Several 2025 Jerome 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 second plan is new for 2025.  This HMO plan has all the of the boxes checked (attractive network, formulary, out of pocket costs, competitive ‘extras’, and MOOP).  If you presently have an HMO plan (or are considering one for 2025) and live in Jerome County we encourage you to add this to your short list.

Also, there are additional 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 Jerome 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, Jerome County has 25 Medicare Advantage plans for residents to consider.  

Here is the high level break down:

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

                  4 of these are PPO;

                  2 are HMO plans.        

                  Veterans should also consider the new HMO plan mentioned above.  Why?  It’s Part B give back is higher than any of the Medicare Advantage plans which do not include prescription drug coverage.  

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

                   9 are HMO plans;

                   4 are PPO plans. 

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

 

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

These are Medigap plans.

When you choose this 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 Jerome 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 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 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 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 $4,200 to $9,350. 

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. 

 

 

There are 3 different audiences for Jerome County Medicare Advantage plans.

Jerome County Medicare Advantage plans for Veterans.

We like the choices Veterans living in Jerome 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 the 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.

Competitive features 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.

 

Jerome 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 Jerome County

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

Jerome County has several hospitals/clinics in reasonable driving distance from Jerome (50-miles). 

Check out the facilities within 50 miles of zip code 83338 by clicking here.

When you get to this web page, enter your zip code (83338) and adjust the radius to 50-miles.

Notice there are 5 hospitals within this radius. 

3 have a 4-star rating the other 2 do not have a CMS rating. The 4 star rating is including Minidoka Memorial, North Canyon Medical Center and the St Lukes resource in Twin Falls.   

 

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. 

 

What insurance companies offer Medicare Advantage plans in Jerome County?

Blue Cross of Idaho

Humana

Molina

Pacific Source

United Healthcare

Other tidbits to be aware of

Hospitals in your immediate area.

There are 2 hospitals within 25 miles of downtown Jerome.

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 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.

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.  Your order is typically shipped 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 depending 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 are interested. Our hours are 8am to 8pm Monday through Saturday. 

 

This page was last modified on May 24, 2025 @ 1:02 PM

 

What you need to know about Bingham County 2025 Medicare plans.

For 2025, Bingham County has 23 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 are PPO plans;

2 are HMO plans.

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

9 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 Bingham 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.

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.

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.

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 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.

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 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 reinforce your understanding how your plan’s MOOP works.

Let’s say you’re 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.

Read this article if you are unfamiliar with this.

At this writing, 45 hospitals (out of over 4500) offer this solution.  Facilities near Idaho include:

Huntsman Cancer Institute (Salt Lake City) (began offering this service in 2021)

The Mayo Clinic Cancer Center (Phoenix…rolled out this service on 2016)

Loma Linda University Cancer Center (began offering this service in 1990)

California Protons Cancer Therapy Center (San Diego) (began offering this service in 2017).

If you are interested in this service, you might check where each of the above facilities are ranked in the top 250 hospitals.

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

Would you consider using the services of the top hospitals in the Seattle area…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’.

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 was a good discussion about these ratings recently.  This article is worthy of your attention.

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?

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 Bingham County Medicare Advantage plans.

Bingham  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.

 

Bingham  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.

Bingham County Medicare Advantage plans for the rest of us. 

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

Quality of care can vary by hospital and CMS helps you separate them.

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

Notice there are 8 hospitals within this radius.

At this moment, 2 of these hospitals have a 4-star rating, 1 is rated as ‘3’ stars, 1 at 2-stars, and the remaining are not rated.  Learn more about CMS hospital star ratings here.

Why don’t all 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. In our opinion, neither situation is a positive sign.

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 are 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 Bingham 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.

What insurance companies offer Medicare Advantage plans in Bingham County?

 

Blue Cross of Idaho

Humana

Molina Health Care

United Healthcare

Other tidbits to be aware of

 

Content last updated May 24, 2025 @ 1:10 PM

Several 2025 Twin Falls 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 second plan is new for 2025.  This HMO plan has all the of the boxes checked (attractive network, formulary, out of pocket costs, competitive ‘extras’, and MOOP).  If you presently have an HMO plan (or are considering one for 2025) and live in Twin Falls County we encourage you to add this to your short list.

Also, there are additional 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 Twin Falls 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, Twin Falls County has 30 Medicare Advantage plans for residents to consider. 

Here is the high level break down:

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

                  4 of these are PPO;

                  2 are HMO plans.        

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

                 11 are HMO plans;

                  6 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 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 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 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 HMO-POS and PPO plans cannot exceed $14,000.   

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

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

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,200 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 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 of 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.  

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? 

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. 

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 leftover 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 Twin Falls County Medicare Advantage plans.

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

Twin Falls County Medicare Advantage plans for Veterans.

 

We like the choices Veterans living in Twin Falls 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? 

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.

Some Medicare Advantage plans include $0/low cost ‘extra’ features not covered by Medicare.

Many of these plans have a $0 monthly premium.  This means a $0 premium Medicare Advantage plans may include a refund on your Part B monthly premium, include a no-cost gym membership, etc.  Not all of these plans offer the same benefits.  The Part B ‘buy-back’ for your Medicare Part B monthly premium ranges from $0 – $100 in Idaho.  Finding plans with this benefit is easy and makes sense when you work with a Medicare insurance broker that is also a veteran and licensed with all of the veteran plans available in your County of residence.  

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 (or outside the network of your Medicare Advantage plan). 

Be aware when you get plan services that 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.

Why are $0 premium plans so popular? 

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 the companies want to increase their market share by offering more attractive features than their competitors.   

They can update their plan(s) annually.  Again, 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.

 

Twin Falls 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 Twin Falls 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).   See this note for details.  

Some of these plans specialize in the St Lukes hospitals in Idaho.  

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

 

What insurance companies offer Medicare Advantage plans in Twin Falls County?

 

American Health Advantage of Idaho

Blue Cross of Idaho

Humana

Molina

Pacific Source

United Healthcare

 

Other Tidbits. 

Hospitals in your immediate area

There are 2 hospitals within 25 miles of downtown Twin Falls. 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 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.  Plans may not cover cosmetic services. It you use an ‘out of network dentist, you may pay for all services.  Some plans require you to pay more for out of network services.  

We suggest you read dental coverage section of the ‘Evidence of Coverage’ document.  Your goal is 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.  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. What can vary by plan?  The cost for an annual checkup, network restrictions, how much the plan will pay covered services. 

Over The Counter benefit.

Some plans have a catalog of ‘drug store‘ items you can order from.  Selected items 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.  Plans 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.  They will explain the differences between your health plan choices and help you through the enrollment process.  They will also be there year after year to help you.   

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

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

 

 

 

 

This page was last modified on May 24, 2025 @ 1:05 PM

What you need to know about 2025 Bannock County Medicare plans. 

For 2025, Bannock County has 23 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.        

         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 (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 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 $6,400. 

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 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. 

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 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?

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 Bannock County Medicare Advantage plans.

Bannock County Medicare Advantage plans for Veterans.

There is a VA Clinic in Pocatello and major hospital in Salt Lake City and Boise.   

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 are offering these plans Bannock 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.

 

Bannock 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.  

 

 Plans for the rest of the Medicare beneficiaries living in Bannock 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.   Your prescription medication refill cost for the year can vary by over 300% between these plans too. 

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) or you have an emergency.   Reference this note for details.  There are other hospitals in the US which no longer accept Medicare Advantage plans. 

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

 

What insurance companies offer Medicare Advantage plans in Bannock County?

 

Blue Cross of Idaho

Humana

Molina

United Healthcare

Other tidbits to be aware of

Hospitals in your immediate area.

There are 5 hospitals within 25 miles of downtown Pocatello. 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 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 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 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. 

 

 

Date last updated May 24, 2025 @ 1:08 PM

What you need to know about the 2025 Medicare plans available to Bonneville County residents. 

This page was last modified on May 24, 2025 @ 1:11 PM

Some 2025 Kootenai County Medicare Advantage plans caught our attention.

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

Also, there are additional plans for people that have been medically diagnosed with serious health issues.  These include Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

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

 

What else you need to know!

For 2025, Kootenai County has 26 Medicare Advantage plans for residents to consider.

Here is the high level breakdown:

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

3 of these are PPO;

3 are HMO plans.

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

9 are HMO plans;

5 are PPO plans.

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

 

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

These are Medigap plans.

When you choose this type of plan, all doctors/hospitals that accept Medicare insurance in the USA are available to you.  This means you do not have the network restrictions/rules found in Kootenai County Medicare Advantage plans.

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

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

Learn more about Idaho Medigap plans here. 

 

What are the differences between these Kootenai County Medicare Advantage plans?

Monthly premiums range from $0 to over $140.

Three of the 14 plans have monthly premiums above $100; another two are above $70. 

People interested in plans with premiums at this price point may be better off with one of the comprehensive Medigap plans. 

These include Plan G, N, and D.  Why these plans?  Because they open up all physicians and hospitals in the USA which ‘accept Medicare insurance’ (most all do).  Also, these 3 plans pay most of the left over copayments/coinsurance/deductibles when you use Medicare Part A and B covered services.  You can now budget with confidence for your health care.

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

Pay attention to your share of the costs for the services you know you will use.  There are documented in the plan’s ‘Evidence of Coverage’ (EOC) document.  You can download this from the insurance company’s website.  Each plan has this document available.

If you were diagnosed with a serious health issue….

Then look at the cost sharing for the services that would be needed if you were diagnosed with a serious health issue.

Look at the hospitals in the plans network.  If you are diagnosed with a serious health issue, would you want to be treated at one of these facilities?  Would you prefer to have access to one of the major hospitals (and physicians) in the Pacific Northwest (or the entire US)?   

What is your cost share for filling/refilling the prescription medications you take?  There is typically a 300% +/- annual difference in medication costs between plans for the same set of medications.

What are the extra (non-Medicare covered services) included in the plan?  What is actually covered?  Are the providers you currently use for these services in the plans network?  What are the limits your plan will pay for these services?

 

The information below is for people that want to know more.  You might scan the paragraph headings to see if the topic is of interest to you. 

What are the actual MOOP figures?

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

The MOOP maximum for HMO-POS and PPO plans cannot exceed $14,000.

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

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

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,900 to $8,950.

The range for HMO-POS and PPO plans is $5,000 to $14,000.

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

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

If you understand how the math works when calculating your MOOP after you use plan services, skip the paragraph below.

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

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

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

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

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

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

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

Specific plan coverages may have limitations.

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

Prior Authorization is an example.

What does this mean?  Your insurance company can approve or deny the service request from your physician.  If the service is denied, your physician has to go to ‘plan B’ and start the process over.  

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

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

For example, a dental plan may exclude certain coverages.  This can be done by dental billing code(s) or by limitations on specific services you need that are in coverage class I, II, and III. 

Implants or braces may be covered by some plans, but not others. 

There may be a limitation on the number of cleanings too (2 per year when you may need 4); periodontal services, if covered, may have their own limitation, etc.   

The dollar value the insurance company offers you for dental coverage can vary widely between plans.

When reviewing 2025 dental coverage for some plans we noticed something we have not seen before.  It reads ‘Submitted claims are subject to a review process which may include a clinical review and dental history to approve coverage’.  To us, this is an example of why people interested in dental coverage included in a Medicare Advantage plan need to read the fine print before choosing a plan. 

Doctors/hospitals/other providers.

Availability of physicians, hospitals, physical therapists, skilled nursing facilities, durable medical equipment providers and all other provider types vary by plan.  Read this article to learn more. 

The insurance companies offering Medicare Advantage plans must meet ‘minimum adequacy’ requirements when they put together their networks together.  This means there is a good probability not all physicians/providers in your geographic area that ‘accept Medicare’ insurance are in your plan’s network.  

You have the tools available to find out how many of a certain type of specialists are in the plan’s network vs how many that ‘accept Medicare’ are in the same area .  If you have existing health issues, would it be important for you to know how many specialists which treat this for you are in the plan you select?  We can show you the tools to do this.   

The above can change during the calendar year.  This announcement is an example of why networks can change during the year.  Another example is found here and here. 

Be aware hospitals may/may not be using current technologies/techniques to treat patients.  Why?  Because of the cost of new technologies is competing for other financial needs of the hospital.   

Proton Therapy is an example of newer technology for treating cancer.  

Read this article if you are unfamiliar with this.  At this time, 45 hospitals (out of over 4500) offer this solution.  Facilities near Idaho include:

               Huntsman Cancer Institute (Salt Lake City) (began offering this service in 2021)

               The Mayo Clinic Cancer Center (Phoenix…rolled out this service on 2016)

               Loma Linda University Cancer Center (began offering this service in 1990)   

               California Protons Cancer Therapy Center (San Diego) (began offering this service in 2017).

If you are interested in this service, you might check where each of the above facilities are ranked in the top 250 hospitals.

 

Are you interested in using the top 250 hospitals in the country OR the top hospitals by type of surgery?

Resources are available to help you find these.

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

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

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

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

 

Medications covered by each plan.

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

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

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

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

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

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

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

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

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

 

There are 3 different audiences for Kootenai County Medicare Advantage plans.

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

Kootenai County Medicare Advantage plans for Veterans

Veterans have several Medicare Advantage plans to consider. These plans do not include prescription drug coverage and are offered by private insurance companies which compete each other for your business.

Each plan sets their ‘giveback’ for the member’s Part B monthly premium. This year this figure varies between $0 to $75/month for this year. These figures can change annually.

The Veterans out of pocket costs for plan covered health care services can vary widely between these plans. This is also true for the ‘non-Medicare’ covered benefits that are often found in these plans (gym membership, dental coverage, etc.). Which hospitals and physicians available to the plan member can also vary by plan.

PPO plans are worth considering.

A veteran may prefer a PPO plan if they want to open up their choice of hospitals and doctors to include those beyond Idaho’s borders. An HMO plan may fit a veteran that wants coverage outside the VA for urgent and emergent care AND the extra benefits often found in these plans. 

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

We recommend Veterans review their Kootenai Veteran Medicare Advantage plans at least every 2-3 years.

This market niche has become quite competitive between the insurance companies. Some of these companies want to increase their market share by offering more attractive features than their competitors. These companies are changing their offerings annually to attract more potential new members.

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

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

Kootenai County residents enrolled in Medicare and Medicaid.

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

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

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

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

Molina continues to serve Idaho residents with these important products.   

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

Additional pertinent information about Idaho Medicaid and your plan choices. 

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

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

Click here to learn more about your options.

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

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

 

Additional information about the Kootenai County Medicare Advantage plans. 

Hospital selection for care is important to some.  

We look at 2-different hospital measurement tools to help find which hospitals stand out (the hospitals we would consider). 

The 1st is the Medicare star rating.  Learn more here about the metrics that are captured to come up with this rating.  We prefer hospitals that have a 4 or a 5-star rating. 

The 2nd tool uses many more metrics to differentiate how the hospitals do what they do.  Some of these focus on the results of the work done in the surgical suite. 

If you are interested in learning which hospitals produce better results on a consistent basis by type of surgery, check out this resource.   A good awareness exercise might be to review the Mayo Clinic hospital in Arizona or Rochester Minnesota.  Tale a look at the recognition by type of surgery they have received.   

Learn more about the company behind this annual report here. 

Check out the hospitals within 50 miles of zip code 83814 by clicking here. When you get to this web page, select ‘hospitals’, enter your zip code and adjust the radius to 50-miles.

Did you notice some of these hospitals are outside of Idaho?

This means they may not be included in any Medicare Advantage plan’s network that is available to you.  If you stay with Original Medicare with or without a Medigap plan, you will have access to them.  

Monthly premiums of Medicare Advantage plans available in Kootenai County range from $0 to over $135.   

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

What insurance companies offer Medicare Advantage plans in Kootenai County?

Blue Cross of Idaho

Molina Healthcare

Pacific Source

Regence Blue Shield of Idaho

United Healthcare

 

Read the fine print on extra Benefits included in Medicare Advantage plans. 

Dental Coverage:  

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

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

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

For example, some plans restrict coverage to preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.).  The plan may cover certain periodontal services.  If covered, the plan may limit the number of times specific service(s) can be used during the year.

Some plans include coverage for class II and III services.  If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

Do you need to use the plans network of dentists? 

Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services. 

Plans may state cosmetic services are not covered. It you use an ‘out of network’ dentist, you may pay for all services…or services you use may cost you more when compared to your cost if you use an in-network dentist. 

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

If you have any questions about whether a service is covered, call customer service.  Their phone number is on your membership card.  your plan’s customer service.  

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

Vision Coverage  

The depth of this coverage varies by plan.  The same issues pointed out for dental coverage can apply to this service too. Look at the cost for an annual checkup, glasses, frames, contacts and any network restrictions. 

Over The Counter benefit

Some plans have a catalog of ‘drug store‘ items you can order from and they are delivered to you at no cost.  It is possible the items you want will not be included in the plan’s catalog of covered items.  Be aware of your plan’s quarterly limit.  This figure can vary widely between plans.  

Gym Memberships

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

Hearing Aids  

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

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

 

Would a Medicare coach be helpful?

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

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

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

 

This page was updated on May 24, 2025 @ 12:50 PM

 

Some 2025 Boundary County Medicare Advantage plans caught our attention.

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

Also, there are additional plans for people that have been medically diagnosed with 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 Boundary 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.

 

What else you need to know!

For 2025, Boundary County has 25 Medicare Advantage plans for residents to consider.

Here is the high level break down:

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

3 of these are PPO;

3 are HMO plans.

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

8 are HMO plans.

4 are PPO plans.

2 of these plans have a monthly premium about $100; another 2 are above $70.  If any of these catch your attention, we encourage you to review your Medigap plan choices too.  

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 Boundary 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 Boundary 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?

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

The MOOP maximum for HMO-POS and PPO plans cannot exceed $14,000.

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

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

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

The range for HMO-POS and PPO plans is $5,700 to $14.000.

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

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

If you understand how the math works when calculating your MOOP after you use plan services, skip the paragraph below.

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

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

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

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

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

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

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

Specific plan coverages may have limitations.

Rules may be imposed on specific 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 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.  

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?

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.

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. 

 

Boundary County Medicare Advantage plans for Veterans

Veterans have several Medicare Advantage plans to consider.

These do not include prescription drug coverage and are offered by private insurance companies which compete each other for your business.

The insurance company behind each plan sets (and can change annually) their ‘giveback’ for the member’s Part B monthly premium. Plans available to you this year vary between $0 to $75/month.

The amount of the Veterans out of pocket costs for plan covered health care services can vary widely between these plans. This is also true for the ‘non-Medicare’ covered benefits that are often found in these plans (gym membership, dental coverage, etc.). Which hospitals and physicians available to the plan member can also vary by plan.

A PPO plan may be a good choice if you want access to doctors/hospitals outside of Idaho.

A veteran may prefer a PPO plan if they want to open up their choice of hospitals and doctors to include those beyond Idaho’s borders. This may open up your choices to the top 50 and 100 hospitals by health issue also. 

An HMO plan may fit a veteran that wants health care from local resources but outside the VA. This includes having access to non-VA urgent and emergent care. If you prefer an HMO plan, we do suggest you pay attention to the HMO plan’s network of hospitals and doctors, as they can vary year over year.

We recommend Veterans review their Boundary Veteran Medicare Advantage plans at least every 3-years.

This market niche has become quite competitive between the insurance companies. Some of these companies want to increase their market share by offering more attractive features than their competitors. These companies are changing their offerings annually to attract more potential new members.

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

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

 

Boundary 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.  

 

Plans for the rest of Boundary County residents. 

Some of the plans available to you have a $0 monthly premium.  Reviewing and comparing the details of each plan’s Summary of Benefits’ document will point out some of the differences between plans. 

We have to dig a bit deeper to understand our other financial exposures. 

Understanding information at this level helps us find the plan that meets our needs and is ‘kind’ to the pocketbook.  

 

 

Additional information about the Medicare Advantage plan(s) available in Boundary County. 

Check out the hospital facilities within 50 miles of zip code 83805 (Bonners Ferry) by clicking here.  When you land on this web page, pick ‘hospitals’, enter zip code 83805, and set the radius to 50 miles. 

Notice 2 of these hospitals are outside of Idaho and may not be in any Idaho Medicare Advantage plan’s network.

Monthly premiums of these Boundary County plans range from $0 to over $135.

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

If you have or are concerned about having a serious health issue, getting treatment at a top hospital in the US may put your mind at ease.  Plans are available which open up these resources to you.

Learn more about your Medigap options here.

We can help you think this through.

What insurance companies offer Medicare Advantage plans in Boundary County?

Blue Cross of Idaho

Molina Healthcare

Pacific Source

Regence Blue Shield of Idaho

United Healthcare

 

Read the fine print on extra Benefits included in Medicare Advantage plans. 

Dental Coverage.

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

If you listen to 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 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. 

We started this business in 2012 explicitly to help Idaho residents work their way through this maze. 

There is no fee when you use our services.

 

This page was updated on May 24, 2025 @ 12:47 PM

Some 2025 Bonner County Medicare Advantage plans caught our attention.

One plan includes access to Medicare covered services provided by certain 5-star hospitals in Oregon, Washington, Utah and Idaho!  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.  A plan member will be paying the plan’s ‘out of network’ rate when this feature is used.  .

This flexibility can be a nice feature if a person wants to access to other provides that will ‘accept your plan’s payment terms’.  This can be useful for ‘snowbirds’ or others wanting flexibility on where they get their health care.

There is a special plan if you 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 Bonner 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.

There are 5 higher premium plans available too.

Three of the remaining plans have monthly premiums above $100; another 2 are above $70.  If these plans catch your attention, we suggest you also consider one of the more comprehensive Medigap plans.  Specifically, plan G, or N.

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, Bonner County has 25 Medicare Advantage plans for residents to consider.

Here is the high level break down:

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

3 of these are PPO;

3 are HMO plans.

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

8 are HMO plans;

5 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 (also known as Medicare Supplement) 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 Bonner 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 Bonner County Medicare Advantage plans?

Plan premiums range from $0 to over $140 a month.

This figure can change each year and is one to watch during AEP (your annual election period that starts on October 15 and ends on December 7).  You also have a 2nd annual time period you can change Medicare Advantage plans.  This is called the annual annual open enrollment period (OEP).  This timeframe starts on January 1 and ends on March 31.  If your plan’s premium goes up for next year, you may want to find plan with a lower premium that has the same characteristics of next years version of your current plan.

Watch your cost share for Skilled Nursing Care.

We may not know when we will use this service, but when we use it, the out of pocket costs can be more than pocket change.

If you stay with Original Medicare, this copay is in place from the 20th day after care begins and ends on the 100th consecutive day of its use.  The daily copay for this year is $204.  If you use this service for the 80 consecutive days it is available (for each benefit period), your financial exposure is $204 * 80 or $16,320.  Your actual cost will be capped by your plan’s MOOP, which is another very important figure to pay attention to.  More on this in a moment.

The insurance company’s offering Medicare Advantage plans can set the daily copay AND the start and end day the copay is in place.

Naturally you want a plan with the lowest daily copay and the fewest days the copay is in place.

Another 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?

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

The MOOP maximum for HMO-POS and PPO plans cannot exceed $14,000.

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

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

The range of MOOP for your County’s HMO Medicare Advantage plans is $4,900 to $9,350.

The range for HMO-POS and PPO plans is $5,000 to $14.000.

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

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

If you understand how the math works when calculating your MOOP after you use plan services, skip the paragraph below.

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

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

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

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

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

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

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

Specific plan coverages may have limitations.

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

Prior Authorization is an example.

Prior authorization may be required on specific plan covered services.  What does this mean?  Your  insurance company can approve or deny the service request.  If the service is denied, your prescribing physician has to go to ‘plan B’ and start the process over.  This is one of the reasons we prefer plans that do not have insurance companies standing between you/your physician to get to the ‘next step’ in your health care. The article found here brings this point to life.

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

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

For example, dental (if included in a plan) may exclude certain coverages.  This can be done by dental billing code(s) or by limitations on specific services you need that are in coverage class I, II, and III.  Implants or braces may be covered by some plans, but not others.  There may be limitation on the number of cleanings too (2-year when you may need 4); periodontal services, if covered, may have their own limitations, etc.   The dollar value the insurance company offers you for dental coverage can vary widely between plans.

Doctors/hospitals/other providers.

Availability of physicians, hospitals, physical therapists, skilled nursing facilities, durable medical equipment providers and all other provider types vary by plan.  Read this article to learn more.

The insurance companies offering Medicare Advantage plans put together their networks of these people/facilities for their plan members.  Medicare requires insurance meet a minimum adequacy requirement when they put their networks together.  This means there is a good probability not all 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.

Read this article if you are unfamiliar with this.  At this writing, 45 hospitals (out of over 4500) offer this solution.  Facilities near Idaho include:

Huntsman Cancer Institute (Salt Lake City) (began offering this service in 2021)

The Mayo Clinic Cancer Center (Phoenix…rolled out this service on 2016)

Loma Linda University Cancer Center (began offering this service in 1990)

California Protons Cancer Therapy Center (San Diego) (began offering this service in 2017).

If you are interested in this service, you might check where each of the above facilities are ranked in the top 250 hospitals.

Are you interested in the top 250 hospitals in the country?

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

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.  These resources are available to you if they accept Medicare insurance (Part A and B).  Some do not accept Medicare Advantage plans (Part C).  Others prefer you 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.

 

Bonner County Medicare Advantage plans for Veterans

Veterans have 8 Medicare Advantage plans to consider. These plans do not include prescription drug coverage and are offered by private insurance companies which compete each other for your business. The insurance company behind each plan sets (and can change annually) their ‘giveback’ for the member’s Part B monthly premium. Plans available to you this year vary between $0 to $75/month.

The amount of the Veterans out of pocket costs for plan covered health care services can vary widely between these plans. This is also true for the ‘non-Medicare’ covered benefits that are often found in these plans (gym membership, dental coverage, etc.). Which hospitals and physicians available to the plan member can also vary by plan.

Should you consider a PPO or an HMO plan?

A veteran may prefer a PPO plan if they want to expand their choice of hospitals and doctors to include those beyond Idaho’s borders. An HMO plan may fit a veteran that wants health care outside the VA and/or urgent and emergent care. We do need to pay attention to the HMO plan’s network of hospitals and doctors, as they can vary year over year.

We recommend Veterans review their Bonner Veteran Medicare Advantage plans at least every 3-years.

This market niche has become quite competitive between the insurance companies. Some of these companies want to increase their market share by offering more attractive features than their competitors. These companies are changing their offerings annually to attract more potential new members.

Some of these plans have a $0 monthly premium. This means if new plans come to market or the insurance companies behind existing plans sweeten the benefits of their plan (s), it may make sense to consider changing plans.

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

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

Bonner County residents enrolled in Medicare and Medicaid.

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

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

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

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

Molina continues to serve Idaho residents with these important products.

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

Additional pertinent information about Idaho Medicaid and your plan choices.

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

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

Click here to learn more about your options.

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

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

 

Additional information about the Medicare Advantage plan(s) available in Bonner County. 

Monthly premiums of these Bonner County plans range from $0 to over $135.

If you are interested in a Medicare Advantage plan with a premium above $70/month, an Out-of-Pocket Limit above of $6,000 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.

We can help you think this through.

What insurance companies offer Medicare Advantage plans in Bonner County?

Blue Cross of Idaho

Molina Healthcare

Pacific Source

Regence Blue Shield of Idaho

United Healthcare

Other tidbits to be aware of

Hospitals in your immediate area

There are 7 hospitals within 50 miles of downtown Hope Idaho (83836). Get a visual of their location by clicking here.  When you land on this web page, select ‘hospitals’ and enter the zip code of 83836 and adjust the radius to 50.

2 of these hospitals are outside Idaho and may not be in any of the Bonner County Medicare Advantage plan’s network.

One of these hospitals are rated by The Center for Medicaid and Medicare Services (CMS) as 5 stars (Kootenai Health Hospital).  There are 4 hospitals with no rating.

Having resources with a ‘5’ Star rating can be important to you when you get regular care, emergency and scheduled surgical procedures.

All of these hospitals may not be in every plan available to you.

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 coverage for class II and III services.  If they do, there may be restrictions on specific services covered and may explicitly exclude certain dental billing codes.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

Do you need to use the plans network of dentists?

Plans may have a network of dentists you can use; some permit the use of any licensed dentist in the US for services.

Plans may state cosmetic services are not covered. It you use an ‘out of network dentist, you may pay for all services.  If your plan permits use of out of network services, your cost may be higher. .

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

Your plan may not pay for services you use which are excluded from your plan.  If you have any question about whether a service is covered, call your plan’s customer service.  You may have to get specific billing codes from your dentist just to be sure you get the right answer.

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

Vision Coverage.

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

Over The Counter benefit.

Some plans have a catalog of ‘drug store‘ items you can order from.  The products you select are typically delivered to you at no cost.

It is possible the items you want will not be included in the plan’s catalog of covered items.  Plan’s have a quarterly limit on how much it gives you to spend on these items. The amount of the quarterly limit can vary widely between plans.

Gym Memberships.

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

Hearing Aids.  

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

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

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

Would a Medicare coach be helpful?

A coach can answer your question(s), 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.

We started this business in 2012 explicitly to help Idaho residents work their way through this maze.

 

Call us.  There is no cost for our services.

This page was last modified on May 24, 2025 @ 12:46 PM

What you need to know about 2025 Blaine County Medicare plans!

For 2025, Blaine 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 is an HMO plan.        

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

                  4 are HMO plans;

                  5 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. 

Medigap plans open up your access to all physicians/hospitals/other providers (that accept Medicare insurance) in the USA. 

They also minimize use of  ‘prior authorizations’.  Learn what an issue this has created for people enrolled in a Medicare Advantage plan here. 

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 $100.  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.

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?

Idaho based 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 several residents in Blaine 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 Blaine 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 $6,000.  

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

Remember, these are the figures you want to compare to the ‘less than $2,900’ for either one of the ‘hi-deductible’ Medigap plans’ mentioned above.

 

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.  

If you use Skilled Nursing Care you may hit your plan’s MOOP! 

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. 

 

Will you save money and grief 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 in the US?

We recommend you consider a Medigap Plan G. 

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

Yes.  

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. 

 

Blaine 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.  

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.  A hi-deductible Medigap plan may save you money and grief. 

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.

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.

 

Blaine 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 Blaine County

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

There is one major hospital in Blaine County.  

Check out the other facilities within 50 miles of zip code 83353 by clicking here.

Be sure and enter your zip code (83353) and adjust the radius to 50-miles.

If you raise the radius to 100 miles, there are 15 hospitals available. These include a hospital in Rupert, Twin Falls, a few other nearby Counties, and in Boise. 

Notice some hospitals on this list have a Star rating (range is 1 – 5) and some do not. 

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.  

We recommend Idaho residents consider any hospital with either 4 or 5 star rating.  

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. 

Additional information on Blaine County plans in just a moment. 

 

What insurance companies offer Medicare Advantage plans in Blaine County?

American Health Advantage of Idaho

Blue Cross of Idaho

Humana

Pacific Source

United Healthcare

Other tidbits to be aware of

Additional details about the plans available in Blaine County

Monthly premiums of Medicare Advantage plans range from $0 to $116.   

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 these plans specialize in the St Lukes hospitals in Idaho.  

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

 

Read the fine print on extra Benefits included in Medicare Advantage plans. 

Dental Coverage. 

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

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

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

For example, some plans restrict coverage to preventative care (a few cleanings annually, x-rays you can get have their own schedule, etc.).  The plan may cover certain periodontal services.  If covered, the plan may limit the number of times specific service(s) can be used during the year. Some plans include 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 let you use any dentist.  Please read your plan’s ‘Evidence of Coverage’ for specific details.

 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 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 depending 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 @ 12:55 PM