If you’re eligible 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. Original Medicare won’t cover all of your medical expenses or prescription drugs. It also doesn’t limit your out-of-pocket costs.
One alternative could be a Medicare Advantage (MA) plan, or Medicare Part C. These plans roll Medicare Part A and Part B services into one plan administered by private insurers. Medicare pays them to provide at least the same coverage as Original Medicare except for 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 You Need to Know
Medicare Advantage plans have to cover the same basic protections as Original Medicare.
Most Medicare Advantage plans in Montana provide prescription drug coverage.
You can join a Medicare Advantage plan during one of the enrollment periods each year.
What Types of Medicare Advantage Plans Are Available in Montana?
Many of Montana’s Medicare Advantage plans work with networks of doctors and healthcare facilities to keep the costs of services more affordable. Some plans let you use out-of-network providers, but often at a higher cost. The different types of plans in Montana are:
- Health Maintenance Organization (HMO): With most HMO plans, you must use in-network doctors for your care. If you use out-of-network doctors, you’ll face higher out-of-pocket costs except in emergencies. You’ll have to pick a primary care physician (PCP) and get referrals to see specialists.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 and vary by county, if available at all.3 Dual Eligible SNP (D-SNP) plans are available to Montanans eligible for Medicare and Medicaid services and either over age 65 or age 18 through 64 with a disability.4 Montana doesn’t offer Institutional SNP (I-SNP) plans, for those living in a nursing home or other facility, or Chronic Condition SNP (C-SNP) plans, for those living with medical conditions such as cancer or epilepsy.
- Private Fee-for-Service (PFFS): You won’t need a PCP, and you can visit any Medicare-approved healthcare provider that accepts your plan. Your plan determines how much it will pay for medical services and how much you’ll pay for care.5
- Medicare Medical Savings Account (MSA): MSA plans combine a high-deductible insurance plan with medical savings account that you use to pay for your healthcare costs. These plans cover the same services as MA plans, but not prescription drugs.6
You’ll save money with most MA plans by using in-network providers.
- Medicare Managed Care: Managed care HMO or PPO plans are available in some counties. They cover all Original Medicare benefits, plus some optional benefits. You must use your plan’s network of preferred providers.7
What Are Prescription Drug Options with Medicare Advantage?
With Original Medicare in Montana, you’ll have to buy a separate Medicare Part D plan to get prescription drug coverage. Most Medicare Advantage plans (except for some MSA and 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 Medicare Advantage plan covers prescription drugs, you can lose that plan by buying a Part D plan.
How Do You Choose Medicare Advantage Plans in Montana?
First, check the doctors and hospitals listed on the plans you’re considering. Are yours in-network or out-of-network? Then compare the costs and benefits of different Medicare Advantage plans in Montana, 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 set percentage of the total cost is your share of the cost of a service.
- 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 routine vision exams.
- Dental: Covers teeth cleaning and checkups.
- Telehealth: Covers remote or virtual visits.
- Additional Perks: Many Montana 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 Montana?
- Initial Enrollment Period (IEP): You can sign up for a Medicare Advantage plan when you enroll in Original Medicare during a seven-month window around your 65th birthday.
- Medicare’s Annual Open Enrollment Period, or Annual Election Period (AEP): 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.
- General Enrollment Period: If you miss your IEP, you can enroll during this period (January 1 – March 31), and your coverage begins July 1. Premium penalties for late enrollment may apply.
- Special Enrollment Period (SEP): Under certain circumstances, you can 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.
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. Starting in 2021, you can join an MA plan with end-stage renal disease.
Who Has Signed Up for Medicare Advantage in Montana?
Around 48,000 of Montana’s 260,000 Medicare-eligible seniors have signed up for Medicare Advantage plans. That number has more than doubled since 2008 and represents a penetration rate of about 19%, which is much lower than the national average of 39%.10
How Much Do Medicare Advantage Plans Cost in Montana?
How much Medicare Advantage coverage will cost depends on your plan type and where you live. For example, one ZIP code in Billings offers five plans with monthly premiums ranging from $0 to $60.12 A ZIP code in Helena has eight available plans with premiums between $0 and $131.13 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 Montana 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?
In Montana, staying with Original Medicare is the most common alternative to Medicare Advantage.
Expenses not paid by Original Medicare can be covered with another option to Medicare Advantage. You can buy a Medicare Supplement insurance plan from a private insurer to help control your out-of-pocket costs. You’ll still need a stand-alone prescription drug plan (Medicare Part D).
Montana doesn’t offer a Program of All-Inclusive Care for the Elderly (PACE), or community-based care program, at this time.14
What Medicare Resources Are Available in Montana?
The State Health Insurance Assistance Program (SHIP) offers free, objective information about Medicare through trained counselors. It is administered by the Montana Office on Aging and operated through the Area Agencies on Aging. Call (800) 551-3191 for one-on-one counseling available in most Montana counties.
Specific provisions are available to members of federally recognized tribes and those using Indian Health Services. Reach out to your tribal health department. If you have a disability, contact the Aging and Disability Resource Center.
The Commissioner of Securities and Insurance (Office of the Montana State Auditor) regulates the insurance industry and advocates for Montana residents who have problems with their insurance companies. Call (800) 332-6148 for consumer protection issues.
You might qualify for the state-level Medicare Savings Programs if you have Medicare, have high medical costs, or live on a limited income. These programs help you pay premiums, deductibles, coinsurance and copayments. Contact SHIP for further information.
If a Medicare Advantage plan in Montana is the best Medicare option for you, compare the coverage and costs of the plans in your area. Be sure you know which plan you want once you’re eligible to sign up.