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Medicare in Idaho

As of 2018, Idaho began requiring Medigap insurers to offer coverage to people under age 65, and premiums are limited to 150% of age-65 premiums

At a glance: Medicare health insurance in Idaho

Medicare enrollment in Idaho

2020 Medicare enrollment datesAs of December 2018, 323,505 Idaho residents had Medicare coverage. That’s about 18 percent of the state’s population, which is fairly consistent with the percentage of the total US population enrolled in Medicare.

For most Americans, Medicare eligibility starts when they turn 65. But Medicare also provides coverage for younger Americans after they have been receiving disability benefits for 24 months. Fifteen percent of Medicare beneficiaries in Idaho are eligible due to disability rather than age, versus 16 percent nationwide. On the high and low ends of the spectrum, 23 percent of Medicare beneficiaries in Alabama, Kentucky, and Mississippi are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.

Read about Medicare’s open enrollment period and other important enrollment deadlines.

Medicare Advantage in Idaho

Medicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. Medicare Advantage plans are offered by private insurers, so plan availability varies from one area to another. Although most areas of the country do have Medicare Advantage plans available in 2019, there are some counties in Idaho where Medicare Advantage plans are not for sale. Residents in 32 of Idaho’s 44 counties can buy Medicare Advantage plans; in the other 12 counties, Original Medicare is the only option. In those 32 counties, Advantage plan availability ranges from just one plan in Franklin County, to 31 plans in Ada and Canyon counties.

Despite the lack of Medicare Advantage availability in some of Idaho’s more rural areas, a third of Idaho Medicare beneficiaries had Advantage plans as of 2017, which was the same as the nationwide average. As of December 2018, there were 104,874 Idaho residents with private Medicare coverage, which amounted to 32 percent of the state’s Medicare population; the other 218,631 beneficiaries had coverage under Original Medicare.

The popularity of Medicare Advantage varies from one state to another. In Minnesota, 56 percent of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Advantage plans (and those are via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).

Original Medicare coverage is provided directly by the federal government, and enrollees have access to a nationwide network of providers. But people with Original Medicare need supplemental coverage (from an employer-sponsored plan, Medicaid, or privately purchased plans) for things like prescription drugs and out-of-pocket costs (out-of-pocket costs are not capped under Original Medicare).

Original Medicare includes Medicare Parts A and B. Medicare Advantage includes all of the benefits of Medicare Parts A and B, and the plans often include additional benefits, such as integrated Part D prescription drug coverage and coverage for things like dental and vision care. But Medicare Advantage insurers establish their own provider networks, which are generally localized and more limited than the nationwide network for Original Medicare. Out-of-pocket costs for Medicare Advantage are often higher than they would be if a beneficiary had Original Medicare plus a Medigap plan. There are pros and cons to either option, and the right solution is different for each person.

Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan). Starting in 2019, people who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.

Medigap in Idaho

Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had only Original Medicare.

As of 2016, there were 74,090 Idaho Medicare beneficiaries with Medigap coverage, according to an AHIP analysis. That’s about a third of the state’s Original Medicare enrollees (Medigap coverage cannot be used with Medicare Advantage plans).

Although Medigap plans are sold by private insurers, the plans are standardized under federal rules, with ten different plan designs (differentiated by letters, A through N). The benefits offered by a particular plan (Plan A, Plan F, etc.) are the same regardless of which insurer sells the plan. There are 40 insurers in Idaho that offer Medigap plans as of 2019.

Idaho state law requires Medigap insurers to spend at least 65 percent of premiums (75 percent for group plans) on benefits for enrollees, as opposed to administrative costs. And for all Medigap plans sold since 1995, state law (see page 35) also prohibits insurers from using attained-age rating, which means that premiums cannot increase simply due to the enrollee’s increasing age. Attained-age rating is the most common approach that Medigap insurers use in most states, but it’s not allowed in Idaho. Instead, insurers must use either issue-age rating (premiums based on the age the person was when they enrolled) or community rating (premiums don’t vary based on age).

Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue. This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a Medigap plan).

People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, which is the case for 15 percent of Idaho’s Medicare beneficiaries. Federal rules do not guarantee access to Medigap plans for people who are under 65, but the majority of the states have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Idaho joined those states in 2018, with changes to Idaho insurance statute that took effect January 1, 2018.

Idaho Medigap insurers are now required to offer their plans to disabled Medicare beneficiaries under age 65, with the same six-month open enrollment period that applies to people who gain eligibility for Medicare due to age (ie, there’s a six-month window when the person is first enrolled in Medicare Part B, during which they can enroll in any Medigap plan, guaranteed issue, regardless of age). Idaho’s new rule included a provision to grant a one-time six-month Medigap open enrollment window (January through June 2018) to people who were under age 65 and already enrolled in Medicare at that point.

In addition, the new rule limits the premiums for under-65 Medigap to no more than 150 percent of the premiums that apply to a person who is 65 years old (see 2019 premiums for a non-smoker under age 65, and for a non-smoker who is age 65). This is an important provision — some states that require Medigap plans to be offered to people under age 65 do not limit premiums and insurers end up charging several times as much as they charge 65-year-old enrollees.

Disabled Medicare beneficiaries have another Medigap open enrollment period when they turn 65. At that point, they can switch to a plan with the lower premiums that apply to people who are aging into Medicare, rather than qualifying due to disability. The new rule notes that for younger Medigap enrollees, their premium has to be reduced once they turn 65 to the rate that applies to people who are enrolling at age 65.

Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure. Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But as noted above, Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care, plus the out-of-pocket cost of prescription drugs.

Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those rules don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months if you didn’t have at least six months of continuous coverage prior to your enrollment (although many of them choose not to do so). And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the Medigap insurer can consider your medical history in determining whether to accept your application, and at what premium.

Medicare Part D in Idaho

Original Medicare does not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.

But Medicare beneficiaries who do not have drug coverage through Medicaid or an employer-sponsored plan need Medicare Part D in order to have coverage for prescriptions. Part D can be purchased as a stand-alone plan, or obtained as part of a Medicare Advantage plan that has integrated Part D coverage. Part D was created under the Medicare Modernization Act of 2003, which was signed into law by President George W. Bush.

There are 26 stand-alone Part D plans for sale in Idaho in 2019, with premiums that range from about $16 to $110/month.

As of December 2018, there were 129,555 Idaho Medicare beneficiaries with stand-alone Part D coverage, amounting to about 40 percent of the state’s total Medicare population. Another 95,093 Idaho Medicare beneficiaries had Part D prescription coverage as part of their Medicare Advantage plans.

Medicare spending in Idaho

Original Medicare’s average per-beneficiary spending in Idaho was 16 percent lower than the national average in 2016, at $8,014; only eight states had lower average per-beneficiary Original Medicare spending. The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage. Nationwide, average per-beneficiary Original Medicare spending stood at $9,533.

Per-beneficiary Medicare spending was highest in Louisiana, at $11,399, and lowest in Hawaii, at just $6,441.

You can read more about Medicare in Idaho in our state Medicare guide. You can also contact SHIBA, Idaho’s Senior Health Insurance Benefits Advisers, with questions related to Medicare coverage in Idaho.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.