Right now, there are potentially costly gaps in coverage associated with Medicare Parts A (hospital services) and B (doctor and outpatient treatment). These gaps may force you to pay for certain medical expenses out of pocket if you aren’t covered by any form of Medicare supplement insurance. Here, we’ll tell you all about one specific kind of supplement: Medicare Part C (Medicare Advantage).

Federal Regulations for Medicare Advantage

Medicare Advantage, a.k.a. “Medicare replacement”, is a type of health insurance policy offered by private companies to help you supplement your Medicare benefits and protect you from coverage gaps. By law, all Advantage plans must offer the same or improved benefits over those of Traditional Medicare. Luckily, though, many of them offer a considerably higher number of coverage options. We will discuss those in greater detail below.

Medicare Advantage Enrollment In North Dakota

Only around 17% of North Dakota seniors are currently signed up for a Medicare Advantage plan. That’s good, but still below the national average. There are a wide variety of Medicare Advantage plans to choose from. As you can see from this chart, some are more popular than others.

Plan Type Enrollment Percentage
HMO Plans 59%
Local PPO Plans 13%
Special Needs Plans 11%
Regional PPO Plans 9%
Private Fee-For-Service Plans 5%
Other (Cost Plans, MSA’s, etc.) 3%

Plan Coverage & Cost

There are a great many number of factors which will determine your final quote for a Medicare Advantage policy. This is why it is nearly impossible to estimate your exact costs without talking to an insurance agent. Below, however, are some sample rates which seniors in your area are more likely to be paying:

Most Popular Medicare Advantage Plans in North Dakota

Medicare’s Overall Star Rating is a system designed to give consumers an unbiased evaluation of companies offering Medicare related services and products. If you are looking for the best plans in Florida, check out the latest report. Medicare evaluates the information and data gathered on each company and then assigns a “star rating” indicating the company’s effectiveness and/or performance. The more stars the better. For Medicare Advantage companies, Medicare rates how well a company uses preventive medicine like lab tests and screenings, how effective their management of chronic conditions is, the experience of plan members, changes in performance levels, complaints, and customer service. If you are looking for a quick review of a plan, check out the Overall Star Rating report.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

Unlike Medicare, Advantage plans are not universally accepted by every doctor and hospital. Some provider networks will only let you see a limited number of doctors or hospitals, and you may be refused service unless you are having a medical emergency. Others are more flexible, and may allow you to receive out-of-network care (for a fee). Keep in mind though that the more choice your network gives you, the more expensive your plan will be.

Where you generally need to get your care and services from for:

  • HMO Plans – If your Medicare Advantage plan is an HMO, it will have a comprehensive network of healthcare resources including doctors, hospitals, labs, surgery centers, therapists, a pharmacy and more. In short, you’ll have everything you need for your healthcare. That’s the reasoning behind limiting your choice of providers to just those in the HMO.
  • PPO Plans – If you opt for a PPO you will have greater latitude in selecting healthcare providers than an HMO. PPOs have networks and it is more cost efficient to use in-network providers, but a PPO will let you use anybody so long as they accept Medicare and the plans terms. If you use out-of-network resources, be prepared to pay higher copays.
  • PFFS Plans – If you have a PFFS plan, the big challenge may be finding providers that will accept your plan. Many doctors won’t. The provider payment schedule is not competitive for all services which means a doctor may accept your coverage for one treatment but decline it for another. Always confirm coverage before accepting services.
  • Special Needs Plans – Special Needs Plans (SNP) are designed to provide focused care for people with chronic diseases. These plans typically limit providers to those in the Medicare SNP Network. These groups are heavily populated with providers who are specialists in a specific disease or condition.

Doctor/Providers List

Finding a doctor who accepts your Medicare Advantage plan:

  • HMO Plans – Finding a doctor that accepts your insurance is not an issue with an HMO. With an HMO, your primary care physician, which you may or may not be able to choose, is your “healthcare dispatcher” responsible for referring you to specialists, labs, hospitals, etc. within the HMO network. Some plans do offer a Point of Service feature that will allow you to use providers outside the network for a premium copay.
  • PPO Plans – Most PPOs have online directories similar to Medicare’s. You’ll find in-network providers by specialty, location, bio, and even patient rating in some directories. If you want to use a provider out-of-network, you can provided they accept Medicare and your insurance terms.
  • PFFS Plans – PFFS plans are perhaps the most difficult when it comes to finding doctors who will accept them. Many PFFS plans are not competitive with other plans when it comes to payment to the providers. The result is a doctor may accept the insurance for one procedure but not for another. In every case, if you have a PFFS always confirm coverage is accepted before receiving services.
  • Special Needs Plans – If you qualify for a SNP, then your healthcare providers have already been selected for you. Your group will be staffed with Medicare SNP Network members who will all accept your plan.

Almost all Medicare Advantage plans have online tools similar to the Medicare’s physician search tool to assist members in finding providers. Generally, those search tools are available to the public, so you can preview your available North Dakota healthcare providers before making a buying decision.

Drug, Vision and Dental Coverage

Original Medicare limits eye care to exams associated with diabetes and adult macular degeneration. Most Medicare Advantage plans offer their members basic eyecare which typically includes an annual eye exam, lenses, and contacts. Benefits may vary from plan to plan. Check your plan’s directory for participating optical shops.

Medicare offers no dental care unless it is in conjunction with an accident or oral disease. Basic dental care is offered by some Medicare Advantage although the benefits vary widely among different programs. At a minimum, benefits usually include an annual dental exam including the cost of x-rays and cleaning. Fillings, dentures, and other non-cosmetic services may be offered. Check the plan for details.

Enrollment Options & Best Time To Enroll

Your IEP, which stand for Initial Enrollment Period, is the best time for you to search for coverage from a Medicare Advantage provider. Should you wait (without qualifying for a Special Enrollment Period) or if you have a serious medical condition, your search will be more difficult. Our Medicare Advantage Enrollment Options page has more information for you. And, if you are struggling with a serious condition, such as End Stage Renal Disease, you can contact your state department of insurance (or a local insurance agent) for tips and strategies to get the coverage you need.

  • Initial Enrollment Period: For best results, try to enroll in a Medicare Advantage plan within your first 6 months of Medicare enrollment.
  • Annual Enrollment Period (AEP): You have the option of changing or cancelling your Medicare Advantage and Part D drug plan between October 15th and December 7th every year.
  • Special Enrollment Period (SEP): If you lose your employer plan coverage, move out of your coverage area, or lose coverage from your provider, you could qualify for an SEP.

What Medicare Advantage Plan Is Best For Me?

To get the best North Dakota Medicare Advantage plan for you, you need to think about what your medical needs will be in the future. Once you have defined those needs, you can research the plans that will best fit those needs. Don’t confine your comparisons of plans to just premium or copay costs. Take into consideration financial stability and the length of time the company has served your area.

Get it right the first time. Unlike other insurance policies, if you want to change plans you may have to wait thanks to special enrollment periods. Do your homework and you’ll find a plan you like and can afford.

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.