What You Need to Know
Medicare Advantage plans have to cover the same basic protections as Original Medicare.
Most Medicare Advantage plans in Iowa provide prescription drug coverage.
You can join a Medicare Advantage plan during one of the enrollment periods each year.
If you qualify for Original Medicare, or Medicare Part A (hospital care) and Medicare Part B (outpatient care), you may be wondering if the federal program offers enough coverage in Iowa. Original Medicare won’t cover all of your medical expenses. It also doesn’t cover prescription drugs or limit your out-of-pocket costs.
One alternative might be a Medicare Advantage (MA) plan or Medicare Part C. These plans are provided by private insurers and offer at least the same coverage as Original Medicare except hospice care, which stays covered under Medicare Part A. Most MA plans include Medicare prescription drug coverage and a limit on your out-of-pocket expenses.
What Types of Medicare Advantage Plans Are Available in Iowa?
Many of Iowa’s Medicare Advantage plans work with networks of doctors and healthcare facilities to keep the costs of services more affordable. The most common types of plans are:
- Health Maintenance Organization (HMO): With most HMO plans, you must use in-network doctors for your care. If your plan lets you use out-of-network doctors, it’s called an HMO with Point of Service (POS). You’ll have to pick a primary care physician (PCP) and get referrals to see specialists. Except in emergencies, you’ll face higher out-of-pocket costs if you go to an out-of-network doctor.1
- Preferred Provider Organization (PPO): With a PPO plan, you won’t have to choose a PCP, get referrals for specialists or be limited to in-network doctors. However, you’ll likely pay more if you go to an out-of-network doctor.2
- Special Needs Plans (SNP): SNP plans are for people with specialized health needs. Like other Medicare Advantage plans, SNPs are available through Medicare-approved private insurance companies.3 Iowa does not offer a Chronic Condition SNP (C-SNP). The two types of SNPs in Iowa are:4
- Dual Eligible SNP (D-SNP): These plans are available if you’re eligible for Medicare and Medicaid services.
- Institutional SNP (I-SNP): You qualify if you live in a nursing home or other institution or if you need in-home nursing care.
- Private Fee-for-Service (PFFS): You won’t need a PCP, and you can visit any Medicare-approved healthcare provider who accepts your plan. Your plan determines how much it will pay for medical services and how much you’ll pay for care.5
- Medicare Cost Plans: In-network providers bill the plan for services with no excess charges. You don’t need a PCP or referrals for specialists, but the plan has to refer you to any out-of-network providers, in which case Medicare pays.6
There are no Medicare Medical Savings Account (MSA) plans available in Iowa at this time.
You’ll save money with most MA plans by using in-network providers.
What Are Prescription Drug Options with Medicare Advantage?
With Original Medicare, you’ll have to buy a separate Medicare Part D plan to get prescription drug coverage in Iowa. Most Medicare Advantage plans (except Medicare Cost plans and some PFFS plans) include prescription drug coverage.
When selecting a Medicare Advantage plan, be sure your prescriptions are included on the plan’s list of covered drugs, known as the drug formulary. If your MA plan provides prescription drug coverage, you could lose that plan by buying a Part D plan.
How Do You Choose Medicare Advantage Plans in Iowa?
First, check if your doctors and hospitals are listed in the plans you’re considering and whether they’re in-network or out-of-network. Then compare the costs and benefits of different Medicare Advantage plans in Iowa, including:
- Premiums: Your monthly cost for health insurance in addition to the Medicare Part B premium ($148.50 for most people in 2021). Zero-premium plans might be an option, but other costs under those plans (like deductibles and coinsurance) could cost more.
- Other Costs:
- Deductible: Your out-of-pocket costs for healthcare services before your plan starts paying each year.
- Coinsurance: This is your share of the cost of a service, usually a set percentage of the total cost.
- Copayment: The fixed price you pay for a specific service.
- Out-of-pocket maximum: The total amount of out-of-pocket expenses you pay each year, except for premiums.
- Plan Benefits:
- Vision: Covers frames and eye exams.
- Dental: Covers teeth cleaning and checkups.
- Telehealth: Covers remote or virtual visits.
- Additional Perks: Many Iowa Medicare Advantage plans cover part or all of your gym memberships or fitness classes.
Vision and Dental
Most Medicare Advantage plans also offer vision and dental coverage.
When and How Do You Enroll in a Medicare Advantage Plan in Iowa?
- Initial Enrollment Period (IEP): You can sign up for a Medicare Advantage plan when you enroll in Original Medicare during the seven months around your 65th birthday.
- Annual Election Period (AEP), or Medicare Open Enrollment Period: You can join, switch or disenroll from a Medicare Advantage plan from October 15 to December 7 each year. New coverage is effective January 1 of the following year.
- Medicare Advantage Open Enrollment Period (OEP): If you have Medicare Part C on January 1, you can change your Medicare Advantage plan or switch back to Original Medicare from January 1 to March 31 each year. After March 31, you can’t disenroll from an MA plan until October 15 unless you qualify for a Special Enrollment Period.8
- Special Enrollment Period (SEP): Under certain circumstances, you might get 60 days to disenroll, join or switch to a different plan outside of regular enrollment periods.9 Reasons include:
- You moved from the plan’s service area.
- You get your healthcare coverage from an employer or union health plan.
- You’re losing your coverage, whether from a job or Medicaid.
- Your plan is being discontinued or is leaving the Medicare program.
- You need an SNP after developing a health condition.
- 5-Star Special Enrollment: Between December 8, 2020, and November 30, 2021, you can enroll in a 5-star Medicare Advantage or Medicare Cost plan once or change from one 5-star plan to another.10
After signing up, you can replace Original Medicare with a Medicare Advantage plan. To qualify, you have to live within the plan’s service area and must be a legal resident of the U.S. for five years or more.
Who Has Signed Up for Medicare Advantage in Iowa?
Nearly 160,000 of Iowa’s 690,000 Medicare-eligible seniors have signed up for Medicare Advantage plans. That is a penetration rate of about 23%, much lower than the national average of 39%.11 Among Iowa residents, the number continues to rise gradually every year.
How Much Do Medicare Advantage Plans Cost in Iowa?
How much Medicare Advantage coverage will cost depends on your plan type and where you live. For example, one ZIP code in Des Moines offers 20 plans with monthly premiums ranging from $0 to $147.13 A ZIP code in Cedar Rapids has 15 available plans with the same price range.14 Be sure to consider costs like deductibles and copays as well when comparing different plans.
What If You Want to Change Your Medicare Advantage Plan?
You can change your Medicare Advantage plan in Iowa during any open enrollment period each year. Just sign up for a new plan. When your new plan starts, your old plan will be canceled automatically.
What Are the Alternatives to Medicare Advantage?
The most common alternative to Medicare Advantage in Iowa is to stay with Original Medicare.
You can cover expenses not paid by Original Medicare by buying a Medicare Supplement insurance plan (or “Medigap”) from a private insurer. You’ll still need a stand-alone prescription drug plan (Medicare Part D).
PACE, the Department of Human Services’ Program of All-Inclusive Care for the Elderly, offers a combination of medical care, long-term care and prescription drugs to help you stay in your community instead of entering a nursing home or other facility. A comprehensive team of healthcare professionals provides care.
What Medicare Resources Are Available in Iowa?
Iowa’s Senior Health Insurance Information Program (SHIIP) offers trained, certified volunteer counselors to help Iowa residents make the best Medicare choices at no cost. Apply online or call (800) 351-4664.
If you have Medicare, you might qualify for the Medicare Savings Programs. These programs help people living on limited resources pay Medicare Part A and B premiums, deductibles, coinsurance and copayments. You have to be eligible for Medicare Part A and meet income and resource requirements.15 Call (800) 351-4664 or email SHIIP.
If a Medicare Advantage plan in Iowa is the best option for you, compare the costs and coverage of the plans in your area. Be sure you know which plan you want once you’re eligible to sign up.