Kootenai County Medicare Advantage Plans
Some 2025 Kootenai County Medicare Advantage plans caught our attention.
The first is an HMO-POS plan with key 5-star hospitals in Oregon, Washington, Utah and Idaho in their network! This means you pay in-network rates when you use these resources. This same plan opens up access to other hospitals/physicians in the US that ‘accept Medicare’ too. This is a useful feature for people that go to warmer climates during the winter.
Also, there are additional plans for people that have been medically diagnosed with serious health issues. These include 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, Kootenai County has 26 Medicare Advantage plans for residents to consider.
Here is the high level breakdown:
6 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.
3 of these are PPO;
3 are HMO plans.
14 plans do include prescription drug coverage and services covered by Medicare Part A and B.
9 are HMO plans;
5 are PPO plans.
The remaining plans are reserved for individuals who qualify for Medicaid special needs plans (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 type of 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 Kootenai 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 these Kootenai County Medicare Advantage plans?
Monthly premiums range from $0 to over $140.
Three of the 14 plans have monthly premiums above $100; another two are above $70.
People interested in plans with premiums at this price point may be better off with one of the comprehensive Medigap plans.
These include Plan G, N, and D. Why these plans? Because they open up all physicians and hospitals in the USA which ‘accept Medicare insurance’ (most all do). Also, these 3 plans pay most of the left over copayments/coinsurance/deductibles when you use Medicare Part A and B covered services. You can now budget with confidence for your health care.
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. There are documented in the plan’s ‘Evidence of Coverage’ (EOC) document. You can download this from the insurance company’s website. Each plan has this document available.
If you were diagnosed with a serious health issue….
Then look at the cost sharing for the services that would be needed if you were diagnosed with a serious health issue.
Look at the hospitals in the plans network. If you are diagnosed with a serious health issue, would you want to be treated at one of these facilities? Would you prefer to have access to one of the major hospitals (and physicians) in the Pacific Northwest (or the entire US)?
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 the plan? 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?
The information below is for people that want to know more. You might scan the paragraph headings to see if the topic is of interest to you.
What are the actual MOOP figures?
Medicare’s maximum MOOP for this year’s HMO is $9,350.
The MOOP maximum for HMO-POS and 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 $4,900 to $8,950.
The range for HMO-POS and PPO plans is $5,000 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.
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 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.
What does this mean? Your insurance company can approve or deny the service request from your physician. If the service is denied, your 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, a dental 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 a limitation on the number of cleanings too (2 per year when you may need 4); periodontal services, if covered, may have their own limitation, 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 must meet ‘minimum adequacy’ requirements when they put together their networks together. This means there is a good probability not all physicians/providers in your geographic area that ‘accept Medicare’ insurance are 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 of new technologies is competing for other financial needs of the hospital.
Proton Therapy is an example of newer technology for treating cancer.
Read this article if you are unfamiliar with this. At this time, 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 using the top 250 hospitals in the country OR the top hospitals by type of surgery?
Resources are available to help you find these.
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. This group of hospitals may not accept the Medicare Advantage plans available to you.
Hospitals are assigned a ‘star rating’ by Medicare. We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities. Learn more about this subject here.
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.
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.
There are 3 different audiences for Kootenai 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.
Kootenai 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 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.
PPO plans are worth considering.
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 coverage outside the VA for urgent and emergent care AND the extra benefits often found in these plans.
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.
We recommend Veterans review their Kootenai Veteran Medicare Advantage plans at least every 2-3 years.
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. 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.
Kootenai County residents enrolled in Medicare and Medicaid.
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.
Additional information about the Kootenai County Medicare Advantage plans.
Hospital selection for care is important to some.
We look at 2-different hospital measurement tools to help find which hospitals stand out (the hospitals we would consider).
The 1st is the Medicare star rating. Learn more here about the metrics that are captured to come up with this rating. We prefer hospitals that have a 4 or a 5-star rating.
The 2nd tool uses many more metrics to differentiate how the hospitals do what they do. Some of these focus on the results of the work done in the surgical suite.
If you are interested in learning which hospitals produce better results on a consistent basis by type of surgery, check out this resource. A good awareness exercise might be to review the Mayo Clinic hospital in Arizona or Rochester Minnesota. Tale a look at the recognition by type of surgery they have received.
Learn more about the company behind this annual report here.
Check out the hospitals within 50 miles of zip code 83814 by clicking here. When you get to this web page, select ‘hospitals’, enter your zip code and adjust the radius to 50-miles.
Did you notice some of these hospitals are outside of Idaho?
This means they may not be included in any Medicare Advantage plan’s network that is available to you. If you stay with Original Medicare with or without a Medigap plan, you will have access to them.
Monthly premiums of Medicare Advantage plans available in Kootenai County range from $0 to over $135.
If you are interested in a Medicare Advantage plan with a premium above $70/month, an Out of Pocket Limit above of $7,000 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.
What insurance companies offer Medicare Advantage plans in Kootenai County?
Blue Cross of Idaho
Molina Healthcare
Pacific Source
Regence Blue Shield of Idaho
United Healthcare
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 coverage for 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 questions about whether a service is covered, call customer service. Their phone number is on your membership card. your plan’s customer service.
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. Look at the cost for an annual checkup, glasses, frames, contacts and any network restrictions.
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. Be aware of your plan’s quarterly limit. This figure 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 on the products they carry.
Visiting the Costco hearing department may provide the education you need to understand product differences.
Would a Medicare coach be helpful?
A coach can answer your questions, 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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