Oneida County MAPD plans
CMS Required Statement for Oneida County residents interested in MAPD (Medicare Advantage Prescription Drug) plans.
We are licensed with all Oneida County Medicare Advantage plans listed on the Medicare Plan Finder tool.
We have 2025 Part D licenses with United Health Care, Silver Script and Humana. The remaining 2 companies either do not use brokers in 2025 or their plans are rated below 3 stars by Medicare. When this company resolves this issue we will pursue a license with them.
Additional information on his subject is documented here.
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If you would rather talk with us about plan details (skip reading the rest of this article), just call . But first:
Brokers must follow CMS rules before they can discuss plan details.
Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and text it to us (1-208-867-0296). Upon receipt we will call you and share the details.
What else you need to know!
For 2025, Oneida County has 10 Medicare Advantage Prescription Drug (MAPD) plans for residents to consider.
Monthly premiums range from $0 to over $100.
Here is the high level break down of these plans:
3 plans do NOT include prescription drug coverage; Veterans may find these plans attractive. Some of these offer the popular Part B ‘giveback’ (lower your Part B monthly premium). This means more money in your pocket.
2 plans are reserved for residents which have been medically diagnosed with Diabetes mellitus; and/or Chronic heart failure; and/or Cardiovascular disorder (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder).
If you have a Medicaid status of QMB and SLMB+ with the above-mentioned health issues, the plans mentioned above are also available.
5 plans are available for the rest of Oneida County residents. 2 of these are HMO plans. HMO means there is a defined network of hospitals/physicians/other providers plan members must use. The other 3 are PPO plans. They also have a defined network of doctors/hospitals/other providers. In addition, you can use non network providers that ‘accept Medicare’ insurance. When you do this, your cost share is higher. We recommend veterans also consider these plans.
There is another type of Medicare plan you should be aware of.
These are Medigap plans.
We recommend you consider 2 of these.
Why? Because they will limit your annual out of pocket costs for Part A and B covered services to less than $2,900. This figure is controlled by Medicare and typically goes up a bit annually. Your Medigap plan pays the rest of your Part A and B cost share if you hit this figure during the calendar year.
Keep these plans in mind when you review the MOOP discussion below.
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 Oneida County Medicare Advantage plans. Also, you do not have an insurance company standing between your physician to get permission to move forward with your treatment plan. Physicians/hospitals prefer these plans because they know they will be paid in a timely manner. Also, there are fewer ‘prior authorizations’ for them to deal with.
Medicare published a document that provides the rest of the details you need to know about Medigap plans. You can download this PDF document by clicking here.
Interested in learning more about your plan choices? Print the ‘Scope of Appointment’ document (available here), sign/date it, then take a picture of the signed document and text it to us (1-208-867-0296). Upon receipt we will call you and share the details.
Call if you have questions.
What are the differences between the 5 Medicare Advantage Prescription Drug plans for residents?
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.
A MAPD plans MOOP is a key figure you should be aware of. Put plans on your short list that have a lower MOOP. This decision may save you money if you use Medicare covered health care services during the plan year.
Be mindful 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 plans is $9,350.
Insurance companies offering Medicare Advantage plans set their plan’s MOOP based on each of their plan’s business goals.
Once you hit your plan’s MOOP, your insurance company pays the rest of your share of the cost when you use Part A/B services.
The range of MOOP for your County’s HMO Medicare Advantage plans is $4,500 to $4,900.
The MOOP for Oneida County residents interested in a PPO plan ranges from $6,700 to $9,350.
We prefer plans that meet a person’s needs, have a low MOOP, AND plans with a monthly premium below $70.
Why $70? You can get a Medigap plan described above for a lower premium AND you will not have an insurance company standing between you and your doctor to get the ‘next step’ in your health care accomplished. There are far fewer ‘prior authorizations’ to contend with too.
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 can 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.
Are your local hospitals current on the technology they use to diagnose and treat you?
Be aware hospitals may/may not be using current technologies/techniques to treat patients. Why? Because of the cost for new technologies are competing for other financial needs of the hospital.
Proton Therapy is an example of newer technology for treating cancer. It is being used as an alternative to radiation treatments.
Read this article if you are unfamiliar with this.
At this writing, 45 hospitals (out of over 4500) offer this solution. Facilities near Idaho include:
Huntsman Cancer Institute (Salt Lake City) (began offering this service in 2021)
The Mayo Clinic Cancer Center (Phoenix…rolled out this service on 2016)
Loma Linda University Cancer Center (began offering this service in 1990)
California Protons Cancer Therapy Center (San Diego) (began offering this service in 2017).
If you are interested in this service, you might check where each of the above facilities are ranked in the top 250 hospitals.
Does Medicare rate hospitals for us?
Yes.
Hospitals are assigned a ‘star rating’ by Medicare. We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.
There are physician rating services too. One is available here. We focus on physicians with a 4 or 5 star rating and have at least 10-ratings. You can use this same tool to find physicians that ‘accept Medicare insurance’.
We also recommend you use a ‘board certified physician‘.
Are you interested in the top 250 hospitals in the country?
Would you consider using the services of the top hospitals in the Seattle area…or the Mayo Clinics?
The top 250 hospitals in the US may have the latest technologies to treat different health issue(s)…and the physicians that know how to use them. These resources are available to you if they accept Medicare insurance (Part A and B). Some do not accept Medicare Advantage plans (Part C). Others prefer you stayed with Original Medicare (Part A and B…and not enrolled in a Medicare Advantage plan). If you have a Medigap plan it will help you pay the left-over costs that Medicare does not completely cover.
Hospitals are assigned a ‘star rating’ by Medicare. We recommend Idaho residents focus on 4 and 5-star rated hospitals AND skilled nursing facilities.
There are physician rating services too. One is available here. We focus on physicians with a 4 or 5 star rating and have at least 10-ratings. You can use this same tool to find physicians that ‘accept Medicare insurance’.
We also recommend you use a ‘board certified physician‘.
Medications covered by each plan.
According to this source, there is a 20+/- % variance between the number of prescription medications covered by the plans available to you. Note none of these plans include 100% of the medications covered by Medicare.
This same resource documents the number of medications each plan has in each of the 5 (or 6) drug tiers AND the fill/refill cost by these same drug tiers. These figures can vary noticeably between plans.
Given the wide variance between plans on the above, it is easy to understand why there can be a 300% +/- variance in your projected annual out of pocket cost between your plan choices for the medications you take.
This is a key reason you should not enroll in any Medicare Advantage plan until you understand your cost for your prescription medications. If you are working with a broker/agent that just tells you your medications are covered, we suggest you work with someone else that will share the whole picture.
Are medications that treat serious health issues (cancer, etc.) covered by my plan?
The Centers for Medicare and Medicaid Services (CMS) has requirements insurance company(s) offering Medicare plan(s) must meet when they put together their list of covered medications.
Below is a cut/paste from (Section 30.2.5) the current Medicare Prescription Drug Benefit Manual.
“Part D sponsor formularies must include all or substantially all drugs in the immunosuppressant(for prophylaxis of organ transplant rejection), antidepressant, antipsychotic, anticonvulsant, antiretroviral, and antineoplastic classes. CMS instituted this policy because it was necessary to ensure that Medicare beneficiaries reliant upon these drugs would not be substantially discouraged from enrolling in certain Part D plans, as well as to mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.“
We feel this is an important statement everyone enrolled/wishing to enroll in a Medicare prescription drug plan should be aware of.
Medicare Supplement plans.
These plans give you the choice of any doctor/hospital/other providers (in the US) that offer services to people enrolled in Medicare (both Part A and B). Over 90% of physicians in the US accept Medicare insurance (Part A and B) and most of the hospitals do.
Physicians and Hospitals have fewer concerns with these plans. Why? Because there are far fewer ‘prior authorizations’ and denial of claims issues to deal with. You and your physician are making the decision on the ‘next step’ in your health care. You do not have an insurance company standing between you and your physician to get the ‘next step’ in your health care done.
Read the articles supporting the above comments here, here, and here.
Do you want a plan that pays for most all of the left-over cost for Part A and B in the US?
We recommend you consider a Medigap Plan G.
The monthly premium for this plan varies by the insurance company offering the plan. The coverage is the same, the only difference is the name of the company on your policy and their monthly premium. Premiums range from below $200/month to over $250 for this same plan. When you work with a broker, they help you navigate you way through the ‘who to do business’ issue.
Why pick Plan G?
Because this plan pays all of your left-over costs that Medicare does not pay except the annual Part B deductible. This deductible is a Medicare controlled figure, and it goes up a bit each year. Your share of the other left-over costs is documented here.
Something else to keep in mind is Medicare typically bumps up the cost of Part A and B services. They do this annually. Your Medigap plan automatically pays your share of these increased costs.
The other Medigap plans typically have a lower premium than Plan G…but you have more ‘left over costs’ you are responsible for. Check out page 11 of the document found here. This shows all of the Medicare covered health care services and what services each of the different Medigap plan pays for you.
If you prefer a lower premium Medigap plan…
If you want a lower premium and are willing to pay for leftover costs, there are 2 different Medigap plans reviewed earlier in this article. They have a Medicare controlled ‘annual deductible’. Yes, it goes up a bit annually.
This ‘deductible’ is similar in concept to the MOOP described above.
The deductible for this year is found here.
This Medigap plan pays the rest of your Part A and B leftover costs for the calendar year once this figure is hit.
When you work with a Medicare broker that is licensed with all/most all insurance companies available to you, they help you navigate your way through this maze and select the company and plan which meets your needs and budget.
We have been helping Idaho residents with this task since 2012.
Call us if you want help.
Would a Medicare coach be helpful?
A coach can answer your question(s) and firm up your understanding of Medicare. Once this is done, they will explain the differences between your choices and help you through the enrollment process. They will also be there year after year to help you.
Will the people behind the TV ads include this service for you?
Call us if you are interested. Our hours are 8am to 8pm Monday through Saturday.
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