Lemhi County Medicare
What you need to know about Lemhi County Medicare Advantage plans!
For 2025, Lemhi County has 5 Medicare Advantage plans for residents to consider. Some of these plans have a $0 monthly premium.
Below is the high level break down of these plans:
1 plan does NOT include prescription drug coverage; Veterans may find this plan attractive.
2 plans are reserved for residents which have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).
If you have a Medicaid status of QMB+, QMB or SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.
2 HMO plans are available for the rest of Lemhi County residents. We recommend veterans also consider these plans.
There is another type of Medicare plan you should be aware of.
These are Medigap plans.
When you choose one of the 12 Medigap plans, 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 Lemhi 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.
These 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.
Keep these plans in mind when you review the MOOP discussion below.
What are the differences between the 2 Medicare Advantage Prescription Drug plans for residents not enrolled in Medicaid?
One item is the plan’s Maximum out of pocket limit (MOOP). Read the information below to learn why this is a key differentiator between plans.
The MOOP 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 aware Medicare pays its lion’s 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 plans is $9,350.
Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals.
The range of MOOP for your County’s HMO Medicare Advantage plans is $4,900 to $6,300.
We prefer plans that meet a person’s needs, have a low MOOP, AND plans with a monthly premium below $70.
Why $70? You can get a Medigap plan described above for a lower premium AND you will not have an insurance company standing between you and your doctor to get the ‘next step’ in your health care accomplished. There are far fewer ‘prior authorizations’ that your physician/hospital have to contend with.
If you understand the math when calculating your MOOP 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 much left you have to pay until your MOOP hits zero. 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 MAPD 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 plans may have prior authorizations on certain covered services.
You find this information in your plan’s ‘Evidence of Coverage’ document. This is available on the insurance company’s web site and can be downloaded.
Your insurance company can approve or deny the service requested by the ‘prior authorization’. If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over. This is one of the reasons we prefer plans that do not have insurance companies standing between you/your physician to get to the ‘next step’ in your health care. The article found here brings this point to life.
The number of days ‘skilled nursing care’ has their daily co-pays in place is something you need to pay attention to. Why? Because if you need this service and have the ‘wrong’ plan, it can be the quickest way for you to hit your plan’s MOOP.
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 physicians/providers in your geographic area that ‘accept Medicare’ insurance are not in your plan’s network.
You have the tools available to find out how many of a certain type of specialists are in the plan’s network vs how many that ‘accept Medicare’ are in the same area . If you have existing health issues, would it be important for you to know how many specialists which treat this for you are in the plan you select? We can show you the tools to do this.
The above can change during the calendar year. This announcement is an example of why networks can change during the year. Another example is found here and here.
Be aware hospitals may/may not be using current technologies/techniques to treat patients. Why? Because of the cost for new technologies is competing for other financial needs of the hospital.
Proton Therapy is an example of newer technology for treating cancer.
Read this article if you are unfamiliar with this alternative to x-ray treatment (photon).
At this writing, 45 hospitals (out of over 4500) offer this solution. Facilities near Idaho include:
Huntsman Cancer Institute (Salt Lake City) (began offering this service in 2021)
The Mayo Clinic Cancer Center (Phoenix…rolled out this service on 2016)
Loma Linda University Cancer Center (began offering this service in 1990)
California Protons Cancer Therapy Center (San Diego) (began offering this service in 2017).
If you are interested in this service, you might check where each of the above facilities are ranked in the top 250 hospitals.
Are you interested in the top 250 hospitals in the country?
Would you consider using the services of the top hospitals in the Seattle area…or the Mayo Clinics?
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 of these facilities do not accept Medicare Advantage plans (Part C). Others open their doors if 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 use a ‘board certified physician‘.
Hospitals in your immediate area.
The nearest hospital to downtown Challis is 48 miles away. Get a visual of this area by clicking here.
Expand the search radius around Challis to 100 miles. Now there are 5 more hospitals to consider. Note that none of these facilities have a ‘star rating‘ by Medicare.
We recommend Idaho residents consider using the services of hospitals with at least a 4-star rating.
Be aware all of the hospitals within 100 miles of Challis may not be in-network of all the Medicare Advantage plans available to Custer County residents. If you have a Medigap plan, all of the listed hospitals (and the rest in the US) are available to you.
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 by available plans. 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.
Medicare Supplement plans.
As mentioned above, these plans give you the choice of any doctor/hospital/other providers (in the US) that accept Medicare insurance. Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do too.
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 in the US?
We recommend you consider a Medigap Plan G.
The monthly premium for this plan varies by the insurance company offering the plan. The coverage is the same, the only difference is the name of the company on your policy and their monthly premium. Premiums range from below $200/month to over $250 for this same plan. When you work with a broker, they help you navigate you way through the ‘who to do business’ issue.
Why pick Plan G?
Because this plan pays all of your left-over costs that Medicare does not pay except the annual Part B deductible. This deductible is a Medicare controlled figure, and it goes up a bit each year. Your share of the other left-over costs is documented here.
Something else to keep in mind is Medicare typically bumps up the cost of Part A and B services. They do this annually. Your Medigap plan automatically pays your share of these increased costs.
The other Medigap plans typically have a lower premium than Plan G…but you have more ‘left over costs’ that you will pay. Check out page 11 of the document found here. This shows all of the Medicare covered health care services by each of the different 12 Medigap plans.
If you prefer a lower premium Medigap plan…
If you want a lower premium and are willing to pay for leftover costs, there are other Medigap plans to consider. These are Plans A, B, D, K, L, M, ad N. Plans C and F are reserved for people enrolled in Medicare prior to 1/1/2020.
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 insurance company and plan which meets your needs and budget.
We have been helping Idaho residents with this task since 2012.
Call us if you want help.
Would a Medicare coach be helpful?
A coach can answer your question(s) and firm up your understanding of Medicare. Once this is done, they will explain the differences between your choices and help you through the enrollment process. They will also be there year after year to help you.
Will the people behind the TV ads include this service for you?
Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.
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