2026 Benewah County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15-20/2026.  Be sure and check back for this important information.

What are we waiting for?  Provider directories which include which hospitals are in the plan’s network.  We have most of the Evidence of Coverage documents now.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

2025 Benewah County Medicare health plans. 

We are an Idaho based Medicare insurance brokerage firm licensed with all Benewah County Medicare Advantage plans.

We have 2025 Part D licenses with Aetna, United Health Care and Humana.  The remaining 2 companies (Wellcare and Cigna) either do not use brokers in 2025 or we chose to not license with them because of low Medicare plan star ratings.  These Part D plans are for people not enrolling in a Medicare Advantage plan (staying with Original Medicare).

Additional information on his subject is documented here.

For 2025, Benewah County has 9 Medicare Advantage plans for residents to consider.

Here is the high level break down of these plans:

A plan targeted for Veterans.

One plan is targeted for Veterans that gets their prescription med’s from the VA.  Veterans may find this plan attractive as it is a back up for health care services you get from the VA.  All health care services offered by Medicare are included in this plan including ‘Emergency services’.  The plan may contain other ‘no-cost’ benefits.

Plans for people with specific chronic health issues.

2 plans are unique and 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 either of these health issues, send us the above mentioned ‘scope of appointment’ document and we will share with the important details of this plan choice.

If you have a Medicaid status of QMB+, QMB or SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.

Plans for people with Medicaid status of ‘enhanced’ or ‘QMB’.

3 others are reserved for people classified as ‘Enhanced’ Medicaid.  If you have this qualification, we suggest you consider these plans?  Why? Because you get a ‘care coordinator’ that helps pave the way for you to get the medical appoints you need AND these plans may have ‘extra’ benefits that go beyond what either Medicare OR Medicaid offers.   These plans are also called a ‘Medicare Medicaid Coordinated plan’.

The next plan is for people assigned a ‘QMB’ Medicaid status. If this includes you, we encourage you to focus on this plan.  Why?  The care coordination covered by either Medicaid or Medicare is taken care of by the plan.  The plan may also include ‘extra benefits’ at little/no cost.

Plans for the rest of Benewah County residents.

2 plans are available for the rest of Benewah County residents.  Both of these are HMO plans.  We you understand their differences and enroll in the play you choose.  We recommend veterans also consider these plans.

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

When you choose this plan type, 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 Benewah 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 may prefer these plans because they know they will be paid in a timely manner.

You will have fewer ‘prior authorizations’ to deal with.

Learn more about Idaho Medigap plans here.

What are the differences between the remaining two Benewah County Medicare Advantage plans.

Plan premiums, your share of the left over costs when you use plan covered services, the plan’s Maximum out of pocket limit (MOOP), your med fill/refill cost, etc.  We will help you understand the details of the differences.

Why the MOOP is important.

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 your Medicare Advantage plan 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.

The insurance company offering your Medicare Advantage 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.

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 $4,900.

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 how the math works 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 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 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.  

Rules may be imposed on specific coverages.  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.  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 a limitation on the number of cleanings too (2-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 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 to treat cancer.

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.

Would you prefer to use the services of the top 250 hospitals in the country?

These facilities may have the the top specialists working for them and the latest technologies to treat different health issue(s).

Some of these facilities do not accept Medicare Advantage plans (Part C), however they will open their doors to you if 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.

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) 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.

Benewah County Medicare Advantage plans for Veterans

Veterans have 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 is 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.

Call us if you want help thinking this through.

Do you just want a plan that is a backup to VA health care and are on with the plan’s network of hospitals/doctors/other providers?

An HMO plan should meet your needs.  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 as well as the Part B buyback.  This can save the Veteran money.

We noticed some plan(s) with a high Part B giveback also come with high cost sharing when plan health care service is used.  Keep this in mind if you may need to use your Medicare Advantage plan.  You may be better off with a plan that has a ‘lower Part B buyback’.

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.

Benewah 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.

Benewah County Medicare Advantage plans available to the rest of the Medicare beneficiaries.

When you look the plan’s 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 also be more profitable).

We are licensed with all plans available to Benewah county residents.  Helping you understand plan differences so you can choose the plan that is right for you is our goal.  When you are comfortable with the plan you choose, we help you with enrollment.

What insurance companies offer Medicare Advantage plans in Benewah County?

Blue Cross of Idaho

Molina Health Care

United Healthcare

Other tidbits to be aware of

Hospitals in your immediate area.

Benewah County has 1 hospital within its borders.  There are several others within 50 miles of St. Maries.

Get a visual of their location by clicking here. Be sure and enter zip code 83861; adjust the ‘radius’ to 50.

Some of these hospitals are not in Idaho and may not be in the network of Medicare Advantage plans available to you.  If you enrolled in a Medigap plan, they will be.

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 Benewah County 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 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 at Costco, you might visit them.  They can provide you the foundation 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 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.

This page was last modified on Oct 11, 2025 @ 7:01 AM

2026 Bear Lake County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15/2026.  Be sure and check back for this important information.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

What you need to know about Bear Lake County Medicare plans. 

For 2025, Bear Lake County has 10 Medicare Advantage and 12 Medigap plans for residents to consider.

Some of these plans have a $0 monthly premium.

Here is the high level break down of the Bear Lake County Medicare Advantage plans:

3 plans do NOT include prescription drug coverage; Veterans, who get their meds from the VA, may find these plan attractive.  Some of these offer the popular Part B ‘giveback’ (lower your Part B monthly premium).  This means more money in your pocket.  These plans also include other useful extras.  The out of pocket costs for plan covered services as well as the networks vary between these plans.  We can help you sort through your options.

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.

5 Medicare Advantage plans are available for the rest of Bear Lake County residents.  2 of these are HMO plans.  The other 3 are PPO plans.  We recommend veterans also consider these plans.  These plans also have a wide variance in out of pocket costs, networks, and extras.  We can help you match up the right plan for your needs and budget.

Bear Lake County has 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 Bear Lake 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 may prefer these plans because they know they will be paid in a timely manner.

You will have fewer ‘prior authorizations’ to deal with.

Learn more about Idaho Medigap plans here.

A note about the Medicare required ‘scope of appointment’ document.

Interested in learning more about your plan choices?  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.

Call if you have questions.

What are the differences between the 5 Medicare Advantage Prescription Drug plans for residents not enrolled in Medicaid?

One item is the plan’s Maximum out of pocket limit (MOOP).  

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 mindful the insurance companies offering these plans 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 plans is $9,350.

The MOOP upper limit for out of network services in a PPO is $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 $4,900.

The MOOP for Bear Lake County residents interested in a PPO plan range from $6,700 thru $9,350 for in network services.  The MOOP for out of network services ranges up to $14,000.

We prefer plans that meet a person’s needs, has 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’ to contend with too.

If you understand the math for calculating the 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 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.  Another is the number of days the copay applies for a stay in a skilled nursing facility.

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.  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 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 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?

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 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 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.

What else you should be aware of.

The Mayo Clinics and other top hospitals are available to Idaho Medicare beneficiaries enrolled in Part A AND B AND not enrolled in a Medicare Advantage plan.  If you choose to enroll in a Medigap plan, it will help paying some/most all of the left-over A and B copays/coinsurance.

Medicare Supplement plans.

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.

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/montb 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’ you are responsible for.  Check out page 11 of the document found here.  This shows all of the Medicare covered health care services and what services each of the different Medigap plan pays for you.

If you prefer a lower premium Medigap plan…

There are 2 different Medigap plans reviewed earlier in this article.  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 leftover costs for the calendar year.

A Medicare insurance broker, that is licensed with all/most all plans available to you, helps 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.

This page was last modified on Oct 4, 2025 @ 4:23 PM

2026 Custer County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15/2026.  Be sure and check back for this important information.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

What you need to know about Idaho 2025 Custer County Medicare plans!

For 2025, Custer 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 Custer 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 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 Custer 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 may prefer these plans because they know they will be paid in a timely manner.

You will have fewer ‘prior authorizations’ to deal with.

Learn more about Idaho Medigap plans here.

What are the differences between the two Custer County Medicare Advantage? 

Monthly premiums range from $0 to $66.

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 your insurance company 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 Custer County Medicare plans 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 to treat cancer.

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.

Do you want access to the top 250 hospitals in the country?

Would you consider using the services of the top hospitals in the Seattle area?   How about the the Mayo Clinics or the rest of the hospitals and physicians (that ‘accept Medicare’) in the US.

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 consider using a ‘board certified physician‘.

Hospitals in your immediate area.

There is a hospital in Challis. However, there are no other hospitals within 50 miles of downtown Challis (83226).

Get a visual of it’s location 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.“

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.

A Medicare insurance broker, that is licensed with all/most all plans available to you, helps 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.

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 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.  If your plan permits use of out of network services, your cost may be higher. .

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document.

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.  The products you select are typically 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.

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 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.

This page was last updated on Oct 4, 2025 @ 4:16 PM.

2026 Lemhi County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15-25/2026.  Be sure and check back for this important information.

What are we waiting for?  Provider directories which include which hospitals are in the plan’s network.  We have most of the Evidence of Coverage documents now.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

What you need to know about 2025 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.

Learn more about Idaho Medigap plans here.

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.

This page was last updated on Oct 11, 2025 @ 7:06 AM.

2026 Caribou County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15/2026.  Be sure and check back for this important information.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

What you need to know about the 2025 Medicare plans available to residents of Caribou County!

For 2025, Caribou County has 10 Medicare Advantage and 12 Medigap plans for residents to consider.

Some of these plans have a $0 monthly premium.

Here is the high level break down of the Caribou County Medicare Advantage plans:

3 plans do NOT include prescription drug coverage; Veterans, who get their meds from the VA, may find these plan attractive.  Some of these offer the popular Part B ‘giveback’ (lower your Part B monthly premium).  This means more money in your pocket.  These plans also include other useful extras.  The out of pocket costs for plan covered services as well as the networks vary between these plans.  We can help you sort through your options.

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.

Plans for the rest of Caribou County residents.

5 Medicare Advantage plans are available for you to pick from.

Two of these are HMO plans.

The other three are PPO plans.  Two of these plans have monthly premiums above $70.

Veterans might also consider these five plans. These plans also have a wide variance in out-of-pocket costs, networks, and extras.  We can help you match up the right plan for your needs and budget.

Caribou County has 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 Caribou 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.

Learn more about Idaho Medigap plans here.

What are the differences between the other 5 Caribou County Medicare Advantage plans?

One item is the plan’s Maximum out of pocket limit (MOOP).

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 mindful the insurance companies offering these plans 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 plans is $9,350.

The MOOP upper limit for out of network services in a PPO is $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 Caribou County’s HMO Medicare Advantage plans is $4,500 to $4,900.

The MOOP for Caribou County residents interested in a PPO plan range from $6,700 thru $9,350 for in network services.  The MOOP for out of network services ranges up to $14,000.

We prefer plans that meet a person’s needs, has 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’ to contend with too.

If you understand the math for calculating the 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 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.  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 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 you are unfamiliar with this technology, read this article.

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 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‘.

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.

Medicare Supplement plans.

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.

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/montb 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’ you are responsible for.  Check out page 11 of the document found here.  This shows all of the Medicare covered health care services and what services each of the different Medigap plan pays for you.

If you prefer a lower premium Medigap plan…

There are 2 different Medigap plans reviewed earlier in this article.  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 leftover costs for the calendar year.

A Medicare insurance broker, that is licensed with all/most all plans available to you, helps 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.

This page was last modified on Oct 4, 2025 @ 4:26 PM.

2026 Idaho  County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15-25/2026.  Be sure and check back for this important information.

What are we waiting for?  Provider directories which include which hospitals are in the plan’s network.  We have most of the Evidence of Coverage documents now.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

What you need to know about 2025 Idaho County Medicare Advantage Plans!

For 2025, Idaho County has 8 Medicare Advantage and 12 Medigap 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 and SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.

1 plan is available for residents with a QMB Medicaid status.

1 Medicare Medicaid Coordinated plan (MMCP) is available for residents with an ‘enhanced’ Medicaid status.

2 HMO plans are available for the rest of Idaho County residents.  We recommend veterans also consider these plans.

1-PPO plan is available also.  PPO plans have a defined network for members to use; they can also go ‘out-of-network’.  Higher out of pocket costs will apply plus there is a higher MOOP. Veterans should also look at this plan.

The above information came from this source.

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

These are Medigap plans.

When you choose this plan type, 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 Idaho 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 may prefer these plans because they know they will be paid in a timely manner.

You will have fewer ‘prior authorizations’ to deal with.

Learn more about Idaho Medigap plans here.

What are the differences between the 3 Medicare Advantage 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 the Medicare Advantage plan 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.

PPO plan(s) have a different maximum MOOP than HMO plans.

What are the actual MOOP figures?

Medicare’s maximum MOOP for this year’s HMO plans is $9,350.

The maximum for PPO plans for out of network service use is $14,000.  In network use the figure 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. 

The PPO plan is $6,900 when in-network services are used; if the member goes out-of-network (even just once) this figure bumps up to $14,000.

The above figures came from this source.

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.

PPO plans have two sets of figures for plan covered services.  One is if the member uses ‘in-network’ providers; the other is if they use ‘out-of-network’ providers.  Out-of-network cost sharing is typically higher than if the same services were from in-network providers.

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.  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‘.

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.

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.

This page was last updated on Oct 11, 2025 @ 7:04 AM

Two of these plans limit your annual out of pocket costs for Part A and B covered services to less than $2,900.

Hospitals in your immediate area

There is 1 hospitals within 25 miles of downtown Orofino (zip code 83554). Get a visual of its location by clicking here. Change the search area radius to 50 miles to check out your other options.Some of these hospitals are rated by The Center for Medicaid and Medicare Services (CMS) as 3 stars.  We recommend hospitals with at least a 4-star rating.Having resources with higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.All of these hospitals may not be in-network for the Medicare Advantage plans available to you.If you have a Medigap plan, they will be.

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 to treat cancer.

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?

Would you consider using the services of the top hospitals in the Seattle area…or the Mayo Clinics?

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.  

This page was last modified on Oct 11, 2025 @ 7:03 AM

2026 Lewis County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/15-25/2026.  Be sure and check back for this important information.

What are we waiting for?  Provider directories which include which hospitals are in the plan’s network.  We have most of the Evidence of Coverage documents now.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

What you need to know about 2025 Lewis County Medicare Advantage plans. 

For 2025, Lewis 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 Lewis 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 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 Lewis 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 may prefer these plans because they know they will be paid in a timely manner.

You will have fewer ‘prior authorizations’ to deal with.

Learn more about Idaho Medigap plans here.

What are the differences between the two Lewis County 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 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 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 to treat cancer.

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?

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.

There is a hospital in down town Orofino.   Get a visual of this area by clicking here.

Expand the search radius around Orofino to 50 miles.  Now there are 6 more hospitals to consider.  Note that 3 of these facilities have a ‘3-star rating‘ by Medicare. There is one 5-star facility in Pullman Washington.

We recommend Idaho residents consider using the services of hospitals with at least a 4-star rating.

Be aware all of the hospitals within 50 miles of Orofino may not be in-network of all the Medicare Advantage plans available to Lewis 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.

This page was last updated on Oct 11, 2025 @ 7:07 AM.

2026 Oneida County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/6/2026.  Be sure and check back for this important information.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

2025 Oneida County Medicare Advantage plans.

Oneida County has 10 Medicare Advantage Prescription Drug (MAPD) plans for residents to consider.

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 are reviewed and approved or denied 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.  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.

Are your local hospitals current on the technology they use to diagnose and treat you?

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.

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‘.

2026 Teton County Medicare Advantage plans.

There is a synopsis of changes to the Idaho Medicare Advantage marketplace here.   If you are not aware of these changes, please take a few minutes and read this material.

An overview of your 2026 County’s Medicare Advantage plans should be updated on this website by 10/20/2026.  Be sure and check back for this important information.

Because of the extensive changes made in the Idaho market, we recommend you defer making 2026 plan changes until you have all the information about your choices.  This means do not make an impulse decision when viewing ads on TV or from mailers you are receiving.

2025 Teton County Medicare Advantage plans.

For 2025, Idaho Teton County has 9 Medicare Advantage Prescription Drug plans for residents to consider.

Some of these plans have a $0 monthly premium.

Here is the high level break down of these plans:

3 plans do NOT include prescription drug coverage; Veterans may find this plan attractive.  Some of these offer the popular Part B ‘giveback’ (lower your Part B monthly premium).   This means more money in your pocket.

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.

4 plans are available for the rest of Teton County residents.  2 of these are HMO plans.  The other 2 are PPO plans.  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 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 Teton 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.

Learn more about Idaho Medigap plans here.

What are the differences between the 4 Medicare Advantage plans with prescription drug coverage for residents not enrolled in Medicaid?

Monthly premiums range from $0 to over $100.

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.

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)?   How do you find them and narrow down the list that excel at treating your specific issue?

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?

Brokers specializing in the Medicare plans are available to you help you navigate your way through this maze.

We have been helping Idaho residents with their Medicare plan choices since 2012.

If you would like to use our ‘cost-free’ help, complete the ‘scope of appointment’ document mentioned above, send it to us.  We will call you for your 1st appointment.

How do brokers get paid for their services?  By the insurance company.  Medicare regulates how much a broker gets paid; all/most all insurance companies offering Medicare Advantage plans in Idaho are paid the same.  To us, that means we focus on the people’s needs we are working with and present plans which meet those needs.

If you want to learn more, additional details are below.

What are the actual MOOP figures?

Medicare’s maximum MOOP for this year’s HMO plans is $9,350.

This year’s PPO plan ‘out-of-network’ figure is $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 $4,900.

The MOOP for Teton County residents interested in a PPO plan range from $6,700 thru $9,350.

We prefer plans that meet a person’s needs, has 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’ to contend with too.

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.

Specific plan coverages may have limitations.

Rules may be imposed on specific coverages.  You find these rules in your plan’s ‘Evidence of Coverage’.  This document is on the insurance company’s website and can be found in the ‘plan details’ area.

Prior Authorization is an example. How many days the covered service is available at a non $0 cost is another.

Prior authorization may be required on specific plan covered services.  What does this mean?  Your insurance company can approve or deny the service request from the physician treating you.  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.

Examples include skilled nursing care comes with a daily copay.  The number of days the cost sharing is in place can vary by plan.  This same is true for inpatient hospital stays.

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 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 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.

The resources used to diagnose and treat your health issue(s) can vary by hospital.

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.

We encourage you to read this article to learn the benefits of this newer technology.

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 Seattle, Salt Lake City, and the rest of the US?

Did you know there are tools available that point out hospitals which have consistently better results performing the more frequent surgeries done in the US?

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) but accept people enrolled in a Medigap plan.  A Medigap plan will help pay the left-over costs that Medicare does not completely cover.

Hospitals are assigned a ‘star rating’ by Medicare. However, a recent article points out results in hospital surgical suites may not adequately be measured in Medicare’s hospital star ratings.

We do recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.  We also recommend you be familiar with the top 250 hospitals in the US.

There are physician rating services to consider 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) 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.

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.

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/montb 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’ you are responsible for.  Check out page 11 of the document found here.  This shows all of the Medicare covered health care services and what services each of the different Medigap plan pays for you.

If you prefer a lower premium Medigap plan…

If you want a lower premium and are willing to pay for leftover costs, there are 2 different Medigap plans reviewed earlier in this article.  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 leftover costs for the calendar year.

A Medicare insurance broker, that is licensed with all/most all plans available to you, helps 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.

This page was last modified on Oct 4, 2025 @ 7:29 PM.