Medicare tries its best to give seniors the medical coverage they need in order to enjoy their retirement years in the best possible health. However, there are certain gaps in Medicare Parts A and B which, if you neglect to cover them, can end up costing you thousands. Thankfully, this is the reason that Medicare supplement insurance exists – to protect you from these coverage gaps. Medicare Advantage is one such form of supplement insurance. We’ll discuss the pros and cons of Medicare Advantage in this article.

Federal Regulations for Medicare Advantage

Some people refer to Medicare Advantage as a “Medicare replacement” policy. This is not far from the truth. These policies are sold by private health insurance companies which provide coverage that is equal to or better than Original Medicare. This minimum level of coverage is required by federal law. Once you purchase an Advantage plan, the government will no longer pay out claims on your Medicare-related procedures. That responsibility of your new health insurance company.

Medicare Advantage Enrollment In South Dakota

Of all the seniors in South Dakota which are enrolled in Medicare, only about 33% have replaced those benefits with a Medicare Advantage plan. Of these, take a look at the chart below to discover which Advantage plans 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

Living in South Dakota, as opposed to somewhere like Florida or New York, will have you paying dramatically different rates. There are many other circumstances, such as age, weight, and current health status, which will influence your specific monthly premium.

Most Popular Medicare Advantage Plans in South Dakota

The star rating for a Medicare Advantage plan gives an overall indication of the quality, performance, and variety of the services offered. Many factors influence a star rating. The largest factor tends to be the variety of services covered for the cost. The more services are covered, the more likely the plan is to have a higher star rating. Common inclusions are standard screenings and investigative testing. However, additional coverages also have bearing on a star rating. The benefit of dedicated programs for managing chronic illnesses is a very popular addition. Lastly, member opinions on individual experiences, such as concerns and complaints, or customer service interactions, all have an influence as well. All of these facets combined are simplified into an easy-to-comprehend scale called a “star rating”.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

Your provider network determines where, when, and how you can get the medical care you need. Smaller, less expensive networks (like HMOs) will limit where you can get care, and there are expensive penalties for seeking care outside of the network. Larger networks, like PPOs or PFFS plans, are more expensive but give you more options as far as doctors and hospitals go.

  • HMO Plans – For HMO Plans, you must seek care and services from in-network providers. Exceptions include emergency care and out-of-area urgent care, as well as out-of-area dialysis. Utilizing in-network providers will almost always cost you less, and is mandatory if available.
  • PPO Plans – In the case of PPO Plans, patients can utilize their personal choice of doctor or health care provider without being limited to a fixed network. However, there is a network of options made available for increased savings, should the patient wish to utilize it.
  • PFFS Plans – Regarding PFFS Plans, the user can choose any doctor, hospital, or provider, as long as the provider accepts the plan’s terms. PFFS also offers a network option, which can cost less, but it does not demand the user to only seek in-network care.
  • Special Needs Plans – With reference to Special Needs Plans, these are typically for members with particular conditions or illnesses which necessitate a specialist. These provide a network that the member must move within to cover their special circumstances.

Doctor/Providers List

Finding a doctor who accepts your Medicare Advantage plan:

  • HMO Plans – These plans will provide you with a fixed list of in-network doctors who accept the plan, often accessible online. Then you’ll choose a primary care provider (PCP) for all normal, routine health care. This provider will refer a specialist only as needed. HMO networks include a wide variety of providers, ranging from general care doctors to labs and even pharmacies.
  • PPO Plans – For PPOs, any doctor or service provider is acceptable, but a list of preferred in-network options will be given for extra cost-saving. These plans also include a diverse offering of medical health professionals, including specialists and hospitals, as well as others for additional healthcare. Extensive lists of covered facilities and medical professionals can be found online.
  • PFFS Plans – Any doctor can be utilized in a PFFS plan, as long as the doctor or provider agrees to the terms set forth by the plan. Some of these plans do not include a provider network option, however, in turn, some doctors opt not to accept these plans. At every doctor visit, be certain to double-check that the provider still accepts the particular PFFS plan to ensure prompt treatment.
  • Special Needs Plans – Patients will be given a list of in-network specialists which they must adhere to in order for the plan to provide coverage. Enrollment in these plans is limited to those who have a need for them. Only in-network providers will be covered, and a list of those providers can be found in the plan itself or online.

The thought of searching for a provider can be daunting, but the task doesn’t need to be. Simply go to the Medicare website and enter the patient’s zip code and condition needing treatment, and a list of providers within 15 miles will be generated. Provider groups will have a small green circle and a check mark just below the name. This indicates that the provider accepts Medicare. From there, patients can select multiple providers to compare side-by-side, and make the best choice for themselves. Also, a more detailed list of individual doctors within provider groups can be expanded or collapsed using the ‘Hide’ button. For more information on any doctor or group, just click on their name.

Drug, Vision and Dental Coverage

There is currently no requirement for Medicare Advantage plans to cover vision for all patients. However, an additional coverage to include eye and vision care may be available for an added cost. Many plans offer “Part D”, which can include vision coverage. If the patient elects to accept this coverage, they will be subject to a network of providers which they must utilize.

Similarly to vision, dental coverage is not inherently included in Medicare Advantage plans. Often, it too can be added to a plan via “Part D”. This will incur an additional cost, and include a mandatory network of providers for all routine dental coverage. In some plans, “Part D” can be crafted to include dental as well as vision, and even prescription drugs or hearing care too.

Enrollment Options & Best Time To Enroll

Are you within your IEP, or is your IEP approaching soon? If so, then you’re in luck. Enrolling in Medicare during your IEP virtually guarantees you coverage with little hassle. And when you enroll in a Medicare Advantage plan during the same time frame, it will be much easier to get approved. You are more likely to run into trouble if you enroll after your IEP has expired, if you are outside of your Special Enrollment Period, or if you have a serious medical condition such as ESRD. However, your state department of insurance or your local insurance agent may be able to help you get covered. For more information, you can also take a look at our Medicare Advantage Enrollment Options page.

  • Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
  • Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.

What Medicare Advantage Plan Is Best For Me?

The best plan for you is one that covers the largest amount of your medical needs for the most economically affordable price. Where that price rests is different in every budget in America. It is vital to consider your healthcare needs, and what those needs will be in the future. Enrollment periods keep patients locked into their choices for a year at a time, in most cases, so it is of the utmost importance that when you make your healthcare choices, you are certain that they will benefit you.

What conditions do you need covered? What might you need covered in the future? How much control do you want to have over your provider selection? Are you satisfied with a network of providers, or would you rather have the freedom to choose any specialist you please? Do you have an uncommon condition that you absolutely must have covered? What can you afford? Answering these questions will guide you to the plan best suited for you and your healthcare needs. Take the time to consider each one carefully, that way, when you make your choice, you can rest assured that not only are you covered, you’re covered well and are on track to stay that way.

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for 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.