan.  

We are licensed with all Jefferson County Medicare Advantage plans listed on the Medicare plan finder tool, except I-SNP (Institutional Special Needs plans). 

3 of the 5 insurance companies offering Part D plans in Idaho use our services. Wellcare does not use brokers and we chose to not be licensed with Cigna.    

Additional information on his subject is documented here. 

2025 Plans available for Jefferson 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.  

Other Plans for 2025. 

There are other Jefferson 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. 

Interested in learning more?  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.   

Don’t forget, if you are enrolled in a Medicare Advantage plan now, you can switch to a different plan between January 1 and March 31. 

What Else you need to know.

For 2025, Jefferson County has 21 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.

                  3 of these are PPO;

        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 (i-SNP, C-SNP or D-SNP).

There is another type of Medicare plan you should be aware of.

This plan limits your share of the annual out of pocket costs for Part A and B covered services to less than $2,900. 

This figure is controlled by Medicare and is similar in concept to a Medicare Advantage plan’s ‘maximum out of pocket limit’ (MOOP).  Medicare typically makes annual increases the maximum MOOP and the ‘deductible’ mentioned above.

A reminder, the MOOP is a Medicare Advantage plan’s cap on your share of left over costs when you use Part A and B services.  If your out-of-pocket cost for health care services covered by your plan gets into the ‘several thousand dollar’ area, you should be able to keep more money in your pocket if you have a plan with a ‘lower’ MOOP.  The plan’s deductible mentioned above works like a Medicare Advantage plan’s MOOP.   The ‘deductible’ mentioned above is typically noticeably lower than any Idaho Medicare Advantage plan’s MOOP.  

When you choose this plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you and prior authorizations are minimal.  This simply means you are not limited by network rules found in Medicare Advantage plans.  This also means you are not charged a ‘premium’ for services received when you use services out of your immediate area (like many PPO plans).

 Call if you have questions.

What are the some of the differences between 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 $4,500 to $6,750. 

The range for PPO plans is $5,900 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 processes to help get this back on track. 

When you stay with Original Medicare (Part A and B….not have a Medicare Advantage plan) these are the Medicare covered services which have prior authorizations. 

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.  The insurance companies offering Medicare Advantage plans put together their networks of these people/facilities for their plan members.  You need to confirm the doctors and hospitals are in the plan’s network. 

A plan’s network can change during the calendar year.  This announcement is an example of why this can happen during the year.  Another example is found here and here. 

When you stay with Original Medicare (Part A and B…not enrolled in a Medicare Advantage plan) all doctors/hospitals in the US, which ‘accept Medicare’ are available to you.   

Choices of physicians/hospitals can become more important as we get older.  Why?  Because we use more medical services as we age (reference exhibit 1.3 of article found here).    This is why some people prefer a Medigap plan in lieu of a Medicare Advantage plan.

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. 

 Will you have more flexibility and less hassle by choosing a Medicare Supplement plan?

Yes. 

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.

This means you do not have an insurance company standing between you and your physician to get the ‘next step’ in your health care done. 

Check out what services have prior authorizations when you are enrolled in Part A and B AND not in a Medicare Advantage plan.  Compare this list to the ‘Evidence of Coverage’ (chapter 4) document of any Medicare Advantage plan you are considering.  Just look for the words ‘prior authorization’.

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 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.

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. 

Jefferson County Medicare Advantage plans for Veterans.

Boise has a top-rated VA hospital. If you 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 Jefferson 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.

Jefferson 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.  

Medicare Advantage plans for the rest of the Medicare beneficiaries living in Jefferson County.

Monthly premiums range from $0 to over $135.

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.

What insurance companies offer Medicare Advantage plans in Jefferson County?

Blue Cross of Idaho

Humana

Molina

United Health Care

Other tidbits to be aware of.

Hospitals in your immediate area.

There are 4 hospitals within 25 miles of downtown Rigby.  

You can have a visual by clicking here.

Change the search radius to see additional hospitals.

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 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 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 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.  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.  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) and help firm up your understanding of Medicare.  Understanding the differences between your choices is important.  Helping you through the enrollment process is another benefit of using a broker.  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.

This page was updated on Feb 19, 2025 @ 9:40 AM