Medicare Advantage is private health insurance available to seniors and some adults with permanent disabilities or chronic illness. Also called Medicare Part C or simply MA, Medicare Advantage plans are provided by Medicare-approved companies. MA plans include all the benefits of Original, or Part A and Part B Medicare. Medicare Advantage serves as an alternative to Original Medicare; however, most MA plans include additional coverage not offered through government Medicare, such as hearing, dental and vision expenses. Some MA plans also provide prescription drug coverage that is comparable to Medicare Part D.
According to a study commissioned by the Kaiser Family Foundation, nationwide Medicare Advantage enrollment among eligible seniors has risen from 24% in 2010 to 39% in 2020. In Idaho, one-third of eligible seniors are members of a Medicare Advantage plan, while the enrollment rate in neighboring Wyoming is just 3%. To the west in Oregon, Medicare Advantage enrollment is 47%, and Utah has an enrollment rate of 39%.
Seniors who want to purchase an Idaho Medicare Advantage plan have a variety of plans and providers to consider. SNP, PPO, HMO and HMO-POS plans are offered, and many of these plans include prescription drug coverage that is comparable to Medicare Plan D coverage. In this guide, you’ll find an overview of the four Medicare Advantage plan types, also with enrollment and eligibility rules. You’ll also find state and local resources for seniors, family members and caregivers who need further assistance with Medicare Advantage plan selection and management.
There are four types of Medicare Advantage plans available in Idaho, including Health Maintenance Organization-Special Needs Plans (HMO-SNP) for dual-eligible seniors and adults with disabilities. Other plan types include Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Health Maintenance Organization with a Point of Service option (HMO-POS).
Health Maintenance Organization-Special Needs Plans (HMO-SNP)
SNPs, also known as HMO-SNPs, are limited-enrollment Medicare Advantage plans administered by a HMP. SNPs are available to adults and seniors who meet strict plan eligibility requirements, such as living full-time in a residential care facility or having dual-eligibility (Medicare and Medicaid). Members may also have a serious, chronic medical condition, such as end-stage kidney disease, or live with a permanent physical or mental disability. Many SNPs cover specialized services to meet the unique needs of their members.
Health Maintenance Organizations (HMO)
HMOs give members access to medical care through a network of contracted providers. HMO plans are usually the least expensive type of Medicare Advantage insurance because members must go through their primary care physician to access tests, specialist care and other covered services. In general, HMO beneficiaries cannot be covered for any out-of-network care; however, some special exemptions may be made for emergency care and other exceptional situations.
Preferred Provider Organizations (PPO)
APPO is a managed-care organization consisting of physicians, specialists, hospitals and other services that provide contracted care to plan members at a pre-negotiated rate. This rate is lower than the usual service fee, and PPO members pay premiums in exchange for access to this network of providers. PPO premiums are higher than premiums for HMO plans, and this additional cost gives members access to a wide range of providers and services.
Health Maintenance Organizations With Point of Service Options (HMO-POS)
An HMO POS is a local HMO that includes a Point of Service option. Like a regular HMO, an HMO POS uses a network of providers that deliver most services to members. What sets this type of Medicare Advantage apart is the fact that beneficiaries enjoy some of the advantages of a PPO plan at a cost that’s higher than HMO plans and lower than PPO plans. In specific situations and with pre-approval from the insurance company, HMO POS members may seek out-of-network care for an additional fee. Some of the out-of-network costs are covered, and HMO POS policies generally offer nationwide POS benefits.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Idaho, seniors who want to enroll in a Medicare Advantage plan and who require prescription drug coverage must choose a Medicare Advantage plan that includes drug benefits. Medicare Advantage members in Idaho cannot enroll in a separate Medicare Part D plan, as doing so will automatically terminate their MA coverage. Seniors and qualifying adults who enroll in an SNP are automatically provided with prescription drug coverage that includes benefits comparable to Medicare Part D.
Choosing the right Medicare Advantage plan can be difficult, and that’s especially true in Idaho, where there are over 40 MA plans. Plan costs, coverage and availability vary in each county. There are a number of free state and local services that help seniors select the best Medicare Advantage plan, and learn about financial aid programs for MA beneficiaries. Below you’ll find a list of resources where seniors can get up-to-date information and unbiased assistance with Medicare Plan C.
Idaho’s Senior Health Insurance Benefits Advisors (SHIBA) provides free, unbiased information on Medicare benefits, plans and costs. Operated by the Idaho Department of Insurance, SHIBA program volunteers and partner organizations deliver group presentations and educational workshops throughout the state. SHIBA-certified Medicare counselors and outreach workers also conduct one-on-one Medicare counseling sessions in-person and by phone. SHIBA offices are located in Boise, Pocatello and Coeur d’Alene.
For more information about SHIBA services or to book an appointment with a SHIBA counselor, call the SHIBA Medicare helpline at (800) 247-4422.
Idaho’s Senior Medicare Patrol program is a volunteer-based fraud prevention program that provides consumers with education and one-on-one counseling. SMP volunteers deliver free Medicare fraud prevention workshops and attend public events throughout the state to raise awareness about Medicare double-billing, over-billing, marketing scams and financial exploitation related to Medicare. Seniors who are concerned about their Medicare Advantage plan billing or service delivery can speak with an SMP volunteer, and cases that may involve criminal actions are escalated to the appropriate authorities.
Idaho Legal Aid Services is a non-profit law firm that helps low-income Idaho residents with civil legal matters throughout the state. The organization operates the Senior Legal Hotline, a free telephone service for seniors age 60 and older who need legal advice. The Senior Legal Hotline is staffed by lawyers and paralegals who can review civil law concerns and provide legal guidance. If a caller requires further assistance, they will be referred to a low-cost or pro bono law clinic in their community.
To speak with a Legal Aid attorney, call the Senior Legal Advice Line at (208) 746-7541.
The Idaho Commission on Aging is a state-run organization that works to ensure Idahoans have access to the resources needed to live independently and with dignity. The Commission maintains an up-to-date listing of resources for seniors throughout the state, advocates for seniors at the state and federal level, and helps connect seniors with community supports. Seniors can find plain-language guides on the ICOA website with information about safety issues, Medicare fraud and Adult Protective Services for vulnerable adults.
Seniors can visit the ICOA online or call (208) 334-3833.
The Dick Eardly Senior Center is a multipurpose community center for adults age 62 and older that is owned and operated by the City of Boise. The center operates a variety of free and low-cost leisure and wellness programs during the week that is designed to help seniors stay active and engaged in their community. Seniors are also able to enjoy low-cost lunchtime meals through the senior nutrition program, and the center frequently hosts informational workshops that cover Medicaid Advantage plan options in the area. Seniors can also learn about local resources such as low-cost transportation, housing, home care and financial assistance.
Seniors can view the monthly newsletter and program calendar on the City of Boise’s website, or call the center at (206) 608-7580.
Located in Coeur d’Alene and serving Benewah, Bonner, Boundary, Kootenai and Shoshone counties, the Area Agency on Aging of North Idaho assists older adults in finding the information and support they need to maintain a satisfactory quality of life. In order to promote independent living, the agency provides home delivered meals, homemaker services, and respite services as well as connecting seniors to Adult Protective Services and Long Term Care Ombudsmen. They also partner with SHIBA to provide free Medicare Advantage workshops and counseling to seniors living in North Idaho.