Original Medicare, also called Medicare A and B, is a federal program that provides standardized care to all recipients. By contrast, Medicare Advantage, or Part C, includes a range of private insurance plans with their own costs and levels of coverage. These plans include the same services covered by Parts A and B, but may provide types of coverage that Original Medicare doesn’t, including prescription drugs, vision and hearing care.
Medicare Advantage enrollment has grown steadily since its introduction, to the point where 39% of all Medicare beneficiaries nationally have chosen a Medicare Advantage plan. That growth is unevenly spread between states. In South Dakota, 22% of Medicare beneficiaries have chosen the Medicare Advantage alternative. This puts the state in a middling range of Medicare C adoption compared with neighboring states. Nearby Minnesota has one of the nation’s highest rates of Medicare Advantage enrollment at 48%. Meanwhile, North Dakota (19%), Iowa (24%), Nebraska (19%) and Montana (20%) are all closely comparable with South Dakota. Wyoming, on the other hand, has one of the lowest rates of Medicare Advantage enrollment at only 3%.
Plan availability can vary by location, as it’s determined by the contracts that various private insurance companies have with Medicare. Seniors in South Dakota can access four types of Medicare Advantage plans: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-For-Service (PFFS) and Special Needs Plans (SNP). This guide explains these plan types, prescription drug coverage for South Dakota’s Medicare Advantage enrollees, and how enrollment works. It also includes statewide and local Medicare resources for South Dakotans seeking guidance about how to pick the plan that’s best for them.
Medicare Advantage provides a choice among several different plan types, and the number of plan types offered in each state may differ. South Dakota seniors can choose from four types: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs) and Private Fee-For-Service (PFFS) plans.
Health Maintenance Organizations (HMOs)
HMO plans tend to offer lower premiums than other Medicare Advantage plan options, although these managed-care plans also tend to be more restrictive in how their beneficiaries can access care. Plan participants need to use doctors, clinics and hospitals specifically within the HMO’s provider network in order to have any portion of their care covered. That can mean paying the entire cost of care if one chooses to use an out-of-network provider. Participants are typically required to select an in-network primary care doctor whose referrals are needed to access specialist care.
Preferred Provider Organizations (PPOs)
Managed-care PPO plans are similar to HMOs in that getting the most cost-effective services requires participants to access their care through a specified provider network. Unlike HMO plans, however, this kind of Medicare Advantage plan is more flexible about accessing out-of-network providers and still offers some coverage for those who choose this option. Members of a PPO plan can also generally access specialist care without a referral from their primary care physician. The trade-off for this improved flexibility tends to come in the form of higher premiums.
Special Needs Plans (SNPs)
Special Needs Plans, or SNPs, are typically designed to serve the needs of specific groups of beneficiaries, and only individuals who meet the guidelines for a particular SNP may enroll. There are three types of SNPs in South Dakota: plans for institutionalized beneficiaries (such as those receiving nursing home care), plans for seniors who have certain kinds of chronic illness and plans for those who are dually eligible for Medicare and Medicaid. SNPs provide care in coordination with medical providers to best serve the needs of each of these types of enrollees, and unlike HMO or PPO plans, they’re required to provide prescription drug coverage.
Private Fee-for-Service (PFFS) Plans
As with Original Medicare, and unlike HMO or PPO plans, PFFS plans don’t require members to seek care within a specific provider network. Beneficiaries can use any provider who agrees to offer care in compliance with their PFFS plan’s terms of service, and each provider must contract separately with the plan. Premiums and co-pays vary widely between plans, and Medicaid-eligible seniors may be able to get additional assistance in covering these costs. Some plans may offer hearing, vision, dental and other benefits, but not all do, so they require specific research to ensure a particular plan is affordable and practical in the long-term.
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.
Beneficiaries of Original Medicare have to enroll separately in a Medicare D plan to get prescription drug coverage. A possible alternative to this is a Medicare Advantage prescription drug plan, or MA-PD. These are available in South Dakota and bring together all of a participant’s Medicare Part A, B and D coverage under a single plan. The specific drugs covered under an MA-PD may vary, so it’s important to check before enrolling in such a plan that it covers all required current medications. Available plans and premiums may vary between counties in South Dakota, and joining an MA-PD may involve paying separate monthly premiums for a Medicare Advantage plan and prescription drug coverage, although the premiums for the latter can go as low as $0. Enrollees in an MA-PD in South Dakota aren’t allowed to join standard Part D prescription drug plans.
Coverage through Medicare is an invaluable resource for seniors, yet navigating all the possible types of coverage and finding the right plan can be complicated for those who wish to enroll. To make it easier for seniors, and those who may help them find coverage, we’ve listed some state and local resources below that can help South Dakotans with this process.
SHIINE is a federally funded, state-run program whose mission is to provide confidential, free and unbiased information to Medicare beneficiaries. The program provides access to hundreds of committed volunteer counselors across South Dakota, drawn from the ranks of retirees and working professionals from Medicare-related fields (including nursing home staff, pharmacists and social workers). These counselors work one-on-one with individuals to educate them about Medicare, showing them how to find and protect the benefits they’re entitled to, how to avoid fraud and safeguard their personal information.
Contact SHIINE through any of its Regional Coordinators to find out more about the program and how to make an appointment with a volunteer counselor. The Eastern South Dakota office can be reached toll free at 1-800-536-8197, the Central South Dakota office at 1-877-331-4834 and the Western South Dakota office at 1-877-286-9072. Further contact information can be found on the program’s website, as well as links to other resources.Visit Website
South Dakota’s Department of Social Services (DSS) offers an array of social service resources that includes providing information and enrollment for Medicaid, information on Medicare prescription drug coverage and links to plan-finding portals and further avenues of support. The department’s website is an excellent starting point for finding information about a wide range of health care needs, including information about Medicare savings programs.
The South Dakota Department of Veterans Affairs provides a wide range of support for veterans and their families, touching on everything from health care to disability benefits and long-term care. Each county in the state provides a dedicated Veterans Service Officer to offer guidance and counseling for veterans, helping them to navigate issues like medical benefits, including programs such as Medicare and Medicare Advantage.
Dakota at Home, operating under the oversight of the South Dakota Department of Human Services, is the state’s Aging and Disability Resource Center (ADRC). The agency provides information and referrals to resources and services that are available to South Dakota seniors in the local area where they live. Dakota at Home also provides options counseling and information about services and assistance available through Medicare.
Seniors can access information by clicking on their county on Dakota at Home’s interactive map and scrolling down a list of providers and organizations available to assist seniors in that locale. Seniors who prefer to talk to someone on the phone in their local area can call Dakota at Home toll free at 1-833-663-9673.Visit Website