Several 2025 Minidoka County Medicare Advantage plans caught our attention.

Plans for people that have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder) are now available.

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

There are other Minidoka County Medicare HMO and PPO plans on our recommend list.  Which medications, hospital preferences, and health issues a person has/does not have are determining factors on which are appropriate. 

Interested in learning more?  Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and text it to us (1-208-867-0296).  Upon receipt we will call you and share the details.   

 

What else you need to know! 

For 2025, Minidoka County has 21 Medicare Advantage plans for residents to consider.  

Here is the high level break down:

          5 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

                  3 of these are PPO;

                  2 are HMO plans.        

        10 plans do include prescription drug coverage and services covered by Medicare Part A and B.  

                   7 are HMO plans;

                   3 are PPO plans. 

           The remaining plans are reserved for individuals who qualify for Medicaid special needs plans (C-SNP or D-SNP).

 

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

When you choose this plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you and prior authorizations are minimal.  This simply means you are not limited by network rules found in Medicare Advantage plans. 

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

You are not charged a ‘premium’ for services received when you use services out of your immediate area (like many PPO plans).

Learn more about Idaho Medigap plans here. 

 Call if you have questions.

 

What are the some of the differences between Minidoka County Medicare Advantage plans?

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

This is a key figure you should be aware of. 

Put plans on your short list that have a lower MOOP.  This decision may save you money if you use Medicare covered health care services during the plan year.    

Be mindful your Minidoka Medicare Advantage plan 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 for Minidoka County Medicare Advantage plans?

Medicare’s maximum MOOP for this year’s HMO plan is $9,300. 

The MOOP maximum for PPO plans cannot exceed $14,300.   

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals. 

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.  

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $6,400.

The range for PPO plans is $5,900 to $14,000. 

The example below will help you understand how your plan’s MOOP works.   

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475. 

After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.     

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket. 

The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B covered service too.  

This simply means that you pay your share of the costs for services provided by your physician, use specific hospital services like MRI or CAT imaging, cancer treatments, services provided in the surgical suite, etc..   The insurance company behind each plan sets their own cost sharing for that plan.  You find these figures in each plan’s ‘Evidence of Coverage’ (EOC).    

The EOC also identifies which services must be approved by the insurance company before they can be performed.  Be aware approval requests can be denied by the insurance company.    

Prior Authorizations.   

Services covered by any Medicare Advantage plan may have a ‘prior authorization’ tag on a service.   These are found in the plan’s EOC. 

The insurance company can approve or deny the prior authorization request.  Learn more about what is going when these requests are reviewed and approved or denied by reading this article, this article,  and this article.  CMS is in the process of implementing changes 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 available in Minidoka Medicare Advantage plans.

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.

 

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

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.  These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.

Does Medicare rate hospitals for us?

Yes.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.  

There are physician rating services too.  One is available here.  We focus on physicians with a 4 or 5 star rating and have at least 10-ratings.  You can use this same tool to find physicians that ‘accept Medicare insurance’.   

We also recommend you use a ‘board certified physician‘.

 

Medications covered by each plan.

According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of 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. 

 

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

Probably. 

These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B).  Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans. 

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with. 

You and your physician are making the decision on the ‘next step’ in your health care.

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

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

Read the articles supporting the above comments here, here, and here. 

Do you want a plan that pays for most all of the left-over cost for Part A and B in the US?

We recommend you consider a Medigap Plan G. 

Are there lower premium Medigap plans what have some copays?

Yes.

The 2 different Medigap plans mentioned above meet these criteria.   They have a Medicare controlled ‘annual deductible’.  Yes, it goes up a bit annually.

This ‘deductible’ is similar in concept to the MOOP described above. 

The deductible for this year is found here. 

Once your share of your costs for the services you use hits this figure, this Medigap plan pays the rest of your Part A and B left over costs for the calendar year. 

When you work with a Medicare broker that is licensed with all/most all plans available to you, they help you navigate your way through this maze and select the plan which meets your needs and budget.  

 

Minidoka County Medicare Advantage plans for Veterans.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

At the current moment, the major insurance companies offering these plans are in Bingham County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs to the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Minidoka County residents on Medicaid and enrolled in Medicare.

Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025. 

Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here.  Answers to ‘frequently asked questions’ is available here.

If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.  

UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026. 

Molina continues to serve Idaho residents with these important products.   

If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help.  We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022. 

Additional pertinent information about Idaho Medicaid and your plan choices. 

There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).

If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider. 

Click here to learn more about your options.

We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP). 

Explaining plan differences and helping you with enrollment are other services we help you with.  

 

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

Check out the hospitals in each plan’s network and where they are located.

Minidoka Memorial Hospital in Rupert and St. Lukes hospital in Twin Falls are key medical resource for Minidoka County for Medicare beneficiaries.

Hospital selection can be a very important decision when you get your health care.

We recommend you research their differences and be sure any plan you choose has those resources you prefer in their plan’s network.

Minidoka  County has several hospitals/clinics in reasonable driving distance from Rupert (50-miles).   Check these out by clicking here.

When this screen pops up, be sure and enter your zip code (83343) and adjust the radius to 50-miles.

Notice there are 5 hospitals within this radius. 

Check out the hospital ratings.  We prefer facilities with either a 4 or 5 star ratng.  

Why don’t hospitals have a rating?

Hospital(s) without a rating may not have reported their results or did not meet the minimum number of procedures to be measured and rated for the current period.

When selecting a health plan, be sure the hospitals and doctors you want to take care of you, no matter the health issue, is available to you.

The CMS hospital rating system is a guideline to consider using.

You can also use another tool that identifies the top 100 hospitals in the US.

This information rates hospitals by type of surgery within hospital too.  Learn more here.  You can consider these resources if you have a plan which opens these facilities to you.

Are plan premiums important?

Yes!  This is a steady monthly outflow of cash from your pocketbook.

Monthly premiums for Medicare Advantage plans in Minidoka County plan range from $0 to over $130.

If you are interested in a Medicare Advantage plan with a premium above $70/month, an Out-of-Pocket Limit above of $7,000 or have copays for stays in a Skilled Nursing Facility after day 60, be sure you understand your other choices.  These include the other lower premium Medicare Advantage plans as well as Medigap plans. Learn more about your Medigap options here.

Additional information on Minidoka County plans in just a moment.

 

What insurance companies offer Medicare Advantage plans in Minidoka County?

 

Blue Cross of Idaho

Humana

United Healthcare

Other tidbits to be aware of

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 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…or services you use may cost you more when compared to your cost if you use an in-network dentist. 

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any 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 Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance. 

Visiting the Costco hearing department may provide the education you need to understand product differences. 

Plans can be different on what specific products (and services) are available to you.  

 

Would a Medicare coach be helpful?

A coach can answer your question(s), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.   

Will the people behind the TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday. 

 

 

 

This page was last modified on May 24, 2025 @ 1:04 PM

 

 

For 2025, Cassia County has 22 Medicare Advantage plans for residents to consider. 

Here is the high level break down:

          5 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

                  3 of these are PPO;

                  2 is an HMO plan.        

        10 plans do include prescription drug coverage and services covered by Medicare Part A and B.  

                  7 are HMO plans;

                  3 are PPO plans. 

           The remaining plans are reserved for individuals who qualify for Medicaid special needs plans (I-SNP, C-SNP or D-SNP).

 

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

These are Medigap 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 Cassia 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 Medicare Advantage plans?

The plan’s monthly premium.  They range from. $0 to over $140. 

We do not recommend plans with a monthly premium above $70?  Why?  The above mentioned Medigap plans may offer you better value.

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.

Think about where you would like to be treated if you have a serious health issue too.

What hospital(s) do you want to use if you are diagnosed with a serious health issue?

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 plans.  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 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.  This includes residents in Cassia County.

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 pay the brokers 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 of Cassia County Medicare plans?

Medicare’s maximum MOOP for this year’s HMO is $9.350. 

The MOOP maximum for PPO plans cannot exceed $14,000.   

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals. 

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.  

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $6,400. 

The range for PPO plans is $5,900 to $14,000. 

 

The example below will help you understand how your plan’s MOOP works.   

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475. 

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 plan coverages may have limitations.

Rules may be imposed on specific coverages.  You find these rules in your plan’s ‘Evidence of Coverage’.  You can find this document on your insurance company’s website or by calling the customer service phone number on your member card.

Prior Authorization is an example.

A ‘prior authorization’ may be required on specific plan covered services.  What does this mean?  Your insurance company is requesting information from the prescribing physician about the service they wish to perform.  The insurance company can approve or deny the service request from your physician.  If the service request is denied, your prescribing physician has to go to ‘plan B’ and start the process over.  In the meantime, the patient/plan member is waiting.

The article found here information on what has been going on in this industry.  

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 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.

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

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.  These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.  Learn about examples of these here and here, 

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.  This article points out further information on this topic.   

There are other 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. 

 

Cassia County Medicare Advantage plans for Veterans.

We like the choices Veterans living in Cassia County have to get VA health care.  Idaho Falls and Twin Falls have clinics available.  Both Salt Lake City and Boise have hospitals too. 

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan. 

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually. 
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.  

Is an HMO or a PPO plan right for you?

A veteran may prefer a PPO plan if they want to open their choice of hospitals and doctors to include those beyond Idaho’s borders. 

Be aware when you get plan services are from ‘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 plans cap on your share of costs for the year.  Check out this figure if you are interested in a PPO plan.  Call us if you want help thinking this through.

An HMO plan may fit a veteran that wants coverage outside the VA for regular health care OR just want access urgent and emergent care when it is needed. 

Some Veterans choose a $0 premium plan so they can get the low/no-cost ‘extra’ benefits which can come with these plans.  We noticed some plan(s) with a high Part B giveback also come with high-cost sharing when plan health care service is used. 

If a Veteran plans to get health care from an HMO plan, we need to pay attention to the plan’s network.  Participating hospitals and doctors can vary by plan and this can change annually. 

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, these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

Some of these companies want to increase their market share by offering more attractive features than their competitors.   Look at the ‘extra’ services not covered by Medicare for each plan you are considering.  Do you see any differences? 

These companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare. 

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Cassia 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.  

 

If you not affected by this Idaho Department of Health and Welfare audit…

There are several different types of plans available to Idaho residents enrolled in Medicaid. These include people eligible for ‘Basic’ or ‘Enhanced’ Medicaid or are eligible for an ISNP or a CSNP. Click here to learn more about your options.

 

Medicare Advantage plans for the rest of the Medicare beneficiaries living in Cassia County

Monthly premiums of Medicare Advantage plans range from $0 to over $135.   

The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans. 

Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’. 

Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’. 

Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory).   Reference this note for details.  

 

What insurance companies offer Medicare Advantage plans in Cassia County?

American Health Advantage of Idaho

Blue Cross of Idaho

Humana

Molina

United Healthcare

Other tidbits to be aware of

Hospitals in your immediate area.

There are 2 hospitals within 25 miles of downtown Burley.

To see these, you will need to enter your zip code and adjust the radius around the search area.  Please start with 25 miles, review there results and then bump it up to 50 or 100 miles.  Click here to see where the hospitals are located. 

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.  If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.  

Having resources with these ratings can be important to you when you get regular care, emergency and scheduled surgical procedures. 

All of these hospitals listed may not be in every plan.

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to the TV commercials, this is sounds like a great and often needed ‘extra’.   

You really need to pay attention to the details as they can vary widely between the plans. 

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…or services you use may cost you more when compared to your cost if you use an in-network dentist. 

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any 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 Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance. 

Visiting the Costco hearing department may provide the education you need to understand product differences. 

Plans can be different on what specific products (and services) are available to you.  

 

Would a Medicare coach be helpful?

A coach can answer your question(s), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.   

Will the people behind the TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday. 

 

 

This page was updated on May 24, 2025 @ 1:00 PM

 

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

We are licensed with all Idaho Franklin County Medicare Advantage plans listed on the Medicare Plan Finder tool.

We have 2025 Part D licenses with Aetna, United Health Care and Humana.

The remaining 3 companies (Wellcare, Clear Spring, and Cigna) either do not use brokers in 2025, their plans are ‘sanctioned by CMS’, or we chose to not license with them.

Additional information on his subject is documented here.

 

Important note about Navigating this article.

There are several ‘hot links’ contained in the text below.  These point to reference material that you should find interesting.

When you are finished reading this information, use your ‘browsers back icon’ to return to this page’.

 

Keep in mind if you would rather talk with us about plan details, just call…but first

Brokers must follow CMS rules before they can discuss plan details.

Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and either text (1-208-867-0296) or email (chuck@getmedicareinsurance.com) the image to us.  Upon receipt we will call you and share the details.

 

2025 Medicare Advantage Plans available for Idaho’s Franklin County residents with chronic health issues.

There are plans for people that have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

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

 

What Else you need to know.

For 2025, Franklin County has 13 Medicare Advantage plans for residents to consider.

Here is the high level break down:

3 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

1 are HMO plans;

2 are PPO plans.

 8 plans do include prescription drug coverage and services covered by Medicare Part A and B.

4 are HMO plans;

4 are PPO plans.

The remaining plans are reserved for individuals which qualify for Medicaid special needs plans (I-SNP, C-SNP or D-SNP).

 

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

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 Franklin 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 8 Franklin County Medicare Advantage plans?

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

This is a key figure you should be aware of.

Put plans on your short list that have a lower MOOP.  This decision may save you money if you use Medicare covered health care services during the plan year.

Be mindful Medicare pays its share of the cost for services you use.  You pay the rest.  Your share of these costs can vary noticeably between plans.

Think of the MOOP as your limit (or cap) for your share of health care costs for Part A and B services you use during the calendar year.   The higher your plan’s MOOP, the more you could end up paying for the services you use.

Medicare sets the maximum figure(s) a plan can have, and they can change it annually.

The insurance company offering your plan sets the plans MOOP where they want it.  It must be at or below Medicare’s limit.  This figure can change annually.

What are the actual MOOP figures?

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

The MOOP maximum for PPO plans cannot exceed $14,000.

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals.

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $6,300.

The range for PPO plans is $5,700 to $14,000.

 

The example below will help you understand how your plan’s MOOP works.

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475.

After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket.

 

The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B 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.

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 this is new to you, read this article.

At this writing, 45 hospitals (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 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‘.

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’.

 

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 current Medicare Prescription Drug Benefit Manual.

“Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant(for prophylaxis of organ transplant rejection), antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes. CMS instituted this policy because it was necessary to ensure that Medicare beneficiaries reliant upon these drugs would not be substantially discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

We feel this is an important statement everyone enrolled/wishing to enroll in a Medicare prescription drug plan should be aware of.

 

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

These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B).  Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans.

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with.  You and your physician are making the decision on the ‘next step’ in your health care. 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?

We recommend you consider a Medigap Plan G.

Are there lower premium Medigap plans what have some copays?

Yes.

There are 2 different Medigap plans we like that meet these criteria.   They have a Medicare controlled ‘annual deductible’.  Yes, it goes up a bit annually.

This ‘deductible’ is similar in concept to the MOOP described above.

The deductible for this year is found here.

Once your share of your costs for the services you use hits this figure, this Medigap plan pays the rest of your Part A and B left over costs for the calendar year.

When you work with a Medicare broker that is licensed with all/most all plans available to you, they help you navigate your way through this maze and select the plan which meets your needs and budget.    

 

 

There are 3 different audiences for Idaho Medicare Advantage plans.

Franklin County Medicare Advantage plans for Veterans.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

At the current moment, the major insurance companies offering these plans are in Franklin County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs to the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

This page was last modified on May 24, 2025 @ 1:14 PM.

 

 

 

What you need to know about 2025 Medicare plans available to Clark County Idaho residents. 

For 2025, Clark County has 16 Medicare Advantage and 12 Medigap plans for residents to consider. 

Here is the high level break down:

          4 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

                  3 of these are PPO;

                  1 is a HMO plan.        

         8 plans do include prescription drug coverage and services covered by Medicare Part A and B.  

                  5 are HMO plans;

                  3 are PPO plans. 

           The remaining plans are reserved for individuals which qualify for Medicaid special needs plans (C-SNP or D-SNP).

 

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

These are Medigap plans.

When you choose this 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 Clark 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 some of the differences between Medicare Advantage plans?

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

This is a key figure you should be aware of.  Put plans on your short list that have a lower MOOP.  This decision may save you money if you use Medicare covered health care services during the plan year.    

Be mindful the insurance company offering a Clark County Medicare Advantage plan 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 years HMO is $9,350. 

The MOOP maximum for PPO plans cannot exceed $14,000.   

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals. 

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.  

The range of MOOP for your County’s HMO Medicare Advantage plans is $5,500 to $6,000. 

The range for PPO plans is $6,700 to $14,000. 

We prefer plans with a premium below $70, meet a person’s needs, AND has a low MOOP. 

Why?  The two Medigap plans mentioned above have lower premiums, a much lower cap on your share of the out of pocket costs, a network of all doctors/hospitals in the US which ‘accept Medicare’ and has far fewer restrictions.

You can check out the above figures by using the resource found here. 

If you understand the math for MOOP, skip to the next paragraph. 

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475. 

When you subtract these figures from your plan’s MOOP the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.     

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket. 

The insurance company offering your plan sets the cost sharing for each Part A and B service.  

This simply means what you pay to see your physician, use hospital services, pay for your MRI/CAT imaging, cancer treatments, skilled nursing care, etc. are often different between plans.  When you compare plans annually, you look at these figures and choose the plan that best fits your pocketbook and needs. These figures can change annually.  

Cost sharing for services used, the plan’s MOOP, monthly premium, and the financial savings you get when you use the plan’s non-Medicare covered services are some of the differentiators between plans.   

Specific plan coverages may have limitations.

Rules may be imposed on specific 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 from your physician.  If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over.  If you have a medigap plan, there are far fewer services with ‘prior authorizations’.   

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 the 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 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 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. 

Are there lower premium Medigap plans what have some copay’s?

Yes.

There are 2 different Medigap plans we like that meet these criteria.   They have a Medicare controlled ‘annual deductible’.  Yes, it goes up a bit annually.

This ‘deductible’ is similar in concept to the MOOP described above. 

The deductible for this year is found here. 

Once your share of your costs for the services you use hits this figure, this Medigap plan pays the rest of your Part A and B left over costs for the calendar year. 

When you work with a Medicare broker that is licensed with all/most all plans available to you, they help you navigate your way through this maze and select the plan which meets your needs and budget.   

 We have been helping Idaho residents with this task since 2012.  Call us if you want help. 

 

There are three different audiences for Clark County Medicare Advantage plans.

Clark County Medicare Advantage plans for Veterans.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

At the current moment, the major insurance companies offering these plans are in Clark County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs to the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Clark County residents enrolled in Medicare and Medicaid.

 

Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025. 

Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here.  Answers to ‘frequently asked questions’ is available here.

If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.  

UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026. 

Molina continues to serve Idaho residents with these important products.   

If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help.  We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022. 

Additional pertinent information about Idaho Medicaid and your plan choices. 

There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).

If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider. 

Click here to learn more about your options.

We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP). 

Explaining plan differences and helping you with enrollment are other services we help you with.  

 

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

Monthly premiums of Medicare Advantage plans range from $0 to over $130.   

The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans. 

Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’. 

Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’. 

Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory).   Reference this note for details.  

Some of the plans offer access to more hospitals beyond Clark County borders. 

 

What insurance companies offer Medicare Advantage plans in Clark County?

 

Blue Cross of Idaho

Humana

Molina

As Clark County’s population of Medicare beneficiaries increases other insurance companies may enter this market. 

Other tidbits to be aware of.

Hospitals in your immediate area.

There are 0 hospitals within 25 miles of downtown Dubois.

To visually see the locations of hospitals around Clark County, click here.  Adjust the radius search area to 100 miles.  This will give you a broader view. 

When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page. 

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.  If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.  

Having resources with these ratings can be important to you when you get regular care, emergency and scheduled surgical procedures. 

All of these hospitals listed may not be in every plan.

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to 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. 

Do you need to use the plans network of dentists? 

Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services.  Plans may state cosmetic services are not covered. It you use an ‘out of network dentist, you may pay for all services…or services you use may cost you more when compared to your cost if you use an in-network dentist. 

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  If you have any question about whether a service is covered, call your plan’s customer service.  

We like plans that let you use any licensed dentist in the US and cover all non-cosmetic dental services. 

Vision Coverage.

The depth of this coverage varies by plan.  The same issues pointed out for dental coverage can apply to this service too. 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.

We have noticed some plans cut this benefit back for 2025. 

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 Membership.

Several insurance companies restructured their gym plans for 2025. 

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, or one of the new vendors in our area.  Be sure you 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), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.   

Will the people behind the TV ads include this service for you?

Call us if you would like help. Our hours are 8am to 8pm Monday through Saturday. 

 

 

This page was last modified on May 24, 2025 @ 1:13 PM

 

Several 2025 Camas County Medicare Advantage plans caught our attention.

The first is an HMO-POS plan with key 5-star hospitals in Oregon, Washington, Utah and Idaho in their network!  This means you pay in-network rates when you use these resources.  This same plan opens up access to other hospitals/physicians in the US that ‘accept Medicare’ too.  

Next are plans for people that have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

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

There are other Camas County Medicare plans on our recommend list.  Which medications, health issues, and hospital preference(s) a person has/does not have are determining factors on which are appropriate.

Don’t forget, if you are enrolled in a Medicare Advantage plan now and the 2025 version of your 2024 plan left you wanting, you can switch to a different plan between January 1 and March 31.

 

What else you need to know!

For 2025, Camas County has 15 Medicare Advantage plans for residents to consider. 

Here is the high level break down:

          4 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

                  2 of these are PPO;

                  2 are HMO plans.        

         9 plans do include prescription drug coverage and services covered by Medicare Part A and B.  

                  5 are HMO plans;

                  4 are PPO plans. 

           The remaining plans are reserved for individuals which qualify for Chronic Special Needs plans (C-SNP).  This plan is available to residents qualifying for this type of care.

The insurance company offering your plan sets the cost sharing for each Part A and B service.  

This simply means what you pay to see your physician, use hospital services, pay for your MRI/CAT imaging, cancer treatments, skilled nursing care, etc. are often different between plans.  When you compare plans annually, you look at these figures and choose the plan that best fits your pocketbook and needs. These figures can change annually.

Cost sharing for services used, the plan’s MOOP, monthly premium, and the financial savings you get when you use the plan’s non-Medicare covered services are some of the differentiators between plans.

Specific plan coverages may have limitations.

Rules may be imposed on specific 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 from your physician.  If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over.  This article documents points out what has been going on in the US on this subject. 

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 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 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 OR the top hospitals by type of surgery?

Resources are available to help you find these.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.  These resources are available to you if they accept Medicare insurance.  This group of hospitals may not accept the Medicare Advantage plans available to you.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.  Learn more about this subject here.

There are physician rating services too.  One is available here.  We focus on physicians with a 4 or 5 star rating and have at least 10 ratings.

We also recommend you use a ‘board certified physician‘.

What are the differences between Camas County Medicare Advantage plans?

One item is the plan’s Maximum out of pocket limit (MOOP).  Read the information below to learn why this is a key differentiator between plans.

This is a key figure you should be aware of.  Put plans on your short list that have a lower MOOP.  This decision may save you money if you use Medicare covered health care services during the plan year.

Be mindful Medicare pays its share of the cost for services you use.  You pay the rest.  Your share of these costs can vary noticeably between plans.

Think of the MOOP as your limit (or cap) for your share of health care costs for Part A and B services you use during the calendar year.   The higher your plan’s MOOP, the more you could end up paying for the services you use.

Medicare sets the maximum figure(s) a plan can have, and they can change it annually.

The insurance company offering your plan sets the plans MOOP where they want it.  It must be at or below Medicare’s limit.  This figure can change annually.

What are the actual MOOP figures?

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals.

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $6,300.  The range for PPO plans is $5,900 to $14,000.

We prefer plans that meet a person’s needs AND have a low MOOP.

You can check out the above figures by using the resource found here.

The example below will help you understand how your plan’s MOOP works.

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475.

When you subtract these figures from your plan’s MOOP the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket.

 

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 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…and prefer people with this insurance when compared to Medicare Advantage plans.

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with.  You and your physician are making the decision on the ‘next step’ in your health care. 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.  

 

Camas County Medicare Advantage plans for Veterans

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.  

Camas County residents have VA Clinics in Twin Falls (and several locations around the State) and hospitals in Boise, Salt Lake City and several other parts of the US.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually. 
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.  

Is an HMO or a PPO plan right for you?

A veteran may prefer a PPO plan if they want to open their 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 ‘out of network’ maximum out of pocket limit.  Check out this figure if you are interested in a PPO plan.  Call us if you want help thinking this through.

An HMO plan may fit a veteran that wants coverage outside the VA for regular health care OR just want access urgent and emergent care when it is needed. 

Some Veterans choose a $0 premium plan so they can get the low/no-cost ‘extra’ benefits which can come with these plans.  We noticed some plan(s) with a high Part B giveback also come with high-cost sharing when plan health care service is used. Call us if you want help thinking this through.

If a Veteran plans to get health care from an HMO plan, we need to pay attention to the plan’s network.  Participating hospitals and doctors can vary by plan and this can change annually. 

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 company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

We expect more insurance companies will enter the Camas County MA marketplace in the future. 

Keep in mind, some of these companies want to increase their market share by offering more attractive features than their competitors.   

When this occurs, we need to pay attention to plan differences.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare. 

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up. 

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals. 

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare. 

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

 

Camas County residents on Medicaid and enrolled in Medicare.

If you are on Medicaid and enrolled in Medicare and recently received a Medicaid cancellation notice, we can help you. 

Please remember you have 60-days from your cancellation date to find replacement insurance for both your health and prescription medications.  If you miss this window, you may have to wait until the next ‘annual enrollment period’. 

You have new options for replacing your health and medication insurance. 

We help you understand the differences between your Medicare Advantage and your Medicare Supplement choices.  Then we explain the specific plans available in each category. 

Others like you recently benefited from our help.

If you not affected by this Idaho Department of Health and Welfare audit…

There are several different types of plans available to Idaho residents enrolled in Medicaid. These include people eligible for ‘Basic’ or ‘Enhanced’ Medicaid or are eligible for an ISNP or a CSNP. Click here to learn more about your options.

 

Medicare Advantage plans for the rest of the Medicare beneficiaries living in Camas County

Check out the hospitals in each plan’s network and where they are located.

 

There are no hospitals in Camas County.  

Check out the other facilities within 50 miles of zip code 83327 by clicking here.  

Notice there are 4 hospitals within this radius. 

Take a look at the Medicare Star rating for each hospital.  We recommend Idaho residents consider hospitals rated 4 or 5. 

Learn more about CMS hospital rating here. 

Hospital(s) without a rating may have not reported their results or did not meet the minimum number of procedures to be measured and rated for the current period.  

When selecting a health plan, be sure the hospitals and doctors you want to take care of you no matter the health issue is available to you.  

The CMS hospital rating system is a guideline to consider using. 

You can also use another tool that identifies the top 100 hospitals in the US.  This information rates hospitals by type of surgery within hospital too.  Learn more here. 

You can consider these resources if you have a plan which opens up these facilities to you.  Depending on the plan you choose, some/all of these facilities may or may not be available to you.

 

What insurance companies offer Medicare Advantage plans in Camas County?

Humana

Pacific Source

United Healthcare

Other tidbits to be aware of

Additional details about the plans available in Camas County.

Monthly premiums of Medicare Advantage plans range from $0 to $68.   

The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans. 

Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’. 

Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’. 

Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory).   Reference this note for details.  

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 is sounds like a great and often needed ‘extra’ benefit.   

You really need to pay attention to the details as they can vary widely between the plans. 

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 co

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 charge you more for services if they you use an out-of-network dentist.   

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

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. 

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), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.   

Will the people behind the TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday. 

                                            .  

 

This page was last modified on Mar 29, 2025 @ 11:20 AM

Several 2025 Lincoln County Medicare Advantage plans caught our attention.

The first is an HMO-POS plan with key 5-star hospitals in Oregon, Washington, Utah and Idaho in their network!  This means you pay in-network rates when you use these resources.  This same plan opens up access to other hospitals/physicians in the US that ‘accept Medicare’ too.  This can be useful for ‘snowbirds’. 

The next two are plans for residents that have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

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

There are other Lincoln County Medicare HMO and PPO plans on our recommend list.  Which medications, hospital preferences, and health issues a person has/does not have are determining factors on which are appropriate. 

Interested in learning more?  Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and text it to us (1-208-867-0296).  Upon receipt we will call you and share the details.   

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

 

What else you need to know! 

For 2025, Lincoln County has 20 Medicare Advantage plans for residents to consider.  

Here is the high level break down:

          5 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

                  4 of these are PPO;

                  1 are HMO plans.        

          9 plans do include prescription drug coverage and services covered by Medicare Part A and B.         

                  4 of these are PPO;

                  5 are HMO plans.                  

           The remaining plans are reserved for individuals who qualify for Medicaid special needs plans

(I-SNP, C-SNP or D-SNP).

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

These are Medigap plans.

Two of the twelve plans deserve your attention.

When you choose this plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you and prior authorizations are minimal.  This means you do not have an insurance company standing between you and your physician to get to the ‘next step’ in your health care.   

Also important, this plan does not charged a ‘premium’ for services received from hospitals/physicians/other providers received outside of your immediate area (like many PPO plans).

Learn more about Idaho Medigap plans here. 

 Call if you have questions.

What are the some of the differences between Medicare Advantage plans?

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

This is a key figure you should be aware of. 

Put plans on your short list that have a lower MOOP.  This decision may save you money if you use Medicare covered health care services during the plan year.    

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 plan is $9,350; for a PPO plan it 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 $6,000. 

The range for PPO plans is $5,900 to $14,000. 

The example below will help you understand how your plan’s MOOP works.   

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475. 

After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.     

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket. 

The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B covered service too.  

This simply means that you pay your share of the costs for services provided by your physician, use specific hospital services like MRI or CAT imaging, cancer treatments, services provided in the surgical suite, etc..   The insurance company behind each plan sets their own cost sharing for that plan.  You find these figures in each plan’s ‘Evidence of Coverage’ (EOC).    

The EOC also identifies which services must be approved by the insurance company before they can be performed.  Be aware approval requests can be denied by the insurance company.    

Prior Authorizations.   

Services covered by any Medicare Advantage plan may have a ‘prior authorization’ tag on a service.   These are found in the plan’s EOC. 

The insurance company can approve or deny the prior authorization request.  Learn more about what is going when these requests are reviewed and approved or denied by reading this article, this article,  and this article.  CMS is in the process of implementing changes 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. 

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.

 

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

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.  These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.

Does Medicare rate hospitals for us?

Yes.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.  

There are physician rating services too.  One is available here.  We focus on physicians with a 4 or 5 star rating and have at least 10-ratings.  You can use this same tool to find physicians that ‘accept Medicare insurance’.   

We also recommend you use a ‘board certified physician‘.

 

Medications covered by each plan.

According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of 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. 

 

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

Yes. 

These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B).  Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans. 

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with. 

You and your physician are making the decision on the ‘next step’ in your health care.

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

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

Read the articles supporting the above comments here, here, and here. 

Do you want a plan that pays for most all of the left-over cost for Part A and B in the US?

We recommend you consider a Medigap Plan G. 

 

Lincoln County Medicare Advantage plans for Veterans, people enrolled in Medicaid and Medicare, and several plans for the rest of us.

Lincoln County Medicare Advantage plans for Veterans.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan. 

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually. 
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.  

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service. 

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

We expect more insurance companies will enter the Lincoln County MA marketplace in the future. 

Keep in mind, some of these companies want to increase their market share by offering more attractive features than their competitors.   

When this occurs, we need to pay attention to plan differences.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare. 

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up. 

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals. 

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare. 

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Lincoln County residents on Medicaid and enrolled in Medicare.

Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025. 

Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here.  Answers to ‘frequently asked questions’ is available here.

If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.  

UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026. 

Molina continues to serve Idaho residents with these important products.   

If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help.  We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022. 

Additional pertinent information about Idaho Medicaid and your plan choices. 

There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).

If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider. 

Click here to learn more about your options.

We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP). 

Explaining plan differences and helping you with enrollment are other services we help you with.  

 

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

Monthly premiums of Medicare Advantage plans in Lincoln County range from $0 to $118.

The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans. 

Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’. 

Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’. 

Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory).   Reference this note for details.  

 

 

What insurance companies offer Medicare Advantage plans in Lincoln County?

Blue Cross of Idaho

Humana

Pacific Source

United Healthcare

Other tidbits to be aware of.

Additional details about the plans available in Lincoln County.

Hospitals in your immediate area.

There are 2 hospitals within 25 miles of downtown Shoshone.

To see these, you will need to enter your zip code and adjust the radius around the search area.  Please start with 25 miles, review there results and then bump it up to 50 or 100 miles.  Click here to see this information.

When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page. 

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.  If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.  

Having resources with these ratings can be important to you when you get regular care, emergency and scheduled surgical procedures. 

All of these hospitals listed may not be in every plan.

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to the TV commercials, this is sounds like a great and often needed ‘extra’.   

You really need to pay attention to the details as they can vary widely between the plans that include this feature. 

For example, some plans restrict coverage to preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.).  The plan may cover certain periodontal services.  If covered, the plan may limit the number of times specific service(s) can be used during the year. Some plans include class II and III services.  If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

Do you need to use the plans network of dentists? 

Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services.  Plans may state  cosmetic services are not covered. It you use an ‘out of network dentist, you may pay for all services…or services you use may cost you more when compared to your cost if you use an in-network dentist. 

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any 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 Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance. 

Visiting the Costco hearing department may provide the education you need to understand product differences. 

Plans can be different on what specific products (and services) are available to you.  

 

Would a Medicare coach be helpful?

A coach can answer your question(s), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.   

Will the people behind the TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday. 

 

 

 

Content last updated May 24, 2025 @ 1:03 PM

 

 

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

We are licensed with all Power County Medicare Advantage plans listed on the Medicare plan finder tool.

We have 2025 Part D licenses with United Health Care, Silver Script and Humana.  One of the remaining companies does not use brokers for 2025.  The plans offered by the other has Medicare star ratings below 3.   When this company resolves this issue, we will pursue licensing with them.

Additional information on his subject is documented here.

Important note about Navigating this article.

There are several ‘hot links’ contained in the text below.  These point to reference material that you should find interesting.

When you have finished reading this information, use your ‘browsers back icon’ to return to this page’.

If you would rather talk with us about plan details (skip reading the rest of this article), just call .   But first:

Brokers must follow CMS rules before they can discuss plan details.

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.

 

What Else you need to know.

For 2025, Power County has 16 Medicare Advantage plans for residents to consider.

Here is the high level breakdown:

4 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

3 are PPO plans;

1 are HMO plans.

8  plans do include prescription drug coverage and services covered by Medicare Part A and B.

5 are HMO plans;

3 are PPO plans.

The remaining plans are reserved for individuals who qualify for Medicaid special needs plans (D-SNP).

 

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 Power County Medicare Advantage plans.

Also, you do not have an insurance company standing between your physicians to get permission to move forward with your treatment plan.  Physicians/hospitals may prefer these plans because they know they will be paid in a timely manner.

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

Learn more about Idaho Medigap plans here.

What are some of the differences between Medicare Advantage plans?

An important differentiator is the plans monthly premiums.  This year they range from $0 to over$140.

We typically do not recommend plans with a monthly premium above $70?  Why?  The above mentioned Medigap plans may offer you better value.

Think about where you would like to be treated if you have a serious health issue too.

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 plans.  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 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 about your 1st appointment.

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

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.

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 is $9,350.

The MOOP maximum for PPO plans cannot exceed $14,000.

Each plan’s MOOP is set by the insurance company offering the plan.  They can be different for each plan available to you.

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 $5,200 to $6,400.

The range for PPO plans is $7,200 to $14,000.

Recall the above discussion about the 2 Medigap plans that limit your annual out of pocket costs to less than $2,900 AND open up access to all hospitals and physicians in the US (that ‘accept Medicare’)?

 

The example below will help you understand how your plan’s MOOP works.

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475.

After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket.

 

The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B service.  

This simply means what you pay to see your physician, use hospital services, pay for your MRI/CAT imaging, cancer treatments, skilled nursing care, etc. are often different between plans.  When you compare plans annually, you look at these figures and choose the plan that best fits your pocketbook and needs. These figures can change annually.

Cost sharing for services used, the plan’s MOOP, monthly premium, and the financial savings you get when you use the plan’s non-Medicare covered services are some of the differentiators between plans.

Specific plan coverages may have limitations.

Rules may be imposed on specific coverage.  You find these rules in your plan’s ‘Evidence of Coverage’.

Prior Authorization is an example.

Prior authorization may be required on specific plan covered services.  What does this mean?  Your  insurance company can approve or deny the service request.  If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over.

The number of days ‘skilled nursing care’ has their daily co-pays in place is something you need to pay attention to.  Why?  Because if you need this service and have the ‘wrong’ plan, it can be the quickest way for you to hit your plan’s MOOP.

Dental coverage is another example where rules are important to know.

For example, 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 limitations on the number of cleanings too (2 per year when you may need 3); 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 companies meet a minimum adequacy requirement when they put their networks together.  This means there is a reasonable 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.

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

The top 250 hospitals in the US may have the top physicians by specialty and the latest technologies to treat different health issue(s).  These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.

Does Medicare rate hospitals for us?

Yes.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.

There are physician rating services too.  One is available here.  We focus on physicians with a 4 or 5 star rating and have at least 10-ratings.  You can use this same tool to find physicians that ‘accept Medicare insurance’.

We also recommend you use a ‘board certified physician‘.

 

Medications covered by each plan.

According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of these plans include 100% of the medications covered by Medicare.

This same resource documents the number of medications each plan has in each of the 5 (or 6) drug tiers AND the fill/refill cost by these same drug tiers.  These figures can vary noticeably between plans.

Given the wide variance between plans on the above, it is easy to understand why there can be a 300% +/- variance in your projected annual out of pocket cost between your plan choices for the medications you take.

This is a key reason you should not enroll in any Medicare Advantage plan until you understand your cost for your prescription medications.  If you are working with a broker/agent that just tells you your medications are covered, we suggest you work with someone else that will share the whole picture.

Are medications that treat serious health issues (cancer, etc.) covered by my plan?

The Centers for Medicare and Medicaid Services (CMS) have requirements that insurance company(s) offering Medicare plan(s) must meet when they put together their list of covered medications.

Below is a cut/paste from (Section 30.2.5) the current Medicare Prescription Drug Benefit Manual.

“Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant (for prophylaxis of organ transplant rejection), antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes. CMS instituted this policy because it was necessary to ensure that Medicare beneficiaries reliant upon these drugs would not be substantially discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

We feel this is an important statement everyone enrolled/wishing to enroll in a Medicare prescription drug plan should be aware of.

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

Yes. 

These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B).  Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans.

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with.

You and your physician are making the decision on the ‘next step’ in your health care.

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

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

Read the articles supporting the above comments here, here, and here.

Do you want a plan that pays for most all of the left-over cost for Part A and B covered services?

We recommend you consider Medigap Plan G.

There are 3 different audiences for Idaho Medicare Advantage plans.

There are Medicare Advantage plans for Veterans, people enrolled in Medicaid and Medicare, and several plans for the rest of us.

Let’s take a closer look at each. 

 

Power County Medicare Advantage (MA) plans for Veterans.

Boise has a top-rated VA hospital. If you are entitled to VA health care this is a great place to get your health care and prescription medications.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive among the insurance companies.

At the current moment, the major insurance companies offering these plans are in Power County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs for the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include a Part B buyback feature.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Power County residents enrolled in both Medicaid and Medicare.

Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025.

Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here.  Answers to ‘frequently asked questions’ is available here.

If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.

UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026.

Molina continues to serve Idaho residents with these important products.

If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help.  We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022.

Additional pertinent information about Idaho Medicaid and your plan choices.

There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).

If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider.

Click here to learn more about your options.

We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP).

Explaining plan differences and helping you with enrollment are other services we help you with.

 

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

What insurance companies offer Medicare Advantage plans in Power County?

Blue Cross of Idaho

Humana

Molina

We expect more insurance companies will be offering their Medicare Advantage plans in Power County when the number of people on Medicare increases.

 

Other tidbits to be aware of.

Hospitals in your immediate area.

There are 2 hospital within 25 miles of downtown American Falls.

You can have a visual by clicking here.

Change the search radius to see additional hospitals.

When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page.

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.

If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.

Having resources with these higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.

All of these hospitals listed may not be in every Medicare Advantage plan.  They will be available, if you are enrolled in a Medigap plan. 

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to the TV commercials, this 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…or services you use may cost you more when compared to your cost if you use an in-network dentist.

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any 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 plans catalog of covered items.  Plan’s have a quarterly limit on how much it gives you to spend on these items. The amount of the quarterly limit can vary widely between plans.

Gym Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance.

Visiting the Costco hearing department may provide the education you need to understand product differences.

Plans can be different regarding what specific products (and services) are available to you.

 

Would a Medicare coach be helpful?

A coach can answer your question, help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.

Will the people behind the Medicare Advantage plan TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.

 

This page was last updated May 24, 2025 @ 3:41 PM

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

At the current moment, the major insurance companies offering these plans are in Fremont County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs to the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Fremont County residents on Medicaid and enrolled in Medicare.

 

Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025.

Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here.  Answers to ‘frequently asked questions’ is available here.

If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.

UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026.

Molina continues to serve Idaho residents with these important products.

If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help.  We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022.

Additional pertinent information about Idaho Medicaid and your plan choices.

There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).

If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider.

Click here to learn more about your options.

We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP).

Explaining plan differences and helping you with enrollment are other services we help you with.

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

What insurance companies offer Medicare Advantage plans in Fremont County?

Blue Cross of Idaho

Humana

Molina

As Fremont County’s population of Medicare beneficiaries increases other insurance companies may enter this market.

 

Other tidbits to be aware of.

Hospitals in your immediate area.

There is 1 hospital within 25 miles of downtown Saint Anthony.

You can have a visual by clicking here.

Change the search radius to see additional hospitals.

When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page.

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.

If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.

Having resources with these higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.

All of these hospitals listed may not be in every Medicare Advantage plan.  They will be available, if you are enrolled in a Medigap plan. 

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to the TV commercials, this is sounds like a great and often needed ‘extra’.

You really need to pay attention to the details as they can vary widely between the plans that include this feature.

For example, some plans restrict coverage to preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.).  The plan may cover certain periodontal services.  If covered, the plan may limit the number of times specific service(s) can be used during the year. Some plans include class II and III services.  If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

Do you need to use the plans network of dentists?

Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services.  Plans may state  cosmetic services are not covered. It you use an ‘out of network dentist, you may pay for all services…or services you use may cost you more when compared to your cost if you use an in-network dentist.

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any 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 Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance.

Visiting the Costco hearing department may provide the education you need to understand product differences.

Plans can be different on what specific products (and services) are available to you.

 

Would a Medicare coach be helpful?

A coach can answer your question(s), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.

Will the people behind the Medicare Advantage plan TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.

 

 

Content last updated Feb 19, 2025 @ 9:38 AM

 

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

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

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

Additional information on his subject is documented here. 

 

2025 Plans available for Jefferson County residents with chronic health issues. 

There are plans for people that have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

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

Other Plans for 2025. 

There are other Jefferson County Medicare HMO and PPO plans on our recommend list.  Which medications, hospital preferences, and health issues a person has/does not have are determining factors on which are appropriate. 

Interested in learning more?  Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and text it to us (1-208-867-0296).  Upon receipt we will call you and share the details.   

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

 

What Else you need to know.

For 2025, Jefferson County has 21 Medicare Advantage plans for residents to consider. 

Here is the high level break down:

         3 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

                  3 of these are PPO;

        12 plans do include prescription drug coverage and services covered by Medicare Part A and B.  

                  8 are HMO plans;

                 4 are PPO plans. 

           The remaining plans are reserved for individuals which qualify for Medicaid special needs plans (i-SNP, C-SNP or D-SNP).

 

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

These are called Medigap plans.

When you choose this plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you and prior authorizations are minimal.  

This simply means you are not limited by network rules found in Medicare Advantage plans.  This also means you are not charged a ‘premium’ for services received when you use services out of your immediate area (like many PPO plans).

Learn more about Idaho Medigap plans here. 

 Call if you have questions.

 

What are the some of the differences between Medicare Advantage plans?

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

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

The MOOP maximum for PPO plans cannot exceed $14,000.

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals. 

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.  

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $6,750. 

The range for PPO plans is $5,900 to $14,000. 

 

The example below will help you understand how your plan’s MOOP works.   

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475. 

After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.     

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket. 

 

The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B covered service too.  

This simply means that you pay your share of the costs for services provided by your physician, use specific hospital services like MRI or CAT imaging, cancer treatments, services provided in the surgical suite, etc..   The insurance company behind each plan sets their own cost sharing for that plan.  You find these figures in each plan’s ‘Evidence of Coverage’ (EOC).    

The EOC also identifies which services must be approved by the insurance company before they can be performed.  Be aware approval requests can be denied by the insurance company.    

Prior Authorizations.   

Services covered by any Medicare Advantage plan may have a ‘prior authorization’ tag on a service.   These are found in the plan’s EOC.  The insurance company can approve or deny the prior authorization request.  Learn more about what is going when these requests by reading this article, this article,  and this article.  CMS is in the process of implementing new processes to help get this back on track. 

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

Doctors/hospitals/other providers.

Availability of physicians, hospitals, physical therapists, skilled nursing facilities, durable medical equipment providers and all other provider types vary by plan.  The insurance companies offering Medicare Advantage plans put together their networks of these people/facilities for their plan members.  You need to confirm the doctors and hospitals are in the plan’s network. 

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

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

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

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

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.  These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.

Does Medicare rate hospitals for us?

Yes.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.  

There are physician rating services too.  One is available here.  We focus on physicians with a 4 or 5 star rating and have at least 10-ratings.  You can use this same tool to find physicians that ‘accept Medicare insurance’.   

We also recommend you use a ‘board certified physician‘.

 

Medications covered by each plan.

According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of the Idaho plans include 100% of the medications covered by Medicare. 

This same resource documents the number of medications each plan has in each of the 5 (or 6) drug tiers AND the fill/refill cost by these same drug tiers.  These figures can vary noticeably between plans. 

Given the wide variance between plans on the above, it is easy to understand why there can be a 300% +/- variance in your projected annual out of pocket cost between your plan choices for the medications you take.   

This is a key reason you should not enroll in any Medicare Advantage plan until you understand your cost for your prescription medications.  If you are working with a broker/agent that just tells you your medications are covered, we suggest you work with someone else that will share the whole picture. 

Are medications that treat serious health issues (cancer, etc.) covered by my plan?

The Centers for Medicare and Medicaid Services (CMS) has requirements insurance company(s) offering Medicare plan(s) must meet when they put together their list of covered medications. 

Below is a cut/paste from (Section 30.2.5) the current Medicare Prescription Drug Benefit Manual.  

“Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant(for prophylaxis of organ transplant rejection), antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes. CMS instituted this policy because it was necessary to ensure that Medicare beneficiaries reliant upon these drugs would not be substantially discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

We feel this is an important statement everyone enrolled/wishing to enroll in a Medicare prescription drug plan should be aware of. 

 

 

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

Yes. 

These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B).  Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans. 

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with. 

You and your physician are making the decision on the ‘next step’ in your health care.

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

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

Read the articles supporting the above comments here, here, and here. 

Do you want a plan that pays for most all of the left-over cost for Part A and B in the US?

We recommend you consider a Medigap Plan G. 

Are there lower premium Medigap plans what have some copays?

Yes.

There are 2 different Medigap plans we like that meet these criteria.   They have a Medicare controlled ‘annual deductible’.  Yes, it goes up a bit annually.

This ‘deductible’ is similar in concept to the MOOP described above. 

The deductible for this year is found here. 

Once your share of your costs for the services you use hits this figure, this Medigap plan pays the rest of your Part A and B left over costs for the calendar year. 

When you work with a Medicare broker that is licensed with all/most all plans available to you, they help you navigate your way through this maze and select the plan which meets your needs and budget.   

 

 

There are 3 different audiences for Idaho Medicare Advantage plans.

There are Medicare Advantage plans for Veterans, people enrolled in Medicaid and Medicare, and several plans for the rest of us.

Let’s take a closer look at each. 

 

Jefferson County Medicare Advantage plans for Veterans.

Boise has a top-rated VA hospital. If you are entitled to VA health care this is a great place to get your health care and prescription medications.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

At the current moment, the major insurance companies offering these plans are in Jefferson County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs to the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Jefferson County residents on Medicaid and enrolled in Medicare.

Blue Cross of Idaho is exiting the IMPlus and MMCP Idaho market on 5/31/2025. 

Idaho Department of Health and Welfare (IDHW) clarified this announcement on February 5, 2025 and is available here.  Answers to ‘frequently asked questions’ is available here.

If you are presently enrolled in either of these plans, you will be receiving correspondence from both Idaho Department of Health and Welfare and Blue Cross of Idaho.  

UnitedHealthcare will be entering the Idaho IMPlus market on 6/1/2025 and the MMCP market on 1/1/2026. 

Molina continues to serve Idaho residents with these important products.   

If you prefer to work with an Idaho based broker to get your coverage realigned, we are here to help.  We have been helping Idaho residents with their Medicare choices since 2012 and MMCP plans since 2022. 

Additional pertinent information about Idaho Medicaid and your plan choices. 

There are several different types of plans available to Idaho residents enrolled in Medicaid. If the Idaho Department of Health and Welfare categorized you in the ‘Basic’ category, you have a different set of Medicare Advantage plans to choose from (compared to individuals categorized as ‘Enhanced’).

If you are eligible for an I-SNP OR a C-SNP plan, you have different plans to consider. 

Click here to learn more about your options.

We are licensed with C-SNP, D-SNP, QMB and Medicare Medicaid Coordinated plans (MMCP). 

Explaining plan differences and helping you with enrollment are other services we help you with.  

 

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

Monthly premiums range from $0 to over $135.

The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans.

Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’.

Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’.

Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory).   Reference this note for details.

 

What insurance companies offer Medicare Advantage plans in Jefferson County?

Blue Cross of Idaho

Humana

Molina

United Health Care

Other tidbits to be aware of.

Hospitals in your immediate area.

There are 4 hospitals within 25 miles of downtown Rigby.  

You can have a visual by clicking here.

Change the search radius to see additional hospitals.

When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page.

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.

If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.

Having resources with these higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.

All of these hospitals listed may not be in every Medicare Advantage plan.  They will be available, if you are enrolled in a Medigap plan. 

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to the TV commercials, this is sounds like a great and often needed ‘extra’.

You really need to pay attention to the details as they can vary widely between the plans that include this feature.

For example, some plans restrict coverage to preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.).  The plan may cover certain periodontal services.  If covered, the plan may limit the number of times specific service(s) can be used during the year. Some plans include class II and III services.  If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

Do you need to use the plans network of dentists?

Plans may have a network of dentists you can use.  Some some permit the use of any licensed dentist in the US for services.  Plans may state  cosmetic services are not covered. It you use an ‘out of network dentist, you may pay for all services.  Services you use may cost you more when compared to your cost if you use an in-network dentist.

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any question about whether a service is covered, call your plan’s customer service.  You may have to get specific billing codes from your dentist just to be sure you get the right answer.

We like plans that let you use any licensed dentist in the US and cover all non-cosmetic dental services. 

Vision Coverage.

The depth of this coverage varies by plan.  The same issues pointed out for dental coverage can apply to this service too. Be sure and look at the cost for an annual checkup, network restrictions, how much the plan will pay for glasses, frames, contacts, etc.

 

Over The Counter benefit.

Some plans have a catalog of ‘drug store‘ items you can order from.  They are delivered to you at no cost.  It is possible the items you want will not be included in the plan’s catalog of covered items.  Plan’s have a quarterly limit on how much it gives you to spend on these items. The amount of the quarterly limit can vary widely between plans.

Gym Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance.

Visiting the Costco hearing department may provide the education you need to understand product differences.

Plans can be different on what specific products (and services) are available to you.

 

Would a Medicare coach be helpful?

A coach can answer your question(s) and help firm up your understanding of Medicare.  Understanding the differences between your choices is important.  Helping you through the enrollment process is another benefit of using a broker.  They will also be there year after year to help you.

Will the people behind the Medicare Advantage plan TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.

 

 

This page was updated on May 24, 2025 @ 3:36 PM

 

 

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

We are licensed with all Madison County Medicare Advantage plans listed on the Medicare Plan Finder tool.

There are 5 insurance companies offering Part D plans to Idaho residents.  We have 2025 Part D licenses with United Health Care, Silver Script and Humana.  One of the other companies is not using brokers anymore.  The other company has Part D plans with a Medicare star rating below 3.  We do not recommend plans with a rating below 3.  When this company resolves this issue, we will pursue a license with them.  

Additional information on his subject is documented here. 

 

Important note about Navigating this article.

There are several ‘hot links’ contained in the text below.  These point to reference material that you should find interesting.

When you are finished reading this information, use your ‘browsers back icon’ to return to this page’.

 

If you would rather talk with us about plan details (skip reading the rest of this article), just call .   But first:

Brokers must follow CMS rules before they can discuss plan details. 

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.  

 

What you need to know.

For 2025, Madison County has 18 Medicare Advantage plans for residents to consider.

Here is the high level break down:

3 plans do NOT include prescription drug coverage; Veterans may find these plans attractive.

1 are PPO plans;

2 are HMO plans.

10 plans do include prescription drug coverage and services covered by Medicare Part A and B.

8 are HMO plans;

2 are PPO plans.

The remaining plans are reserved for individuals which qualify for Medicaid special needs plans (I-SNP, C-SNP or D-SNP).

 

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

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 Madison County Medicare Advantage plans.

Also, you do not have an insurance company standing between your physician ahd the hospital/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.

Learn more about Idaho Medigap plans here. 

 

What are the some of the differences between Madison County Medicare Advantage plans?

Plan monthly premium range from $0 to over $140. 

We do not typically recommend plans with a monthly premium above $70?  Why?  The above mentioned Medigap plans may offer you better value.

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.

Think about where you would like to be treated if you have a serious health issue too.

What hospital(s) do you want to use if you are diagnosed with a serious health issue?

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 plans.  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 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.  This includes residents in Madison County.

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.

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

 

The Maximum out of Pocket Limit (MOOP).  Why this 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.    

Your insurance company 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 is $9,300. 

The MOOP maximum for PPO plans cannot exceed $14,000.   

Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals. 

Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.  

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $6,400. 

The range for PPO plans is $5,200 to $10,100. 

The example below will help you understand how your plan’s MOOP works.   

Let’s say your plan’s MOOP is $7,000 for the year.

In January you are admitted to the hospital for surgery.  Your bill for the 5-day hospital stay is $1,750.  Your post-op visits to your physician and physical therapist(s) are $475. 

After you pay for these services, you subtract them from your plan’s MOOP; the result is how your new MOOP.  When, after you use additional services, and your MOOP hits zero, your plan pays the rest of your share of the cost for Medicare A  & B services.     

If you have a plan with a ‘lower MOOP’ you have the opportunity to keep more money in your pocket. 

 

The insurance company offering your Medicare Advantage plan sets the cost sharing for each Part A and B covered service too.  

This simply means that you pay your share of the costs for services provided by your physician, use specific hospital services like MRI or CAT imaging, cancer treatments, services provided in the surgical suite, etc..   The insurance company behind each plan sets their own cost sharing for that plan.  You find these figures in each plan’s ‘Evidence of Coverage’ (EOC).    

The EOC also identifies which services must be approved by the insurance company before they can be performed.  Be aware approval requests can be denied by the insurance company.    

Prior Authorizations.   

Services covered by any Medicare Advantage plan may have a ‘prior authorization’ tag on a service.   These are found in the plan’s EOC.  The insurance company can approve or deny the prior authorization request.  Learn more about what is going when these requests 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. 

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 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.

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

The top 250 hospitals in the US may have the top physicians by specialty and the latest technologies to treat different health issue(s).  These resources are available to you if they accept Medicare insurance, and you have a Medigap plan.

Does Medicare rate hospitals for us?

Yes.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.  

There are physician rating services too.  One is available here.  We focus on physicians with a 4 or 5 star rating and have at least 10-ratings.  You can use this same tool to find physicians that ‘accept Medicare insurance’.   

We also recommend you use a ‘board certified physician‘.

 

Medications covered by each plan.

According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of 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. 

 

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

Yes. 

These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B).  Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do…and prefer people with this insurance when compared to Medicare Advantage plans. 

When you have a Medicare Supplement plan, typically the hospital as well as physicians you work with have far fewer ‘prior authorizations’ and denial of claims issues to deal with. 

You and your physician are making the decision on the ‘next step’ in your health care.

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

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

Read the articles supporting the above comments here, here, and here. 

Do you want a plan that pays for most all of the left-over cost for Part A and B in the US?

We recommend you consider a Medigap Plan G. 

Are there lower premium Medigap plans what have some copays?

Yes.

There are 2 different Medigap plans we like that meet these criteria.   They have a Medicare controlled ‘annual deductible’.  Yes, it goes up a bit annually.

This ‘deductible’ is similar in concept to the MOOP described above. 

The deductible for this year is found here. 

Once your share of your costs for the services you use hits this figure, this Medigap plan pays the rest of your Part A and B left over costs for the calendar year. 

When you work with a Medicare broker that is licensed with all/most all plans available to you, they help you navigate your way through this maze and select the plan which meets your needs and budget.   

 

There are 3 different audiences for Idaho Medicare Advantage plans.

There are Medicare Advantage plans for Veterans, people enrolled in Medicaid and Medicare, and several plans for the rest of us.

Let’s take a closer look at each. 

 

Madison County Medicare Advantage (MA) plans for Veterans.

Boise has a top-rated VA hospital. If you are entitled to VA health care this is a great place to get your health care and prescription medications.

Veterans enrolled in Medicare Part A and B can enroll in a Medicare Advantage or a Medigap plan.

Why would a Veteran consider a Medicare Advantage plan? Because:

• You will have flexibility to get your health care services from the VA and the network of providers in your Medicare Advantage plan. Available services include urgent, emergency, and regular health care.  You can still get services from the VA.
• Take advantage of the Part B buyback offered by some of these plans.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  At this writing, this ‘give back’ varies from $0 to $100 a month for plans available in Idaho.  These figures are determined by the insurance company offering the plan and can change annually.
• Get the $0/low cost ‘extra’ features not covered by Medicare. Some plans have attractive features that may benefit the Veteran.
• Many of these plans have a $0 monthly premium.

 

Why the interest by insurance companies in the Veterans Medicare niche?

A couple of obvious reasons could include they want to say thank you to the Veteran for their service.

Another can be these plans can be more profitable to the company if the Veteran continues to get their health care from the VA.

This market niche has become quite competitive between the insurance companies.

At the current moment, the major insurance companies offering these plans are in Madison County. There may be more new entrants next (or following) years.

In our opinion, these companies want to increase their market share by offering more attractive features than their competitors.

These plans have different features and costs to the Veteran.

These can include the doctors/hospitals in the plan’s network, the cost for health care services provided to the plan member, and the details of any ‘extra’ services not covered by Medicare.

Why is the Part B ‘buyback’ important?

Many MA plans in Idaho also include the Part B buyback.  This means the insurance company MAY offer to pay part of the Veterans Part B monthly premium.  In other Idaho Counties, this figure varies from $0 and up.

Some Veterans that get their health care from the VA simply enroll in one of these plans to get help paying for their Part B monthly premium and to take advantage of the $0/low cost for the other features included in the plan.  Others want access to urgent and emergency care outside of the VA.  Others simply want a broader choice of doctors and hospitals.

Another key point is these companies may improve their offerings annually.  They do this to attract Veterans already enrolled in another insurance company’s plan as well as Veterans new Medicare.

We suggest Veterans work with an Idaho broker that is also a veteran and is licensed with all these plans.

We can help you with this when you are ready. Learn more about us here.

 

Madison 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.  

 

What insurance companies offer Medicare Advantage plans in Madison County?

Blue Cross of Idaho

Molina

United Health Care

Other tidbits to be aware of.

All Medicare Advantage plans have their specific network of doctors and hospitals available to plan members.  Some plans (PPO) let you go ‘out of network’ at higher cost sharing for services used.  These plans also have a higher ‘out of pocket maximum’.  This figure can be over $13,000.  Be aware the doctor/hospital may not accept the terms/conditions in the PPO plans contract. 

Also, be aware Mayo Clinics in the US do not accept PPO plans unless the plan includes their facilities in their network.

See their announcement on this here.

The insurance companies offering these plans negotiate with the resources included their network.   Doctors/hospitals participation in a Medicare Advantage plan’s network can change during the plan year and annually.  Read this announcement which recently happened in Kootenai County.

Where are the 5 star rated hospitals in Idaho?

Some plans include the resources in Ada and Canyon County in addition to hospitals in Northern, Central, and Eastern Idaho.

If you want the flexibility to choose any hospital and physician in the US, we suggest you consider a Medicare Supplement plan.  They offer more flexibility than you will find with a Medicare Advantage plan.

Having a plan with a broader selection of hospital(s) available may offer more peace of mind if you are diagnosed with serious health issues.

Be aware CMS star ratings change as data is collected often.  We suggest you always check the current star rating of any hospitals you may use.

We will help you think through your options.

 

 

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

Monthly premiums range from $0 to over $135.

The differences between these plans include the available hospital(s), physicians, skilled nursing facilities, physical therapists, durable medical equipment providers, etc. Your share of the cost for services received AND the ‘out of pocket maximum limit’ also vary between plans.

Some plans let you use ‘out of network’ providers at a higher cost sharing and ‘out of pocket maximum limit’.

Be aware out of network providers are not required to accept your plan, unless you have an ’emergency’.

Also note Mayo Clinic no longer accepts Medicare beneficiaries enrolled in a Medicare Advantage plan, unless their facilities are part of the plan(s) network (reference the plan’s provider directory).   Reference this note for details.

 

What insurance companies offer Medicare Advantage plans in Jefferson County?

Blue Cross of Idaho

Molina

United Health Care

Other tidbits to be aware of.

Hospitals in your immediate area.

There are 1 hospital within 25 miles of downtown Rexburg.  

You can have a visual by clicking here.

Change the search radius to see additional hospitals.

When done reviewing this, be sure and hit your browsers ‘back button’ to return to this page.

Hospitals are rated by The Center for Medicaid and Medicare Services (CMS).  We recommend people use facilities rated 4 or 5 stars.

If you see a hospital without a star rating, this can mean that the hospital did not submit information to be rated or they did not do enough procedures to be rated.

Having resources with these higher ratings can be important to you when you get regular care, emergency and scheduled surgical procedures.

All of these hospitals listed may not be in every Medicare Advantage plan.  They will be available, if you are enrolled in a Medigap plan. 

 

Read the fine print that describes ‘extra’ benefits included in Medicare Advantage plans. 

Dental Coverage.  

Please review the verbiage on dental care found in the Evidence of Coverage. 

If you listen to the TV commercials, this is sounds like a great and often needed ‘extra’.

You really need to pay attention to the details as they can vary widely between the plans that include this feature.

For example, some plans restrict coverage to preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.).  The plan may cover certain periodontal services.  If covered, the plan may limit the number of times specific service(s) can be used during the year. Some plans include class II and III services.  If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

Do you need to use the plans network of dentists?

Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services.  Plans may state  cosmetic services are not covered. It you use an ‘out of network dentist, you may pay for all services…or services you use may cost you more when compared to your cost if you use an in-network dentist.

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document just to be sure you understand the plan’s rules.  Your plan may not pay for services you use which are excluded from your plan.  If you have any 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 Membership.

You need to pay attention to the depth/variety of facilities that are available and close to you.  Some plans include a ‘Silver and Fit’, ‘Silver Sneakers’,  a membership with their own network of facilities.  Some plans may charge ‘extra’ for this feature.  Read the plan’s rules for this service…and which facilities in your area are available to you.

Hearing Aids.  

Many Medicare Advantage plans have 3rd party business partners that handle this extra benefit.  This means you are using that vendor to spend your hearing allowance.

Visiting the Costco hearing department may provide the education you need to understand product differences.

Plans can be different on what specific products (and services) are available to you.

 

Would a Medicare coach be helpful?

A coach can answer your question(s), help firm up your understanding of Medicare, explain the differences between your choices, and help you through the enrollment process.  They will also be there year after year to help you.

Will the people behind the Medicare Advantage plan TV ad’s include this service for you?

Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.

 

 

 

This page was last updated on May 24, 2025 @ 3:37 PM