How to find hospitals in and around Jefferson County.

Click here to find hospitals in a 50 mile radius around Rigby.   

Notice one of the hospitals listed have a 4 or 5 ‘star rating’ by Medicare.   We recommend people consider hospitals with this rating if they will be treated with more serious health issues. 

You can change the search radius around zip code 83442 to find more hospitals.  Be sure and look to see if the new hospitals are still in Jefferson County; if they are ‘out of state’, they may not be in the provider directory of Medicare Advantage plans available to you. 

Resources are available to help you find the top hospitals in the US.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.

These resources may be available to you if you have the right Idaho Medicare insurance (Original Medicare with or without a Medigap plan or a PPO plan, if they will accept your PPO plan).

Some of these hospitals may not accept Medicare Advantage plans.   If you have a Medigap most will accept your insurance.

Medicare assigns Hospitals a ‘star rating’.  We recommend you focus on four and five-star rated hospitals AND skilled nursing facilities.

There are several organizations which rate hospitals too.  Each of these services may use different metrics to rank hospitals.  We favor the Health Grades resource as it focuses on results of services performed in the surgical suite.  

Learn more about this subject here.

Medications covered by each plan.

According to this source, there can be a 25+/- % variance between the number of prescription medications covered by Idaho Medicare Advantage plans.

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.

Dot your I’s and cross your T’s.

We recommend you 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. Reports can be produced which show you your fill/refill cost for your specific prescription medications and if each of the plans available to you cover all of your medications.  They will also show you the refill cost by up to five pharmacies you select.  

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

The Centers for Medicare and Medicaid Services (CMS) have requirements insurance companies(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 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.

This page was last modified on Mar 1, 2026 @ 1:54 PM

 

 

 

 

2026 Madison County Medicare Advantage plans.

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

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

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

 

2025 Madison County Medicare Advantage Plans.

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

Here is the high level break down:

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

1 are PPO plans;

2 are HMO plans.

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

8 are HMO plans;

2 are PPO plans.

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

 

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

These are Medigap plans.

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

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

Learn more about Idaho Medigap plans here. 

 

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

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

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

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

Pay attention to your share of the costs for the services you know you will use.

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

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

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

Would you prefer to have access to one of the major hospitals (and physicians) in the Pacific Northwest (or the entire US)?   How do you find them and narrow down the list that excel at treating your specific issue?

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

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

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

We have been helping Idaho residents with their Medicare plan choices since 2012.  This includes residents in Madison County.

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

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

 

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

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

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

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

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

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

What are the actual MOOP figures?

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

Prior Authorizations.   

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

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

Doctors/hospitals/other providers.

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

The insurance companies offering Medicare Advantage plans put together their networks of these people/facilities for their plan members.  Medicare requires insurance meet a minimum adequacy requirement when they put their networks together.  This means there is a good probability not all of the physicians/providers that ‘accept Medicare’ insurance are not in your plan’s network.  

If, during your plan research, you wish to find out how many of a certain type of specialists are in the plan’s network vs how many that ‘accept Medicare’ are in the same area, you have tools available to figure this out.  It may be useful knowing which plans have the higher percentage of cardiologists, oncologists, etc. are in their network.  We can show you how to get the answer to this question.  

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

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

Proton Therapy is an example of newer technology for treating cancer.  It is being used as an alternative to radiation treatments.  

Read this article if you are unfamiliar with this technology. 

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

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

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

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

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

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

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

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

Does Medicare rate hospitals for us?

Yes.

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

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

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

 

Medications covered by each plan.

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

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

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

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

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

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

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

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

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

 

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

Yes. 

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

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

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

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

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

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

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

We recommend you consider a Medigap Plan G. 

Are there lower premium Medigap plans what have some copays?

Yes.

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

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

The deductible for this year is found here. 

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

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

 

There are 3 different audiences for Idaho Medicare Advantage plans.

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

Let’s take a closer look at each. 

 

Madison County Medicare Advantage (MA) plans for Veterans.

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

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

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

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

 

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

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

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

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

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

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

These plans have different features and costs to the Veteran.

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

Why is the Part B ‘buyback’ important?

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

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

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

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

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

 

Madison County residents on Medicaid and enrolled in Medicare.

 

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

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

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

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

Molina continues to serve Idaho residents with these important products.   

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

Additional pertinent information about Idaho Medicaid and your plan choices. 

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

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

Click here to learn more about your options.

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

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

 

What insurance companies offer Medicare Advantage plans in Madison County?

Blue Cross of Idaho

Molina

United Health Care

Other tidbits to be aware of.

All Medicare Advantage plans have their specific network of doctors and hospitals available to plan members.  Some plans (PPO) let you go ‘out of network’ at higher cost sharing for services used.  These plans also have a higher ‘out of pocket maximum’.  This figure can be over $13,000.  Be aware the doctor/hospital may not accept the terms/conditions in the PPO plans contract. 

Also, be aware Mayo Clinics in the US do not accept PPO plans unless the plan includes their facilities in their network.

See their announcement on this here.

The insurance companies offering these plans negotiate with the resources included their network.   Doctors/hospitals participation in a Medicare Advantage plan’s network can change during the plan year and annually.  Read this announcement which recently happened in Kootenai County.

Where are the 5 star rated hospitals in Idaho?

Some plans include the resources in Ada and Canyon County in addition to hospitals in Northern, Central, and Eastern Idaho.

If you want the flexibility to choose any hospital and physician in the US, we suggest you consider a Medicare Supplement plan.  They offer more flexibility than you will find with a Medicare Advantage plan.

Having a plan with a broader selection of hospital(s) available may offer more peace of mind if you are diagnosed with serious health issues.

Be aware CMS star ratings change as data is collected often.  We suggest you always check the current star rating of any hospitals you may use.

We will help you think through your options.

 

 

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

Monthly premiums range from $0 to over $135.

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

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

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

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

 

What insurance companies offer Medicare Advantage plans in Jefferson County?

Blue Cross of Idaho

Molina

United Health Care

Other tidbits to be aware of.

Hospitals in your immediate area.

There are 1 hospital within 25 miles of downtown Rexburg.  

You can have a visual by clicking here.

Change the search radius to see additional hospitals.

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

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

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

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

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

 

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

Dental Coverage.  

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

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

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

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

Do you need to use the plans network of dentists?

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

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

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

Vision Coverage.

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

 

Over The Counter benefit.

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

Gym Membership.

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

Hearing Aids.  

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

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

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

 

Would a Medicare coach be helpful?

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

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

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

 

 

 

This page was last updated on Oct 4, 2025 @ 7:17 PM

 

2026 Jerome County Medicare Advantage plans.

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

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

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

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 Oct 4, 2025 @ 4:19 PM

 

The 17 Bingham County Medicare Advantage plans are broken down into 3 categories.  They are:

     Veterans, which get their prescription medications from the VA

     Residents with special needs (Medicaid, chronic health issues, and people with institutional  level of care)

     Plans for the rest of the Bingham County Medicare beneficiaries.

When you review your options, we encourage you to consider the 2 low premium Medigap plans too.

Why? 

More of the Bingham County Medicare plans are requiring permission to see a specialist.  Blue Cross of Idaho has already implemented this and United Health Care announced the same.  Read their announcement here.  Waiting for this approval may slow your treatment plan.

The Medicare Advantage plans available to you may have fewer licensed physicians in their plan’s network than those available to you if you remained with ‘Original Medicare’.

The Kaiser Family Foundation published a report on this point dated 10/25/2025 and it is available to read here.

The title of this informative document is: “Medicare Advantage Provider Networks Limit Enrollees to About Half of the Physicians in Their Area That Are Available to Beneficiaries in Traditional Medicare, on Average.”

More hospitals in the US are no longer accepting Medicare Advantage plans.  Read this report and this one too.  Both were recently published.

Medigap plans are becoming more attractive for some.

With 2026 premiums and cost sharing of some Bingham County Medicare Advantage plans increasing to the point where these lower premium Medigap plans are attractive and competitive.

There are many positive benefits that come with these two plans which are not available from Medicare Advantage plans.  A few of these are:

the doctors/hospitals in the Salt Lake City area, Boise, Seattle, and surrounding areas (including the rest of the US) are available to you; you just make the appointment;

you do not need referrals to see a specialist,

the limit on your share of the cost for your Medicare covered services is $2,950; remember this figure when you read about the ‘Maximum out of Pocket Cost’ for the Medicare Advantage plans available to you.  These are reviewed below.

More on this below.

 

The seventeen plans are broken down into different categories

                 Plans without prescription drug coverage

There are five plans in this category.

Premium range:  $0 to over $30.

Medicare Part B ‘credit’ (also called ‘giveback’) ranges from: $0 to $100.

Veterans, who chose one of these plans for health care services, need to pay attention to the plan’s provider directory as it identifies which hospitals, physicians, etc. are available to plan members.  Not all physicians in the area which ‘accept Medicare’ may not be available to plan members.

There are six Special Needs plans (C-SNP and D-SNP) in 2026.

These include:           

      C-SNP  (Chronic health care Special Needs plans)

C-SNPs are designed to provide benefits tailored to people with specific chronic health issues . Qualifying conditions include Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

The plan qualification process includes:

• Doctor Verification: The plan provider will work with your doctor to verify your chronic condition before you are fully approved for the plan.
• Special Enrollment Period: You can use a one-time special enrollment period to join a C-SNP at any time of the year, not just during the annual fall enrollment period.

If you have one of these health issues and feel it you are not making progress getting it managed, one of these plans might help.

 D-SNP (Dual eligible Special Needs plans).

If the Idaho Department of Health and Welfare has classified you as having ‘Enhanced Status’ you have Medicaid/Medicare coordinated (MMCP) plans to consider.

Individuals awarded with QMB status have their own unique plans available.

If you have a different Medicaid status, the plans discussed below are available to you.

 

All other Bingham County Medicare beneficiaries have 3 HMO and 3 PPO plans to consider.

HMO Plans.

Monthly premiums range from $0 to over $150. If you are interested in the higher premium HMO plans, we recommend you also consider the 2 hi deductible Medigap plans.  More on this below.

Plan MOOP’s range from $5900 to $6700.  When you review these figures in these plans, remember your health care costs for this year are capped at $2,950 if you enroll in a hi-deductible Medigap plan.

As a general reminder, confirm the physicians, hospital(s), and other providers are in any plan(s) ‘provider directory’ before you enroll in a plan.  If you work with a broker, they do this for you.

Your cost sharing when plan services are used vary by the service you use.  Pay attention to these figures and other rules that apply to any ‘extras’ which may be included in plans. The plan’s ‘Evidence of Coverage’ document explains this and is available on the insurance company’s website.

Why review this document?  Because it tells you the ‘rest of the story’.  The higher level documents (marketing material, messages you hear in TV ads, the Summary of Benefits document typically offer a subset of plan covered services.

We can help you understand the differences between your plan choices, and when you are ready, help with enrollment too.

 PPO Plans.

2026 monthly premiums for this County’s PPO plans range from $19 to over $80.

Like the higher premium HMO plans, if you are interested in a PPO plan with a premium of $60/higher, you may be better off with one of the two hi-deductible Medigap plans.  These are reviewed below.

PPO plans have two MOOP figures.  You must consider both when selecting a plan.  These figures set the ‘cap’ for your share of the cost for plan covered health care services.  These figures can be important when comparing plans.  Your plan covered health care costs with one if the hi-deductible Medigap plans is capped at $2,950.

If you choose the ‘out of network’ option, be aware some hospitals in the US do not accept appointments from people insured with Medicare Advantage plans.  The information found here is an up-to-date report on this subject.

Also be aware of the phrase in section 2 of the plan’s ‘Evidence of Coverage’.    It reads: “However, providers that don’t contract with us are under no obligation to treat you, except in emergency situations.”  This document is available on the insurance company’s website.

 

With the rising cost of Medicare Advantage plan premiums AND cost share, Medigap Plan G High-Deductible (HD-G) or Plan F High-Deductible (HD-F) are attractive alternatives.

Don’t let the words ‘high deductible’ scare you.  The figure is usually less than 1/2 of a Medicare Advantage plan’s ‘Maximum out of pocket limit’.  Your cost sharing for Medicare covered health services is capped at $2,950.

We recommend you understand the difference between the Hi Deductible Medigap Plans before considering a new Idaho Medicare Advantage plan.

We are seeing more Idaho residents chose these plans.

Why?  Because you have:

• Freedom to choose any physician/hospital which ‘accepts Medicare insurance’ (most do)
• Few ‘prior authorizations; you do not have an insurance company standing between you and your physician to get to the next step in your health care;
• Few/no referrals are needed; you just make the appointment
• Stable coverage year after year
• Nationwide access to health care; this means you minimize the growing issue of hospitals not accepting Medicare Advantage plans
• More predictable costs when you use care.
• Medigap HD-G is tied directly to Original Medicare’s cost structure.  Cost sharing for Part A and B covered services is here.  This means Medicare (CMS) is setting your cost share, not individual insurance companies.

Remember, Medicare is paying the ‘lions’ share of your health care costs (for Part A and B covered services) and you are paying the balance.  This concept is the same with a Medicare Advantage plan.

The ‘Deductible’ compared to the ‘Maximum out of pocket limit’.

Medicare sets this deductible and it goes up a bit annually.  Individual insurance companies offering these plans cannot adjust this figure.

Once your annual out of pocket cost for the Part A and B services hit the plans ‘deductible’, you are done paying for Part A and B costs for the calendar year.

• 2025 deductible: $2,870
• 2026 deductible: $2,950

This is different from Medicare Advantage, where the insurance company sets the out-of-pocket cost maximum limit.  The company can change each of their plan’s cost sharing figures annually.  Medicare sets the maximum this ‘out of pocket limit’ can be. The insurance company sets their own figure, provided it does not exceed the permitted maximum for the year.

If you joined Medicare before January 1, 2020, you qualify to join Hi Deductible Plan F.  This plan also covers the annual Part B deductible where Plan G will leave exposed to this potential expense.  This year that figure is $283.  Often the monthly premium for the F and G versions of this hi-deductible plan are the same.

Call us if you have questions.

 Premium Comparison (for Idaho)

Both Medigap HD-G and HD-F often costs less than $85 per month in Idaho (rates vary by insurance company and can go up annually).

More comprehensive Medigap plans (Plan F, Plan G, Plan N) have higher premiums, but they require noticeably less cost sharing when you use care.

Plan Type	Monthly Premium	Out-of-Pocket When You Use Care
HD-G	Lower < $85	$2950 deductible, then full coverage
Plan G	Higher; varies by insurance company.	Cost sharing is less than $290/year
Plan N	Less than Plan G	Some additional copays and cost sharing
Plan F*	More than Plan G	$0 cost sharing for Part A&B services.

 

*Plan F is only available to people who became eligible for Medicare before January 1, 2020.

Call us if you have questions about this choice.

Other issues to consider when selecting a Bingham County Medicare plan.

If your doctor ran tests on you to diagnose the reason you are visiting them, and unfortunately the diagnosis came back as a serious health issue.  Would you start thinking about where you want to be treated and by whom?

If you are diagnosed with Cancer…

Proton Therapy is an example of newer technology for treating some cancers. Read this article if you are unfamiliar with this. At this point, forty six hospitals (out of over 4500) offer this solution.  One of them is in Northern Utah.   This video does a good job of describing how this works.  A map of facilities that offer this resource is available here.

Some medications treating cancer are covered by Medicare Part B.  These medications can be expensive.  If a person is treated with these medications (and are covered by Medicare), it will contribute to reaching the plan’s MOOP (or ‘deductible if they enrolled in a hi-deductible Medigap plan).

Resources are available to help you find the top hospitals in the US.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.

Some of theses resources in the Western Part  of the US include:

     Mayo Clinic Hospital (Phoenix)

     Cedars-Sinai Medical Center (West Hollywood)

     Northridge Hospital Medical Center (Northridge)

     Providence Holy Cross Medical Center (Mission Hills)

     Scripps Mercy Hospital San Diego (San Diego)

     Stanford Hospital (Stanford)

     Sutter Roseville Medical Center (Roseville

Some of these hospitals may not accept the Medicare Advantage plans.  If you have a Medigap most will accept your insurance.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on four and five-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 four or five star rating and have at least ten ratings.

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

This tool will point out hospitals in/around Bingham County.

Click here to see a map of the hospitals 50 miles around downtown Blackfoot (zip code 83221).

We recommend Bingham County residents focus on 4 or 5-star rated facilities.  Notice 1 of the 8 facilities appearing on this map are rated in this category.

Medications covered by each plan.

According to this source, there can be a 25+/- % variance between the number of prescription medications covered by Idaho Medicare Advantage plans.

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.

Dot your I’s and cross your T’s.

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 (show you the reports which show cost differences between plans AND the pharmacies within plan).

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

The Centers for Medicare and Medicaid Services (CMS) have requirements insurance companies(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 discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

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

 

What insurance companies offer Medicare Advantage plans in Bingham County?

Blue Cross of Idaho

Humana

Molina Healthcare

United Healthcare.

Would a Idaho based Medicare coach be helpful?

 

A coach can firm up your understanding of Medicare, explain differences between your choices, and help you with enrollment.  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.

 

Content last updated Mar 1, 2026 @ 11:56 AM

The 22 Twin Falls Medicare Advantage plans are broken down into 3 categories.  They are:

     Veterans, which get their prescription medications from the VA

     Residents with special needs (Medicaid, chronic health issues, and people with institutional  level of care)

     Plans for the rest of the Twin Falls County Medicare beneficiaries.

When you review your Medicare Advantage plan options, consider the 2 low premium Medigap plans too. 

Why? 

More of the Twin Falls County Medicare plans are requiring permission to see a specialist.  Blue Cross of Idaho has already implemented this and United Health Care announced the same.  Read their announcement here.  With Medigap plans, this is not necessary.

Medicare Advantage plans often have fewer licensed physicians in their plan’s network than those available to you if you remained with ‘Original Medicare’.  The Kaiser Family Foundation published a report on this point dated 10/25/2025 and it is available to read here.  The title of this informative document is: “Medicare Advantage Provider Networks Limit Enrollees to About Half of the Physicians in Their Area That Are Available to Beneficiaries in Traditional Medicare, on Average.”

More hospitals in the US are no longer accepting Medicare Advantage plans.  Read this report and this one too.  Both were recently published.  The largest hospital in Northern Idaho terminated their contract with Humana for similar reasons (read this announcement) and they are not in-network with St. Luke’s hospitals either.  Note this hospital is available with Humana PPO plans, however, ‘out of network’ cost sharing will be in place if you do such.

With 2026 premiums and cost sharing of some Twin Falls Medicare Advantage plans increasing to the point where these lower premium Medigap plans are attractive and competitive. 

There are many positive benefits that come with these two Medigap plans which are not available from Medicare Advantage plans.  A few of these are:

the doctors/hospitals in the Salt Lake City, Boise, Seattle, and surrounding areas (including the rest of the US) are available to you; you just make the appointment; 

you do not need referrals to see a specialist,

the limit on your share of the cost for your Medicare covered services is about half of the ‘Maximum out of Pocket Cost’ for most Medicare Advantage plans available to you.  

More on this below.                                                         

The twenty two plans are broken down into different categories 

                 Plans without prescription drug coverage

There are six plans in this category. 

            Premium range:  $0 to over $30.

            Medicare Part B ‘credit’ (also called ‘giveback’) ranges from: $0 to over $100.

Veterans, who chose one of these plans for health care services, need to pay attention to the plan’s provider directory as it identifies which hospitals, physicians, etc. are available to plan members.  Not all physicians in the area which ‘accept Medicare’ may not be available to plan members.   

There are 7 Special Needs plans (C-SNP, I-SNP, and D-SNP) in 2026.

These include:           

      C-SNP  (Chronic health care Special Needs plans)

C-SNPs are designed to provide benefits tailored to people with specific chronic health issues . Qualifying conditions include Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).  

The plan qualification process includes:                      

• Doctor Verification: The plan provider will work with your doctor to verify your chronic condition before you are fully approved for the plan.
• Special Enrollment Period: You can use a one-time special enrollment period to join a C-SNP at any time of the year, not just during the annual fall enrollment period. 

If you have one of these health issues and feel it you are not making progress getting it managed, one of these plans might help. 

 I-SNP (Institutional Special Needs Plan) 

There is one plan available for Idaho residents which have both Medicare Part A and Part B and live in the plan’s service area.  This includes this county.

 Additionally, policy holders must either reside in a qualifying institution or require an institutional level of care at home for at least 90 days.  Qualifying individuals should contact American Health Advantage of Idaho at 1-855-521-0627 for further information.  Brokers cannot help you with this plan.

D-SNP (Dual eligible Special Needs plans).

If the Idaho Department of Health and Welfare has classified you as having ‘Enhanced Status’ you have Medicaid/Medicare coordinated (MMCP) plans to consider.

Individuals awarded with QMB status have their own unique plans available.

If you have a different Medicaid status, the plans discussed below are available to you. 

 

All other Twin Falls County Medicare beneficiaries have 4 HMO and 5 PPO plans to consider.

HMO Plans.

Monthly premiums range from $0 to over $60. 

The cap (or limit on your share of plan covered health services)  varies between $5900 to $6700.  Remember these figures when you compare options.   

Why is MOOP important?

When y0u share of your plan covered health care services hits your plans MOOP, you do not have further cost sharing for the rest of the calendar year.   

 

What you need to know about Humana Medicare Advantage plans in Twin Falls County. 

Humana does not include access to the St. Luke’s hospital (unless it is in an ’emergency’ or you have a PPO plan). 

If you have a PPO plan from Humana, remember two key items.

1).  St. Lukes Hospital (and their physicians) are not ‘in-network).  TThe physician; then they can use the plan’s ‘out of network’ access to the facility).  When this occurs the policy holder is paying ‘out of network cost sharing’.   

As a general reminder, confirm the physicians, hospital(s), and other providers are in any plan(s) ‘provider directory’ before you enroll in a plan.  If you work with a broker, they do this for you. 

Cost sharing when plan services are used vary as are the details of any ‘extras’ which may be included in plans.   

Be sure you understand these before you choose a plan.  Do this by reviewing a plan’s ‘Evidence of Coverage’ document before enrolling in a plan.  Why?  Because it tells you the ‘rest of the story’.  The higher level documents (marketing material, items you hear in TV ads, the Summary of Benefits document typically offer a subset of plan covered services.   

• We recommend you consider one of the 2 High Deductible Medigap plans described below in lieu of  any HMO plan with a premium above $60/month.   

 PPO Plans.

2026 monthly premiums for this County’s PPO plans range from $0 to over $80.  Like the higher premium HMO plans, if you are interested in a PPO plan with a premium of $60/higher, you may be better off with one of the two hi-deductible Medigap plans.  These are reviewed below.

PPO plans have two MOOP figures.  You must consider both when selecting a plan.  Be sure and check these figures as they set the ‘cap’ for your share of the cost for plan covered health care services.  These figures can be important when comparing plans.

If you choose the ‘out of network’ option, be aware some hospitals in the US do not accept appointments from people insured with Medicare Advantage plans.  The information found here is an up-to-date report on this subject.  

Also be aware of the phrase in section 2 of the plan’s ‘Evidence of Coverage’.    It reads: “However, providers that don’t contract with us are under no obligation to treat you, except in emergency situations.”  This document is available on the insurance company’s website.

 

With the rising cost of Medicare Advantage plan premiums AND cost share, Medigap Plan G High-Deductible (HD-G) or Plan F High-Deductible (HD-F) are attractive alternatives.

Don’t let the words ‘high deductible’ scare you.  The figure is usually less than 1/2 of a Medicare Advantage plan’s ‘Maximum out of pocket limit’.  Your cost sharing for Medicare covered health services is capped at $2,950. 

We recommend you understand the difference between the Hi Deductible Medigap Plans before considering a new Idaho Medicare Advantage plan. 

We are seeing more Idaho residents chose these plans. 

Why?  Because you have:

• Freedom to choose any physician/hospital which ‘accepts Medicare insurance’ (most do)
• Few ‘prior authorizations; you do not have an insurance company standing between you and your physician to get to the next step in your health care;
• Few/no referrals are needed; you just make the appointment
• Stable coverage year after year
• Nationwide access to health care; this means you minimize the growing issue of hospitals not accepting Medicare Advantage plans 
• More predictable costs when you use care.
• Medigap HD-G is tied directly to Original Medicare’s cost structure.  Cost sharing for Part A and B covered services is here.  This means Medicare (CMS) is setting your cost share, not individual insurance companies.

Remember, Medicare is paying the ‘lions’ share of your health care costs (for Part A and B covered services) and you are paying the balance.  This concept is the same with a Medicare Advantage plan.

The ‘Deductible’ compared to the ‘Maximum out of pocket limit’.

Medicare sets this deductible and it goes up a bit annually.  Individual insurance companies offering these plans cannot adjust this figure. 

Once your annual out of pocket cost for the Part A and B services hit the plans ‘deductible’, you are done paying for Part A and B costs for the calendar year.  

• 2025 deductible: $2,870
• 2026 deductible: $2,950

This is different from Medicare Advantage, where the insurance company sets the out-of-pocket cost maximum limit.  The company can change each of their plan’s cost sharing figures annually.  Medicare sets the maximum this ‘out of pocket limit’ can be. The insurance company sets their own figure, provided it does not exceed the permitted maximum for the year.

If you joined Medicare before January 1, 2020, you qualify to join Hi Deductible Plan F.  This plan also covers the annual Part B deductible where Plan G will leave exposed to this potential expense.  This year that figure is $283.  Often the monthly premium for the F and G versions of this hi-deductible plan are the same. 

Call us if you have questions.

 Premium Comparison (for Idaho)

Both Medigap HD-G and HD-F often costs less than $85 per month in Idaho (rates vary by insurance company and can go up annually).

More comprehensive Medigap plans (Plan F, Plan G, Plan N) have higher premiums, but they require noticeably less cost sharing when you use care.

Plan Type	Monthly Premium	Out-of-Pocket When You Use Care
HD-G	Lower < $85	$2950 deductible, then full coverage
Plan G	Higher; varies by insurance company.	Cost sharing is less than $290/year
Plan N	Less than Plan G	Some additional copays and cost sharing
Plan F*	More than Plan G	$0 cost sharing for Part A&B services.

 

*Plan F is only available to people who became eligible for Medicare before January 1, 2020.

Call us if you have questions about this choice.

 

Other issues to consider when selecting a Twin Falls County Medicare plan.

If your doctor ran tests on you to diagnose the reason you are visiting them, and unfortunately the diagnosis came back as a serious health issue.  Would you start thinking about where you want to be treated and by whom? 

If you are diagnosed with Cancer…

Proton Therapy is an example of newer technology for treating some cancers.  

Read this article if you are unfamiliar with this technology. 

At this point, forty six hospitals (out of over 4500) offer this solution.  One of them is in Northern Utah.   This video does a good job of describing how this works.  A map of facilities that offer this resource is available here.

Resources are available to help you find the top hospitals in the US.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them. 

Some of theses resources in the Western Part  of the US include:

     Mayo Clinic Hospital (Phoenix)

     Cedars-Sinai Medical Center (West Hollywood)

     Northridge Hospital Medical Center (Northridge)

     Providence Holy Cross Medical Center (Mission Hills)

     Scripps Mercy Hospital San Diego (San Diego)

     Stanford Hospital (Stanford)

     Sutter Roseville Medical Center (Roseville

Some of these hospitals may not accept the Medicare Advantage plans.  If you have a Medigap most will accept your insurance.

Hospitals are assigned a ‘star rating’ by Medicare.  We recommend Idaho residents focus on four and five-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 four or five star rating and have at least ten ratings.   

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

This tool will point out hospitals in/around Twin Falls County. 

Click here to see a map of the hospitals 50 miles around downtown Twin Falls (zip code 83301). 

We recommend Twin Falls County residents focus on 4 or 5-star rated facilities.  Notice 1 of the 5 facilities appearing on this map are rated in this category.

If you are considering orthopedic surgery, check out the St Luke’s Orthopedic hospital (here).  

 

Medications covered by each plan.

According to this source, there can be a 25+/- % variance between the number of prescription medications covered by Idaho Medicare Advantage plans.

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. 

Dot your I’s and cross your T’s.

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 (show you the reports which show cost differences between plans AND the pharmacies within plan). 

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

The Centers for Medicare and Medicaid Services (CMS) have requirements insurance companies(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 discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

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

 

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

American Health Advantage of Idaho

Blue Cross of Idaho

Humana

Molina Healthcare

Pacific Source

United Healthcare.

Would a Idaho based Medicare coach be helpful?

 

A coach can firm up your understanding of Medicare, explain differences between your choices, and help you with enrollment.  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 Apr 24, 2026 @ 3:04 PM

You have 17 Medicare Advantage plans to consider.  

These plans are broken down into several categories. 

Some of these are not available to all County residents.

When you review your Bannock County Medicare options, we encourage you to consider the low premium Medigap plans too. 

Why? 

More of the Bannock County Medicare plans are requiring permission to see a specialist.  Waiting for this may slow your treatment plan.

The Medicare Advantage plans available to you may have fewer licensed physicians in their plan’s network than those available to you if you remained with ‘Original Medicare’.

The Kaiser Family Foundation published a report on this point dated 10/25/2025 and it is available to read here.

The title of this informative document is: “Medicare Advantage Provider Networks Limit Enrollees to About Half of the Physicians in Their Area That Are Available to Beneficiaries in Traditional Medicare, on Average.”

More hospitals in the US are no longer accepting Medicare Advantage plans.  Read this report and this one too.  Both were recently published.

Medigap plans are becoming more attractive for some.

With 2026 premiums and cost sharing of some Bannock County Medicare Advantage plans increasing to the point where these lower premium Medigap plans are attractive and competitive.

There are many positive benefits that come with these two plans which are not available from Medicare Advantage plans.  A few of these are:

the doctors/hospitals in the Salt Lake City are, Boise, Seattle, and surrounding areas (including the rest of the US) are available to you; you just make the appointment;

you do not need referrals to see a specialist,

the limit on your share of the cost for your Medicare covered services is $2,950; remember this figure when you read about the ‘Maximum out of Pocket Cost’ for the Medicare Advantage plans available to you.  These are reviewed below.

More on this below.

The 17 plans are broken down into different categories 

                 Plans without prescription drug coverage

There are five plans in this category. 

            Premium range:  $0 to over $30.

            Medicare Part B ‘credit’ (also called ‘giveback) are available in several plans and the credit ranges from: $0 to over $80.

If the ‘giveback’ is important to the Veteran and they plan to get health care through the plan, they need to pay close attention to plan cost sharing differences between their choices.

Veterans, who will be using covered health care services from a plan, need to pay attention to the plan’s network (what doctors/hospitals are available), and cost sharing.  Not all physicians in the area which ‘accept Medicare’ are available to plan members.   

There are six Special Needs plans (C-SNP and D-SNP) in 2026.

These include:           

      C-SNP  (Chronic health care Special Needs plans)

C-SNPs are designed to provide benefits tailored to people with specific chronic health issues . Qualifying conditions include Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).  

The plan qualification process includes:                      

• Doctor Verification: The plan provider will work with your doctor to verify your chronic condition before you are fully approved for the plan.
• Special Enrollment Period: You can use a one-time special enrollment period to join a C-SNP at any time of the year, not just during the annual fall enrollment period. 

If you have one of these health issues and feel it you are not making progress getting it managed, one of these plans might help. 

D-SNP (Dual eligible Special Needs plans).

If the Idaho Department of Health and Welfare has classified you as having ‘Enhanced Status’ you have Medicaid/Medicare coordinated (MMCP) plans to consider.

Individuals awarded with QMB status have their own unique plans available.

If you have a different Medicaid status, the plans discussed below are available to you. 

 

All other Bannock County Medicare beneficiaries have three HMO and three  PPO plans to consider.

HMO Plans.

Monthly premiums range from $0 to $153.

Plan MOOP’s range from $5900 to $6700.

As a general reminder, confirm the physicians, hospital(s), and other providers are in any plan(s) ‘provider directory’ before you enroll in a plan.  If you work with a broker, they do this for you.

Your cost sharing when plan services are used vary by the service you use.  Pay attention to these figures and other rules that apply to any ‘extras’ which may be included in plans. The plan’s ‘Evidence of Coverage’ document explains this and is available on the insurance company’s website.

Why review this document?  Because it tells you the ‘rest of the story’.  The higher level documents (marketing material, messages you hear in TV ads, the Summary of Benefits document typically offer a subset of plan covered services.

We can help you understand the differences between your plan choices, and when you are ready, help with enrollment too.

 

 PPO Plans.

Monthly premiums range from $19 to over $80.

Plan MOOP’s range from $6,700 for in-network usage up to $13,900 when out of network resources are used.

You must consider both when selecting a plan.

Be sure and check these figures as they set the ‘cap’ for your share of the cost for plan covered health care services.

These figures can be important when comparing plans.

If you choose the ‘out of network’ option, be aware some hospitals in the US do not accept appointments from people insured with Medicare Advantage plans.  The information found here is an up-to-date report on this subject.

Also be aware of the phrase in section 2 of the plan’s ‘Evidence of Coverage’.    It reads: “However, providers that don’t contract with us are under no obligation to treat you, except in emergency situations.”  This document is available on the insurance company’s website.

We can help you understand the differences between your plan choices, and when you are ready, help with enrollment too.

 

With the rising cost of Medicare Advantage plan premiums AND cost share, Medigap Plan G High-Deductible (HD-G) or Plan F High-Deductible (HD-F) are attractive alternatives.

Why one of the Medigap High-Deductible plans?   You have:

• Freedom to choose any physician/hospital which ‘accepts Medicare insurance’ (most do)
• Few ‘prior authorizations; you do not have an insurance company standing between you and your physician to get to the next step in your health care;
• Few/no referrals are needed; you just make the appointment
• Stable coverage year after year
• Nationwide access to health care; this means you minimize the growing issue of hospitals not accepting Medicare Advantage plans 
• More predictable costs when you use care
• The potential issue of recurring cancellation of an insurance company’s Idaho Medicare Advantage plans is eliminated; in 2025 over 70,000 Idaho residents had their Idaho Medicare Advantage plan cancelled by their insurance company.  This issue forced these policyholders to find a new plan for 2026.Premium Comparison (for Idaho)
• Both Medigap HD-G and HD-F often costs less than $85 per monthin Idaho (rates vary by insurance company and can go up annually).
• More comprehensive Medigap plans (Plan F, Plan G, Plan N) have higher premiums, but they require less cost sharingwhen you use care.

Plan Type	Monthly Premium	Out-of-Pocket When You Use Care
HD-G	Lower (often < $85)	$2950 deductible, then full coverage
Plan G	Higher; varies by insurance company.	Cost sharing is less than $290/year
Plan N	Less than Plan G	Some additional copays and cost sharing
Plan F*	More than Plan G	$0 cost sharing for Part A&B services.

• *Plan F is only available to people who became eligible for Medicare before January 1, 2020.
• Call us if you have questions about this choice.

Call us if you have questions.

Other issues to consider when selecting a plan.

If your doctor ran tests on you to diagnose the reason you are visiting them, and unfortunately the diagnosis came back as a serious health issue.  Would you start thinking about where you want to be treated and by whom? 

The decision about getting treatment outside of your plan’s network may come to mind.   

Remember, if you choose an HMO plan, you have access to the plan’s network of facilities.   This typically means a sub-set of the ‘providers’ which ‘accept Medicare insurance’

If you choose a PPO plan, you can use the plan’s in-network facilities or go out of network. 

If you choose the ‘out of network’ option, be aware some hospitals in the US do not accept appointments from people insured with Medicare Advantage plans.  The information found here is an up-to-date report on this subject.  There are other reports for 2023 and 2024. 

Also be aware of the phrase in section 2 of the plan’s ‘Evidence of Coverage’.    It reads: “However, providers that don’t contract with us are under no obligation to treat you, except in emergency situations.”

If you are diagnosed with Cancer…

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

Why consider this?  If may produce better results than traditional approaches.

Read this article if you are unfamiliar with this technology.  At this point, forty six hospitals (out of over 4500) offer this solution.  One of them is in Northern Utah.   This video does a good job of describing how this works.  A map of facilities that offer this resource is available here.

 

How to find hospitals in and around Bannock County.

Click here to find hospitals in a 50 mile radius around Pocatello.  

Notice none of the hospitals listed have a 4 or 5 ‘star rating’ by Medicare.  We recommend people consider hospitals with this rating if they will be treated with more serious health issues. 

You can change the search radius around zip code 83201 to find more hospitals.  Be sure and look to see if the new hospitals are still in Bannock County; if they are ‘out of state’, they may not be in the provider directory of Medicare Advantage plans available to you. 

Resources are available to help you find the top hospitals in the US.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.

These resources may be available to you if you have the right Idaho Medicare insurance (Original Medicare with or without a Medigap plan or a PPO plan, if they will accept your PPO plan).

Some of these hospitals may not accept Medicare Advantage plans.   If you have a Medigap most will accept your insurance.

Medicare assigns Hospitals a ‘star rating’.  We recommend you focus on four and five-star rated hospitals AND skilled nursing facilities.

There are several organizations which rate hospitals too.  Each of these services may use different metrics to rank hospitals.  We favor the Health Grades resource as it focuses on results of services performed in the surgical suite.  

Learn more about this subject here.

Medications covered by each plan.

According to this source, there can be a 25+/- % variance between the number of prescription medications covered by Idaho Medicare Advantage plans.

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.

Dot your I’s and cross your T’s.

We recommend you 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. Reports can be produced which show you your fill/refill cost for your specific prescription medications and if each of the plans available to you cover all of your medications.  They will also show you the refill cost by up to five pharmacies you select.  

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

The Centers for Medicare and Medicaid Services (CMS) have requirements insurance companies(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 discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

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

 

What insurance companies offer Medicare Advantage plans in Bannock County?

Blue Cross of Idaho

Humana

Molina Healthcare

United Healthcare.

 

Would a Medicare coach be helpful?

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

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

We have been helping Pocatello and other people in Bannock County 2015. 

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

 

 

Date last updated Mar 1, 2026 @ 11:01 AM

 

How to find hospitals in and around Bonneville County.

Click here to find hospitals in a 50 mile radius around Idaho Falls.   

Notice one of the hospitals listed have a 4 or 5 ‘star rating’ by Medicare.  We recommend people consider hospitals with this rating if they will be treated with more serious health issues. 

You can change the search radius around zip code 83402 to find more hospitals.  Be sure and look to see if the new hospitals are still in Bonneville County; if they are ‘out of state’, they may not be in the provider directory of Medicare Advantage plans available to you. 

Resources are available to help you find the top hospitals in the US.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.

These resources may be available to you if you have the right Idaho Medicare insurance (Original Medicare with or without a Medigap plan or a PPO plan, if they will accept your PPO plan).

Some of these hospitals may not accept Medicare Advantage plans.   If you have a Medigap most will accept your insurance.

Medicare assigns Hospitals a ‘star rating’.  We recommend you focus on four and five-star rated hospitals AND skilled nursing facilities.

There are several organizations which rate hospitals too.  Each of these services may use different metrics to rank hospitals.  We favor the Health Grades resource as it focuses on results of services performed in the surgical suite.  

Learn more about this subject here.

Medications covered by each plan.

According to this source, there can be a 25+/- % variance between the number of prescription medications covered by Idaho Medicare Advantage plans.

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.

Dot your I’s and cross your T’s.

We recommend you 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. Reports can be produced which show you your fill/refill cost for your specific prescription medications and if each of the plans available to you cover all of your medications.  They will also show you the refill cost by up to five pharmacies you select.  

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

The Centers for Medicare and Medicaid Services (CMS) have requirements insurance companies(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 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.

This page was last modified on Mar 1, 2026 @ 12:08 PM

 

 

Kootenai County residents have several Medicare coverage options.

The right choice depends on more than the monthly premium.

Provider access, prescription drug coverage, cost sharing, maximum out-of-pocket costs, and where you may want to receive healthcare should also be considered.

Medicare Advantage plans available to Kootenai County residents include:

• Plans that may appeal to Veterans who obtain prescription medications through the VA
• Special Needs Plans (SNPs) for people who meet specific Medicaid or chronic-condition requirements
• Medicare Advantage plans available to the general Medicare population

Don’t Overlook Medigap

When comparing your Kootenai County Medicare options, also consider Medicare Supplement (Medigap) coverage with Original Medicare.

Higher Medicare Advantage premiums, cost sharing and maximum out-of-pocket limits have made the comparison between Medicare Advantage and lower-premium Medigap options increasingly useful.

Depending on the Medigap plan selected, differences can include:

• Nationwide access to healthcare providers that participate in Medicare
• No Medicare Advantage provider network requirements
• No referrals required to see specialists
• Original Medicare does not require prior authorization for most Medicare-covered services
• More predictable out-of-pocket costs for Medicare-covered healthcare

Healthcare Access Beyond Kootenai County

This issue deserves particular attention in North Idaho.

Kootenai County residents are close to Spokane and other healthcare resources in eastern Washington. A serious diagnosis may also cause you to consider specialists or major medical centers elsewhere in the Northwest or across the country.

Before choosing Medicare coverage, consider whether the physicians and hospitals you might want to use are available through that coverage.

With Original Medicare and Medigap, you can use Medicare-participating physicians and hospitals throughout the country.

Medicare Advantage works differently. HMO members normally receive non-emergency care within the plan’s network. PPO plans may provide out-of-network benefits, but an out-of-network provider is not required to accept the plan for non-emergency treatment.

We discuss this provider-access difference in greater detail below.

                                                

                 Plans without prescription drug coverage

Some Medicare Advantage plans available in Kootenai County do not include Part D prescription drug coverage.

These plans may be useful for people who already have creditable prescription drug coverage from another source, including Veterans who obtain medications through the VA.

For 2026:

• Five plans are available in this category.
• Monthly premiums range from $0 to more than $30.
• Several plans offer a Part B premium reduction, commonly called a “giveback,” with reductions ranging from $0 to more than $80.

A large Part B giveback does not necessarily make a plan the least expensive choice.

If you expect to obtain healthcare through the Medicare Advantage plan, compare its medical copayments, coinsurance and maximum out-of-pocket limit as well as the giveback.

Also review the plan’s provider directory.

A physician or hospital that accepts Original Medicare is not necessarily part of a Medicare Advantage plan’s network. This can be especially significant for Kootenai County residents who use healthcare providers in both North Idaho and the Spokane area.

Special Needs Plans (SNPs) in Kootenai County

Kootenai County residents who meet specific eligibility requirements may have access to Chronic Condition Special Needs Plans (C-SNPs) and Dual Eligible Special Needs Plans (D-SNPs).

For 2026, six C-SNP and D-SNP plans are available.

Chronic Condition Special Needs Plans (C-SNPs)

C-SNPs provide benefits and care coordination designed for people with qualifying chronic health conditions.

Depending on the plan, qualifying conditions may include:

• Diabetes mellitus
• Chronic heart failure
• Certain cardiovascular disorders

Enrollment requires verification that you meet the plan’s medical criteria. The plan works with your healthcare provider to confirm eligibility.

People who become eligible for a C-SNP may qualify for a Special Enrollment Period outside the fall Annual Enrollment Period, subject to Medicare’s enrollment rules.

When comparing C-SNPs, consider the provider network, prescription drug formulary, cost sharing and care-management programs.

Dual Eligible Special Needs Plans (D-SNPs)

D-SNPs are designed for people who qualify for both Medicare and Medicaid.

The plans available to you depend on your Idaho Medicaid eligibility category. Different options may apply to people receiving Qualified Medicare Beneficiary (QMB) benefits and people with other levels of Medicaid assistance.

Verify your current Medicaid status before comparing D-SNP options.

 

HMO and PPO Medicare Advantage Plans

Kootenai County residents who do not qualify for a Special Needs Plan have four HMO and one PPO plan to consider.

The two types work differently, particularly when you need healthcare outside the plan’s provider network.

HMO Plans

For 2026, four HMO plans are available in Kootenai County.

• Monthly premiums range from $0 to $94
• Maximum out-of-pocket (MOOP) limits range from approximately $5,900 to $6,700

An HMO normally requires you to receive non-emergency healthcare from providers in the plan’s network, subject to the plan’s rules and exceptions.

Before enrolling, check the provider directory for the physicians, hospitals and specialists you use—or may want to use.

This deserves extra attention in Kootenai County because Spokane-area healthcare is nearby. A physician or hospital that accepts Original Medicare is not necessarily available through a Kootenai County Medicare Advantage HMO.

PPO Plans

For 2026, one PPO plan is available in Kootenai County.

• Monthly premium: $29
• In-network MOOP: $6,700
• Combined in-network/out-of-network MOOP: $13,900

A PPO provides more flexibility to obtain covered healthcare outside its network, usually at higher cost.

However, an out-of-network benefit does not guarantee that an out-of-network physician or hospital will accept the plan for non-emergency treatment.

Before using an out-of-network provider, verify that the provider will accept your particular Medicare Advantage plan and determine how the plan will cover the proposed service.

Compare Medicare Advantage With High-Deductible Medigap

Before selecting a Kootenai County HMO or PPO based primarily on its monthly premium, compare it with Original Medicare and a Medicare Supplement plan.

High-Deductible Plan G (HD-G) is particularly useful for this comparison.

For 2026, the High-Deductible Plan G deductible is $2,950.

People who became eligible for Medicare before January 1, 2020 may also have High-Deductible Plan F available to them.

Why Consider High-Deductible Medigap?

Original Medicare combined with Medigap offers several differences from Medicare Advantage:

• Access to Medicare-participating physicians and hospitals nationwide
• No Medicare Advantage provider network
• No referrals required to see specialists
• Original Medicare does not require prior authorization for most Medicare-covered services
• Coverage that is not dependent upon an annual Medicare Advantage provider network
• More predictable cost sharing for Medicare-covered Part A and Part B services

High-Deductible Plan G also provides a useful comparison with Medicare Advantage maximum out-of-pocket limits.

The $2,950 HD-G deductible and a Medicare Advantage MOOP are not identical measures. They operate under different coverage structures. However, comparing your potential annual healthcare cost exposure under each alternative can help you understand the financial differences.

Medigap Plan Comparison

Plan	Premium Relationship	Medicare-Covered Cost Sharing
High-Deductible Plan G	Lower; often under $85 in Idaho	You pay Medicare-covered costs up to the $2,950 annual high deductible before Plan G benefits begin
Plan G	Higher	Part B deductible remains your responsibility
Plan N	Often lower than standard Plan G	Part B deductible plus certain office and emergency-room copayments; Part B excess charges aren’t covered
Plan F*	Often higher	Covers Medicare-approved Part A and Part B deductibles and cost sharing according to Plan F benefits

*Plan F is available only to people who were eligible for Medicare before January 1, 2020.

What Happens If Your Health Changes?

Your current physicians and hospitals may meet all of your healthcare needs today.

But suppose testing identifies cancer, a serious heart problem, a neurological disorder or another condition requiring specialized treatment.

You may begin asking different questions:

Who has the most experience treating my condition?

Which hospitals have the best outcomes?

Is a treatment or technology available somewhere else that isn’t available locally?

Will my Medicare coverage allow me to use that physician or hospital?

These questions are worth considering before you select your Medicare coverage.

Kootenai County’s Location Makes This Especially Relevant

Kootenai County residents have healthcare resources in North Idaho and are also close to Spokane-area medical facilities.

A serious or unusual medical condition could cause you to look farther—to Seattle, Salt Lake City, Phoenix or another major medical center.

Your Medicare coverage can affect which of those resources are realistically available to you.

With Original Medicare, you can obtain Medicare-covered healthcare from participating Medicare providers throughout the United States. A Medigap policy supplements Original Medicare and does not establish its own provider network.

A Medicare Advantage HMO normally limits non-emergency care to its network.

A PPO may provide out-of-network benefits, but the existence of that benefit does not require an out-of-network physician or hospital to accept you for non-emergency care.

Finding Hospitals With Strong Clinical Outcomes

There are several resources for evaluating hospitals, and they measure different things.

Medicare’s Care Compare provides information about hospitals across a broad range of quality measures.

Healthgrades provides another perspective that we believe is particularly useful when evaluating care for a serious condition or procedure: clinical outcomes.

Healthgrades analyzes Medicare inpatient claims and compares actual patient outcomes with predicted outcomes after adjusting for differences in patient risk.

Its hospital analysis evaluates mortality and complications across numerous medical conditions and procedures.

For example, Healthgrades evaluates mortality outcomes for conditions and procedures that include:

• Coronary artery bypass surgery
• Heart attack
• Heart failure
• Stroke
• Sepsis
• Pneumonia
• Colorectal surgery
• Cranial neurosurgery

For other procedures—including total hip replacement, total knee replacement, spinal fusion and several other surgeries—it evaluates in-hospital complications.

Healthgrades’ America’s 250 Best Hospitals represent the top 5% of eligible hospitals in its analysis for overall clinical excellence.

For someone facing major surgery or treatment for a serious illness, this information can help identify hospitals worth investigating.

Use Hospital Ratings as a Starting Point

Once you identify a highly rated hospital, investigate further.

Consider:

• Its outcomes for your particular condition or procedure
• The experience of the physicians who would provide your care
• Whether the hospital offers the treatment or technology you need
• Physician board certification and specialty training
• Whether the hospital and physicians will accept your Medicare coverage

A highly rated hospital doesn’t help you if you cannot obtain non-emergency treatment there under your insurance arrangement.

That brings the comparison back to one of the most significant differences between Medicare Advantage and Original Medicare with Medigap:

If your health changes, how much freedom will you have to choose where—and from whom—you receive your healthcare?

 

Your Insurance Matters

A highly rated hospital doesn’t help you if you cannot obtain non-emergency treatment there under your insurance arrangement.

This is especially relevant for Kootenai County residents because Washington healthcare facilities are nearby but are outside Idaho.

A Medicare Advantage PPO’s out-of-network benefit does not guarantee that a Washington physician or hospital will accept the plan.

Original Medicare with Medigap does not have the same Medicare Advantage provider-network restriction.

That brings the comparison back to an important question:

If your health changes, how much freedom will you have to choose where—and from whom—you receive your healthcare?

 

Prescription Drug Coverage Can Vary Significantly by Plan

Prescription drug coverage deserves close attention when comparing Medicare Advantage plans that include Part D coverage.

Don’t simply ask:

“Does this plan cover my prescriptions?”

You also need to know:

• Which formulary tier each medication is assigned to
• Your cost to fill or refill each prescription
• Whether prior authorization, step therapy or quantity limits apply
• Which pharmacies provide the plan’s preferred pricing
• Whether your medications are subject to a deductible
• Your estimated total prescription cost for the year

Two plans can cover the same medication but produce very different annual costs because of differences in formulary tiers, copayments, coinsurance and pharmacy pricing.

Check Your Actual Prescriptions Before Enrolling

Before enrolling in a Medicare Advantage plan with drug coverage, compare the plan using the medications you actually take, including dosage and frequency.

Medicare’s Plan Finder can estimate your prescription costs under the plans available in Kootenai County and allows you to compare pharmacy pricing.

A good comparison should show more than whether a drug is covered. It should help you understand what you are likely to pay for your prescriptions throughout the year.

What About Medications Used to Treat Serious Conditions?

Medicare Part D provides special formulary protections for six classes of medications.

Part D formularies must include all or substantially all drugs in these protected classes, subject to Medicare’s rules:

• Antineoplastics (cancer medications)
• Anticonvulsants
• Antidepressants
• Antipsychotics
• Antiretrovirals
• Immunosuppressants used for transplant rejection

These protections do not mean every prescription will have the same cost or utilization requirements under every plan.

If you take expensive or specialized medications, review the specific drug, formulary tier, cost-sharing requirements and applicable coverage rules before choosing a plan.

 

Medicare Advantage Insurance Companies in Kootenai County

For 2026, Medicare Advantage plans in Kootenai County are offered by:

• Blue Cross of Idaho
• Molina Healthcare of Idaho
• PacificSource
• UnitedHealthcare

Plan availability can change from year to year. Verify the plans available for your ZIP code before enrolling.

Need Help Comparing Kootenai County Medicare Plans?

 

Medicare Advantage, Medigap and Part D plans can differ substantially in premiums, healthcare cost sharing, prescription costs, provider access and additional benefits.

An independent Medicare insurance broker can help you understand those differences and compare the options available to you.

We help Kootenai County residents:

• Understand the differences between Original Medicare, Medigap and Medicare Advantage
• Compare plan premiums and healthcare costs
• Check North Idaho and Spokane-area physician and hospital access
• Compare prescription drug coverage and estimated costs
• Understand plan benefits and limitations
• Complete enrollment in the plan they choose

Our assistance does not end when you enroll. We are available to help our clients with Medicare questions and plan issues throughout the year.

Idaho Medicare Insurance Choices has been helping Idaho Medicare beneficiaries since 2012.

If you would like help comparing your Kootenai County Medicare options, call us. Our regular hours are 8:00 a.m. to 8:00 p.m., Monday

 

This page was updated on Aug 7, 2026 @ 6:46 PM

 

2026 Boundary  County Medicare Advantage plans.

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

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

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

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

 

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 Oct 11, 2025 @ 7:03 AM

Bonner County has 16 Medicare Advantage plans. Six of these have special enrollment rules and are not available to all residents.

These plans are broken down into three categories

When you review your Bonner County Medicare options, you should also consider the low premium Medigap plans.

Why? 

Because some of the premiums, cost sharing, and ‘Maximum out of pocket limits’ of Medicare Advantage plans have increased to the point where these Medigap plans are attractive.

There are positive benefits that come with these two lower premium Medigap plans.

A few of these include:

opening up access to the top hospitals in the Northwest including Evergreen Health in Kirkland, Wa, and Providence Holy Family Hospital in Spokane.   Also, check out the Mayo Clinic’s (Scottsdale Arizona) website to learn why they are ranked as one of the top 50 hospitals in the US.

no need for referrals from your primary care physician to see a specialist.  You just make the appointment

another important point is your annual cost sharing limit for the Medicare covered health services you use is about half of the ‘Maximum out of Pocket Cost’ found in most Idaho Medicare Advantage plans.

                 Plans without prescription drug coverage

There are five plans in this category.

Premium range:  $0 to over $30.

Medicare Part B ‘credit’ (also called ‘giveback) are available in several plans and the credit ranges from: $0 to over $100.

If the ‘giveback’ is important to the Veteran and they plan to get health care through the plan, they need to pay close attention to plan cost sharing differences between their plan choices.

Also reviewing he plan(s) ‘provider directory’ must be done.  This document lists the hospital(s)/physicians/other providers that are available through the plan. All the resources (which ‘accept Medicare’) may not be available through the plan.

If you qualify, there are six Special Needs plans (C-SNP and D-SNP)

These include:           

      C-SNP  (Chronic health care Special Needs plans)

C-SNPs are designed to provide benefits tailored to people with specific chronic health issues . Qualifying conditions include Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).

The plan qualification process includes:

• Doctor Verification: The plan provider will work with your doctor to verify your chronic condition before you are fully approved for the plan.
• Special Enrollment Period: You can use a one-time special enrollment period to join a C-SNP at any time of the year, not just during the annual fall enrollment period.

If you have one of these health issues and feel it you are not making progress getting it managed, one of these plans might help.

D-SNP (Dual eligible Special Need Plans)

If the Idaho Department of Health and Welfare has classified you as having ‘Enhanced Status’ you have Medicaid/Medicare coordinated (MMCP) plans to consider.

Individuals awarded with QMB status have their own unique plans available.

If you have a different Medicaid status, the plans discussed below are available to you.

 

All other Bonner County Medicare beneficiaries have three HMO and one PPO plans to consider.

HMO Plans.

There are five plans to consider.

Monthly premiums range from $0 to $153.

Plan MOOP’s range from $5900 to $6700.

If you are interested in the higher premium plans, you owe it to yourself to review and understand the two low premium Medigap plans discussed below.

• We recommend you consider one of the 2 High Deductible Medigap plans described below in lieu of  any HMO plan with a premium above $60/month.   

 

 PPO Plans.

There is one PPO plan available in 2026.

Its monthly premium is $29.

Plan MOOP’s range from $6,700 for in-network usage and $13,900 if out of network resources are used.

We encourage to read the next paragraph if you have an interest in a PPO plan.

• We recommend you consider one of the 2 High Deductible Medigap plans described below in lieu of  any PPO plan described above. 

 

The two low premium Medigap plans are: the High-deductible ($2,950) version of Medigap Plan G, or if you joined Medicare prior to 1/1/2020, Plan F version is also available.

Why one of these  plans?   

You have:

• Freedom to choose any physician/hospital which ‘accepts Medicare insurance’ (most do)
• Few ‘prior authorizations; you do not have an insurance company standing between you and your physician to get to the next step in your health care;
• Few/no referrals are needed; you just make the appointment
• Stable coverage year after year
• Nationwide access to health care; this means you minimize the growing issue of hospitals not accepting Medicare Advantage plans
• More predictable costs when you use care
• The potential issue of recurring cancellation of Idaho Medicare Advantage plans is eliminated; in 2025 over 70,000 Idaho residents had their Idaho Medicare Advantage plan cancelled by their insurance company.  This issue forced these policyholders to find a new plan for 2026.

Study the matrix below; this gives you a high level overview of some differences between your plan choices.

Plan Type	Monthly Premium	Out-of-Pocket When You Use Care
HD-G	Lower (often < $85)	Your cost share for Part A and B services is $2,950/yr , then full coverage
Plan G	Higher; varies by insurance company.	Your cost share is less than $290/year (the Part B dedictible)
Plan N	Less than Plan G	Some cost sharing on doctor  ($20 max) and ER visits ($50) & the annual Part B deductible
Plan F*	More than Plan G	$0 cost sharing for Part A&B services.

• *Plan F is only available to people who became eligible for Medicare before January 1, 2020.
• Call us if you have questions about this choice.

Call us if you have questions.

Other issues to consider when selecting a plan.

If your doctor ran tests on you to diagnose the reason you are visiting them, and unfortunately the diagnosis came back as a serious health issue.  Would you start thinking about where you want to be treated and by whom?

The decision about getting treatment outside of your plan’s network may come to mind.

Remember, if you choose an HMO plan, you have access to the plan’s network of facilities.   This typically means a sub-set of the ‘providers’ which ‘accept Medicare insurance’ in your area.

If you choose a PPO plan, you can use the plan’s in-network facilities or go out of network.

Some hospitals in the US do not accept appointments from people insured with Medicare Advantage plans.  The information found here is an up-to-date report on this subject.  There are other reports for 2023 and 2024.

Also be aware of the phrase in section 2 of the plan’s ‘Evidence of Coverage’.    It reads: “However, providers that don’t contract with us are under no obligation to treat you, except in emergency situations.”

If you are diagnosed with Cancer…

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

Why consider this?  If may produce better results than traditional approaches.

Read this article if you are unfamiliar with this technology.  At this point, forty six hospitals (out of over 4500) offer this solution.  One of them is in Northern Utah another is at the Mayo Clinic in Scottsdale, Arizona.  This video does a good job of describing how this works.  A map of facilities that offer this resource is available here.

How to find hospitals in and around Bonner County.

Click here to see the location of the hospitals in a 50 mile radius around Sandpoint.

Notice one of the hospitals listed has a 4 ‘star rating’ by Medicare.  Two of the 6 hospitals are in Washington and may not be in the provider directory of all Medicare Advantage plans available to you.

We recommend people consider hospitals with either a 4 or 5 star rating.

You can change the search radius around zip code 83864 to find more hospitals.  Be sure and verify all of the new hospitals are still in the provider directories of any Medicare Advantage plan you have an interest.

Resources are available to help you find the top hospitals in the US.

The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them.

These resources may be available to you if you have the right Idaho Medicare insurance (Original Medicare with or without a Medigap plan or a PPO plan, if they will accept your PPO plan).

Some of these hospitals may not accept some/all Medicare Advantage plans.   Read this and this article  to learn why.

If you have a Medigap plan most hospitals will accept your insurance.

Medicare assigns Hospitals a ‘star rating’ (learn more about these here).  If available, we recommend you focus on four and five-star rated hospitals AND skilled nursing facilities.

There are several organizations which rank hospitals.  Each of these services may use different metrics to rank hospitals.  We favor the Health Grades resource as it focuses on results of services performed in the surgical suite.  

Learn more about this subject here.

Medications covered by each plan.

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.  The fill/refill cost by these same drug tiers is also displayed.  These figures can vary noticeably between plans.

Dot your I’s and cross your T’s.

We recommend you 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. Reports can be produced which show you your fill/refill cost for your specific prescription medications and if each of the plans available to you cover all your medications.  They will also show you the refill cost of five pharmacies you select.

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

The Centers for Medicare and Medicaid Services (CMS) have requirements insurance companies(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 discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“

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

 

What insurance companies offer Medicare Advantage plans in Bonner County?

Blue Cross of Idaho

Molina Healthcare of Idaho

Pacific Source

United Health Care.

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 Feb 22, 2026 @ 1:51 PM