What You Need to Know
Medicare Advantage plans include everything Original Medicare covers.
Unlike Original Medicare, Medicare Advantage caps your annual out-of-pocket healthcare expenses.
South Dakota is one of the limited areas that offers Medicare Cost plans as an option.
If you’re approaching age 65 or are already there, you are eligible for Medicare. Among your options for coverage in South Dakota are Medicare Advantage (MA) plans. Medicare Advantage, also known as Part C, covers everything that Original Medicare does. But in addition to Medicare Part A and Part B, most MA plans offer additional benefits. And unlike Original Medicare, MA plans cap annual out-of-pocket costs.
What Types of Medicare Advantage Plans Are Available?
Health Maintenance Organization (HMO) plans offer lower premiums compared to other plans. You can only go to providers in the network, except for emergencies. And you need a referral from your primary care provider to see a specialist.
Preferred Provider Organization (PPO) plans have more flexibility. You can go to out-of-network providers, but you pay more when you do so. You don’t need a referral to see a specialist.
Special Needs Plans (SNPs) tailor care for individuals with specific needs, including:
- Those with chronic health conditions (C-SNP)
- Those eligible for both Medicare and Medicaid (D-SNP)
Those requiring institutional care in a skilled nursing facility or other types of long-term
- Care (I-SNP)
Private Fee-For-Service (PFFS) plans choose how much the plan will pay healthcare providers and how much you will pay out of pocket. You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will.
Medicare Savings Accounts (MSAs) are high-deductible plans combined with a medical savings account. The plan deposits money into a bank account which you use to pay for Medicare-covered services before you meet your deductible. Once met, your plan pays covered expenses.
Medicare Cost plans are available in limited areas where there are fewer than three private insurance companies offering MA plans. Cost plans allow you to get care outside the provider network. You only pay the out-of-pocket expenses that you would with Original Medicare. Cost plan providers must offer an enrollment period of at least 30 days. The dates for enrollment vary by plan. But all plans allow you to switch back to Original Medicare at any time.
Understand all costs
Even if you have a zero-premium plan, you will still have costs.
What Are Prescription Drug Options with Medicare Advantage?
Your options depend on your plan. All SNPs provide prescription drug coverage. Most Medicare Advantage HMO and PPO plans include prescription drug coverage, known as Medicare Part D.1 But if your HMO or PPO plan doesn’t, you can’t enroll in a separate prescription drug plan. You can enroll in a standalone Medicare Part D plan if you have a PFFS or MSA plan.
How Do You Choose Medicare Advantage Plans?
Cost and coverage are key factors in choosing any health insurance plan. Understanding these terms will help you pick a plan that’s right for you.
Your premium is the amount you pay each month for the plan. In addition to your MA plan premium, you are also responsible for the Part B premium. As you weigh your options, you will see that in South Dakota, you can choose a zero-premium plan. While these plans sound like they’re free, you still pay the Medicare Part B premium. You may also have a higher deductible and other out-of-pocket costs with a zero-premium plan.
In addition to your premium, you will also pay a portion of the cost when you get care:
The deductible is the amount you must spend before your plan starts to contribute toward your healthcare expenses.
- Coinsurance is a percentage of the cost for services you pay once you meet your deductible.
- Copayments are fixed amounts you pay for office visits and/or prescription drugs.
- Out-of-pocket maximum is the highest amount you’re required to pay during the plan year.
Medicare Advantage plans often provide benefits that Original Medicare does not. These may include coverage for vision, dental, hearing, transportation, and telehealth services. Some even include access to gyms or fitness programs.
Most Medicare Advantage plans include benefits that Original Medicare doesn’t offer, such as hearing and vision coverage.
When and How to Enroll in Medicare Advantage
You must enroll in Medicare Part A and B before you can enroll in an MA plan. For all other MA plans, you must choose the appropriate enrollment period.
Initial Enrollment Period: The seven-month period beginning three months before, the month of, and the three months after your 65th birthday.
Open Enrollment Period (Annual Election Period): October 15 through December 7 annually. You can change MA plans, switch between MA and Original Medicare plans, and enroll in a Part D plan.
General Enrollment Period: January 1 through March 31 annually with coverage beginning July 1.
Medicare Advantage Open Enrollment Period: If you enrolled in Medicare during the General Enrollment Period, you may enroll in an MA plan from April through June with coverage beginning July 1.
Special Enrollment Period: Under certain circumstances, you may be able to enroll outside the scheduled periods without incurring a penalty:
- Change of service area – includes moving out of the provider network.
- Loss of coverage – such as losing coverage under Medicaid or an employer’s plan.
- Gain coverage – such as qualifying for group coverage under an employer or union plan.
- Plan changes – if your plan’s contract is terminated by Medicare.
- Special circumstances – such as development of a chronic condition which qualifies you for a C-SNP.
What’s the Medicare Advantage Enrollment in South Dakota?
There are approximately 41,000 people enrolled in MA plans in South Dakota. That represents about 20% of all Medicare-eligible individuals in the state.
How Much Do Medicare Advantage Plans Cost in South Dakota?
How Do You Change Your Medicare Advantage Plan?
If you’re already enrolled, you can make a change during Open Enrollment or General Enrollment periods. You can switch to a different MA plan or drop your MA plan and join Original Medicare.
What Are Alternatives to Medicare Advantage?
Original Medicare is the other alternative to Medicare Advantage plans in South Dakota.4 Most people who choose Original Medicare also enroll in a Medicare Part D plan to pay for prescriptions. If you’re considering this route, you may also want to purchase a Medigap policy from private insurers to pay for expenses that Part A and Part B doesn’t cover.
What Are Medicare Resources in South Dakota?
Medicare Savings Program – provides information regarding assistance available to pay for Medicare plans in South Dakota.
Senior Health Insurance Information & Education (SHIINE) – provides free information and assistance to help you choose Medicare coverage.
Now that you know more about Medicare insurance and specifically, Medicare Advantage Plans for South Dakota residents, speak to a licensed professional to learn about your options. You can use the Medicare Plan Finder to learn more about plan availability where you live.