Medicare Advantage, also known as Medicare Part C, is an alternative way for seniors to get Medicare benefits. Unlike Original Medicare, which is provided directly by the federal government and is the same for all beneficiaries, Part C plans are issued by private insurers in each state and offer a range of coverage options. Medicare Advantage plans also frequently cover benefits not paid for by Original Medicare, such as vision care, dental procedures and prescription drugs.
When a Medicare-eligible citizen enrolls in a Part C plan, the process works similarly to buying insurance from a private company. Unlike fully private insurance, however, Medicare Advantage plans bill the Medicare program for much of their costs, and applicants cannot be rejected or charged more for having preexisting conditions. Medicare Advantage plans are required to meet minimum coverage standards, but beyond that the plans offered vary by state and by participation levels.
In North Dakota, only 19% of the eligible population of Medicare beneficiaries choose Medicare Advantage plans to deliver their coverage, according to the Kaiser Family Foundation. This is low, relative to the 39% of seniors nationwide who participate in the program. North Dakota is tied with three other states, Montana, Oklahoma and Virginia, for 38th place in Part C enrollment.
Seniors in North Dakota who opt into a Medicare Advantage plan have several options for how to receive care. While most North Dakotans who switch from Original Medicare sign up for a Medicare Cost plan, which is only offered in a few places around the country, Medicare Advantage beneficiaries can choose from a full range of HMO, PPO and PFFS plans. In this guide we clarify the differences between these coverage options and explain some plans unique to North Dakota. We also cover the rules for enrolling in a Medicare Advantage plan, and include information about Medicare resources that can help eligible North Dakota seniors get the most out of their Part C benefit plan.
Medicare Advantage plans in North Dakota, like those available elsewhere in the country, are mainly grouped into four types of policies: Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service plans and Special Needs Plans. Each of these have advantages and drawbacks, and seniors can research each company’s offered plans to find one that’s right for them.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations provide all or most of their services under one umbrella. Health services are provided by the same organization that issues the insurance plan. This can keep costs low, especially for monthly premiums, but service options can be limited. HMO members often need authorization for specialist visits and other services delivered outside of the organization. HMOs also typically require members to get approval from a primary care physician before receiving specialist care.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations are similar to HMOs, except the in-plan providers are more likely to be independent, rather than being employed directly by the network. Members with PPO coverage can get low rates when they receive health services from preferred providers, but they are generally free to visit outside providers if needed. PPOs can be more flexible than HMOs, though members tend to pay more in monthly premiums.
Private Fee-for-Service (PFFS)
Private Fee-for-Service Plans pay negotiated rates to any health provider that accepts the plan. Under a PFFS plan, members can shop around for the provider they prefer, and providers are free to either accept or decline payment terms from the insurer. This option can come with relatively high monthly premiums, and not all providers accept coverage terms, but it can maximize the flexibility members enjoy when seeking medical care.
Special Needs Plans (SNPs)
Special Needs Plans are designed for members with very specific needs that are typically unusually costly. People with diabetes, physical disabilities or other chronic conditions may opt into an SNP to provide the above-average care they need for a manageable price. SNPs coordinate health services between insurance providers and health practitioners to deliver the most efficient service possible. SNPs operate under a special rule that requires them to provide prescription drug coverage, which the other care options do not have to do. Participation in an SNP is usually limited to people with a qualifying condition, or who meet other criteria such as being dual-eligible for Medicare and Medicaid, for example.
Medicare Cost Plans
Medicare Cost Plans are an alternative to Medicare Advantage that operate like MA plans in many ways. Included within the standard Medicare Part C coverage area, a Medicare cost plan allows beneficiaries to look for care in or outside their designated network without a doctor’s referral. Services that are normally paid for by Original Medicare are generally paid for under a cost plan, although vision and other non-Medicare services may not be provided for. These plans are only available in areas where they are not expected to compete with Medicare Advantage plans. Medicare Cost Plans are available in North Dakota, where they represent over 99% of Part C enrollment.
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.
Seniors in North Dakota can get prescription drug coverage through Medicare in two basic ways. Original Medicare beneficiaries can enroll in any of 23 privately offered Part D plans, while Medicare Advantage plan participants have six options to choose from.
Part C providers who offer a prescription drug benefit have a lot of flexibility in how they structure benefits and what costs they cover. Insurers can choose whether or not to pay for specific drugs, although every provider must cover at least two drugs in each class designated by Medicare. Monthly premiums may be set by the insurer, but Medicare imposes a price cap that Medicare Advantage plans are not allowed to exceed.
Seniors in North Dakota who are enrolled in a Medicare Advantage plan that does not offer prescription drug coverage may be eligible to enroll in a stand-alone Part D plan to fill the gap. In 2018, the least expensive stand-alone Part D plan offered in North Dakota charged $21 a month, although the plan included co-pay requirements and an annual share of cost.
As helpful as Medicare can be for seniors, the complexity of the program’s offerings can make it hard to sign up and get adequate coverage. Many seniors struggle to understand the details of what’s offered, as well as the rules for eligibility and enrollment. To help clarify the options available to seniors in North Dakota, we have listed several state and local resources that can help Medicare beneficiaries find and obtain the care they need.
The North Dakota Insurance Department regulates the private insurance companies that are allowed to offer Part C coverage in the state. Seniors can access online information about each part of Original Medicare, requirements for seniors’ Medicare Advantage plans and an overview of Part D prescription drug coverage. The department also administers the State Health Insurance Counseling (SHIC) program, which provides invaluable advice to seniors about what kind of coverage they are eligible for, how to sign up and how to appeal a denial of claim. Trained counselors working for SHIC are fully independent and not affiliated with any private insurance company to ensure conflict-free advice seniors can rely on.
To learn about Medicare and Medicare Advantage options in the State of North Dakota, visit the North Dakota Insurance Department’s website, where educational articles are available to the public. To speak to a SHIC counselor, call 1-888-575-6611 or submit an email inquiry to [email protected]. The department may also be reached by mail at its main office in Bismarck.Visit Website Email
North Dakota Medicaid is a health insurance program that offers basic coverage for eligible adults with low income and limited assets throughout the state. In addition to the Medicaid program’s ability to supplement Original Medicare, most seniors’ coverage includes a prescription drug benefit that can help close the coverage gap between co-payments and the annual spend down requirements. Medicaid workers can also answer questions for seniors about plan compatibility with various Medicare Advantage and supplemental programs.
To contact the North Dakota Medicaid program, seniors can visit the Medical Services Division online here. Interested applicants, or seniors with general inquiries about health coverage options in North Dakota, can also call the division directly at 1800-755-2604 or 701-328-2321. The Medical Services Division may be reached by mail through the North Dakota Department of Human Services in Bismarck.Visit Website
The North Dakota Department of Veterans Affairs is a statewide agency that helps honorably discharged veterans find and obtain benefits they may be eligible for. Veterans who need help researching or signing up for Medicare Advantage can contact the department for advice and referrals to professional senior care planners. The department also provides information and links to supplemental plans senior veterans can apply to lower their Original Medicare and Medicare Advantage premiums. Veterans with special needs can contact one of the state’s Veterans Service Officers (VSOs) who provide in-person advice and assistance for senior veterans in all areas of North Dakota. In addition to helping eligible veterans in North Dakota obtain federal and state veterans’ benefits, VSOs are also available to receive and process inquiries and applications for health care and case worker assistance.
Contact the North Dakota Department of Veterans Affairs by phone at 1-866-634-8387. Inquiries to the department may be made online, or by email through the online contact form. Mail to the department should be sent to the NDVA’s main office in Fargo. To contact a local VSO, find a local office online via the searchable state map. Inquiries about finding a VSO may also be directed through the state Department of Veterans Affairs main telephone number.Visit Website
The federal Indian Health Services (IHS) office operates 15 hospitals and several smaller clinics in the Great Plains division, which serves over 130,000 Native Americans in the region. Based in Aberdeen, South Dakota, this office works with tribal elders across its service area, including 17 Native American nations in North Dakota. Counselors working with the office, and with individual tribes, help eligible seniors sign up for Medicare and Medicare Advantage plans, locate Part D benefits and other prescription assistance and apply for Medicaid supplemental coverage for gaps in existing health services.
Seniors of all backgrounds may contact the Indian Health Services office for the Northern Great Plains by calling 605-226-7581. The office can also be reached by mail at its Aberdeen location, which is listed on the program’s website. Online inquiries can be made through the office’s contact form.Visit Website
Human Service zones are county-level offices of the North Dakota Department of Human Services that can help seniors and low-income residents learn about and sign up for means-tested programs they may be eligible for. Additionally, workers at each county office are available to help seniors sign up for Medicare, Medicare Advantage, Medicare supplements, Medicaid cost-sharing assistance and Part D Extra Help options to lower their out-of-pocket and prescription drug costs. Most Human Service offices also offer educational materials and personal counseling about benefits seniors may be entitled to receive, and workers can provide seniors with some help planning for long-term care services.
Human Services county office locations and contact information may be viewed in a searchable online map of the state here. The North Dakota Department of Human Services may be reached by calling 1-800-472-2622 or by mail at its Bismarck main office, which is listed on the department’s website.Visit Website