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Medicare in Idaho

Idaho has extensive consumer protections for Medigap, including guaranteed-issue for beneficiaries under age 65, and as of 2022, a "birthday rule" annual plan change window and a community rating requirements

Key takeaways

  • More than 358,000 residents are enrolled in Medicare in Idaho.
  • About 40% of Idaho’s Medicare beneficiaries are enrolled in Medicare Advantage plans.
  • Medicare Advantage plans are available in 34 of Idaho’s 44 counties; availability in those counties ranges from two plans to 46 plan options in 2021.
  • 40 insurers offer Medigap plans in Idaho; the state began requiring Medigap insurers to offer coverage to people under age 65 as of 2018, and limits premiums to 150% of age-65 premiums. As of March 2022, Idaho will also have a “birthday rule” annual window when people with Medigap can switch to a different plan with equal or lesser benefits, and will require all new plans to be community rated, with issue-age rating no longer allowed.
  • There are 22 stand-alone Part D prescription plans available in Idaho for 2022, with premiums that range from about $7 to $112 per month. About 36%8 percent of all beneficiaries of Medicare in Idaho have stand-alone Part D plans.
  • Per-enrollee spending on Medicarein Idaho is among the lowest in the nation.

Medicare enrollment in Idaho

As of August 2021, 358,873 Idaho residents were enrolled in Medicare, amounting to about 19% of the state’s population.

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 (or have ALS or end-stage renal disease; people with these diagnoses do not have to wait two years for their Medicare enrollment to start).

Thirteen percent of beneficiaries of Medicare in Idaho are eligible due to disability rather than age, versus 14% nationwide. On the high and low ends of the spectrum, 21% of Medicare beneficiaries in Alabama, Arkansas, Kentucky, and Mississippi are under 65, while just 8% of Hawaii’s Medicare beneficiaries are eligible due to disability.

Medicare Advantage in Idaho

Medicare beneficiaries can choose to get their healthcare coverage directly from the federal government via Original Medicare, or through private Medicare Advantage plans — assuming Advantage plans are available in their area.

Medicare Advantage plans are offered by private insurers that each have their own service area, so plan availability varies from one part of the state to another. Although most areas of the country do have Medicare Advantage plans available, there are some rural counties in Idaho where Medicare Advantage plans are not for sale in 2021. Residents in 34 of Idaho’s 44 counties can buy Medicare Advantage plans; in the other 10 counties, Original Medicare is the only option. In those 34 counties, Advantage plan availability ranges from just two plans in Benewah County, to 46 plan options in Ada and Canyon counties.

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Despite the lack of Medicare Advantage availability in some of Idaho’s more rural areas, almost third of Idaho Medicare beneficiaries had Medicare Advantage plans as of 2018, which was nearly the same as the nationwide average. As of August 2021, there were 144,825 Idaho residents with private Medicare coverage, which amounted to about 40% of the state’s Medicare population; the other 214,048 beneficiaries had coverage under Original Medicare.

Total Medicare enrollment has been climbing steadily in Idaho, as has been the case nationwide. But Medicare Advantage enrollment has been increasing even more sharply in recent years, resulting in declining enrollment in Original Medicare in Idaho.

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 for deductibles and coinsurance are not capped under Original Medicare).

Original Medicare includes Medicare Parts A (inpatient hospital care) and B (outpatient care). Medicare Advantage plans include all of the benefits of Medicare Parts A and B, and they often provide additional benefits and programs, such as integrated Part D coverage for prescription drugs, dental and vision coverage, a 24-hour nurse hotline, gym memberships, and even assistance with things like transportation and in-home safety.

The Medicare Advantage insurers also work to manage and coordinate members’ care in an effort to keep costs down and reduce hospitalizations. 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, but the monthly premium costs for Medicare Advantage tend to be lower than the monthly premium costs for Medigap plus Part D. 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). 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: State law provides strong consumer protections including guaranteed-issue for beneficiaries under age 65, community rating as of 2022, and a new “birthday rule” enrollment widow

Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental healthcare 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 (deductible and coinsurance) they would otherwise have to pay if they were covered only by Original Medicare.

As of 2019, there were 92,403 Idaho Medicare beneficiaries with Medigap coverage, according to an AHIP analysis. That’s about 43% 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 G, Plan K, etc.) are the same regardless of which insurer sells the plan. There are 40 insurance companies in Idaho that have been approved to offer Medigap plans as of 2021, although some do not actively market their plans (according to the Idaho Department of Insurance, roughly 30 insurers actively offer Medigap plans in the state).

Idaho state law requires Medigap insurers to spend at least 65% of premiums (75% 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).

And as of March 2022, Medigap insurers in Idaho will no longer be allowed to use issue-age rating for new policies, under the terms of legislation that was enacted in 2021.

That law, SB1143, also allows the Idaho Department of Insurance to establish an annual window when people with Medigap coverage can switch to a different Medigap plan on a guaranteed-issue basis. The proposed rulemaking on this was issued in September 2021, and a bulletin was also issued, to provide guidance to insurers while they await the final rules.

Idaho will have a “birthday rule” as of March 2022. According to the Idaho Department of Insurance, this will allow people who already have Medigap coverage to switch to any other Medigap plan — of equal or lesser benefits —during a 63-day window that starts each year on their birthday.

For perspective, unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no federal 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). It’s important to secure coverage during this window; if you submit an application later on, Medigap insurers are allowed to use medical underwriting to determine your eligibility for coverage. And to clarify, the “birthday rule” will not allow a person to newly enroll in Medigap coverage without medical underwriting after their initial enrollment window has ended — it will only allow people who already have Medigap to make a plan change. But that’s an important consumer protection, and one that’s available in very few states.

Medigap in Idaho for beneficiaries under age 65

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 (or if they have ALS or end-stage renal disease), which is the case for 13% 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 2021 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.

As of March 2022, under the terms of SB1143, Idaho will require community rating for all new Medigap enrollees, which means premiums for people 65+ will not vary by age. But the state will still allow Medigap insurers to charge up to 150% of that community rated amount if the beneficiary is under age 65.

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 (again, as of March 2022, this is the rate that applies to any new enrollee who is 65 or older, as issue-age rating will no longer be used for that population, and rates will not vary by age for new enrollees who are 65+).

Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare. 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 $7,550 in 2021, plus the out-of-pocket cost of prescription drugs.

And crucially, there are ten rural counties in Idaho where Medicare Advantage plans are not available for purchase. This makes it particularly important for disabled Medicare beneficiaries in Idaho to have access to guaranteed-issue Medigap plans, as those in counties without Medicare Advantage plans would otherwise have no access to an out-of-pocket cap of any sort, since Original Medicare on its own doesn’t include one.

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.

Idaho Medicare Part D

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 22 stand-alone Medicare Part D plans for sale in Idaho for 2022 (open enrollment runs from October 15 to December 7, 2021), with premiums that range from about $7 to $112/month.

As of August 2021, there were 130,202 Idaho beneficiaries with stand-alone Medicare Part D plans in Idaho, amounting to about 36% of the state’s total Medicare population. Another 133,237 beneficiaries of Medicare in Idaho had Part D prescription coverage as part of their Medicare Advantage plans.

Medicare Part D enrollment is available during the annual open enrollment period each fall, from October 15 to December 7. The plan choice you make during this window will take effect January 1. You can change your mind more than once during the fall enrollment period; the last plan you select will be the one that covers you for the coming year.

Medicare spending in Idaho

Average per-beneficiary spending on Original Medicare in Idaho was 18% lower than the national average in 2019, at $8,578; 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 $10,409.

Per-beneficiary spending for Medicare was highest in Louisiana, at $12,202 and lowest in Hawaii, at just $7,143.

How does Medicaid provide financial assistance to Medicare beneficiaries in Idaho?

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums, prescription drug expenses, and services not covered by Medicare – such as long-term care.

Our guide to financial assistance for Medicare beneficiaries in Idaho includes overviews of these programs, including Extra Help, long-term care coverage, and eligibility guidelines for assistance.

Medicare in Idaho: Resources and assistance for Medicare beneficiaries and their caregivers

Need help filing for Medicare benefits, or with your Medicare enrollment in Idaho? Questions about Medicare eligibility in Idaho? You can contact SHIBA, Idaho’s Senior Health Insurance Benefits Advisers, with questions related to Medicare in Idaho. The SHIBA website provides a variety of helpful information, including a series of Medicare FAQs.

The Medicare Rights Center has a comprehensive national website and a helpful call center that can provide a variety of assistance with Medicare-related questions.

Programs of All-Inclusive Care for the Elderly (PACE): A Medicare/Medicaid program that helps seniors receive the care they need in their homes and local communities, without having to move into a nursing home.

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.

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