MAPD
Medicare Advantage Prescription Drug Plans
Medicare Advantage prescription Drug Plans (MAPDs) have many options. It can be difficult and time-consuming to filter through all of your choices. By reviewing the information we’ve provided here, you’ll have the necessary knowledge to get started.
The most important thing to understand is that when you enroll in an MAPD plan, you must follow the rules of the insurance carrier. Your prescription claims (and any other medical claims) will no longer be processed by the federal government, but by the private insurance company that provided the plan.
When you enroll in a Medicare Advantage Prescription Drug plan, your benefits through Original Medicare – Parts A and B – are replaced by the MAPD plan. You are still required to pay your Medicare Part B premium and there may also be a monthly premium for the MAPD plan. That premium will vary based on the insurance carrier and the benefits of the plan.
How do MAPD plans work?
As we’ve mentioned, Medicare Advantage Prescription Drug plans are offered by private insurance companies. These companies have been approved by the Medicare program to offer the plans. To be approved, they must provide the same benefits as Medicare Parts A and B and the most basic prescription drug coverage. Most MAPD plans offer more than that.
Medicare Advantage plans have specific networks of providers and facilities that are contracted with the insurance carrier that is offering the plan. Claims are submitted directly to the insurance carrier, not the federal government.
Medicare Advantage Prescription Drug plans often have rates that are lower than their counterparts, Medicare supplements, because MAPD plan members agree to pay a higher cost share of the expenses.
Provider Networks for MAPD Plans
MAPD plans are usually associated with a network. There are three types of network that an MAPD can belong to.
When a patient enrolls in a Medicare Advantage Prescription Drug (MAPD) plan, they must decide which plan type they desire and they can choose between a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Special Needs Plans (SNP), and Private Fee-For-Service (PFFS).
HEALTH MAINTENANCE ORGANIZATION (HMO)
A Medicare Advantage HMO plan provides a network of health care providers and practices that patients can visit. This type of Medicare Advantage plan requires its patients to have a primary care provider that coordinates their care. It is also necessary for patients to request referrals if they want or need to see an out-of-network specialist. HMO plans usually have lower monthly premiums in comparison to other plan types which gives these plans a certain advantage.
PREFERRED PROVIDER ORGANIZATION (PPO)
MAPD Preffered Provider Organization plans also have a network of doctors who have agreed to accept a negotiated rate. When a member uses an in-network provider they will have the maximum amount of coverage. There is still coverage outside of the network, but it will be at a reduced rate and the member will have higher out-of-pocket expenses. Generally speaking, PPO networks are larger than HMO networks.
SPECIAL NEEDS PLANS (SNPS)
Special Needs Plans are different from other plans mentioned here because they limit membership to serve only specific groups of people with certain conditions. What are considered to be qualifying membership factors and qualified individuals for an SNP are those living in certain institutions such as nursing homes, and those eligible for Medicare and Medicaid Services. Individuals who are also considered to be eligible for this plan are the ones who have chronic disabling conditions such as diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia.
Additionally, like an HMO plan, SNPs require their patients to have a primary care doctor or care coordinator, and it’s common for patients to require referrals for certain specialists.
PRIVATE FEE-FOR-SERVICE (PFFS)
On one hand, PFFS Medicare Advantage plans provide patients with a network of providers and practices they can visit. On the other hand, unlike an HMO plan, a PPO plan does not require a primary care provider. It is because of this that patients have more flexibility when it comes to receiving their health care services as they themselves decide who they will see when they see them, and why.
Comparing Medicare Advantage Plans to Medicare Advantage Prescription Drug Plans
Unless a Medicare Advantage plan lists “Prescription” in the name, it does not include prescription drug coverage. If you enroll in a Medicare Advantage plan without prescription drug coverage, you’ll need to also enroll in a stand-alone Part D plan.
MAPD Costs
When it comes to MAPD plans, healthcare costs may vary depending on the individual’s insurance provider, network, and coverage options. However, costs usually break down into premiums, deductibles, copayments, and coinsurance. It is necessary to pay the Part B premium which amounts to $164.90 in 2023.
Medicare Advantage Prescription Drug Plan Benefits
We’ve already discussed the fact that MAPD plans include a prescription drug benefit. There are a few other benefits to these plans.
Many MAPD plans include coverage for dental, vision, and hearing services. This may include coverage for dental exams and cleanings, as well as restorative treatment. It may also cover an annual eye exam and some payment towards prescription eyeglasses or contact lenses. The same goes for hearing exams and hearing aids.
In addition to prescriptions, some MAPD plans have an allowance for over-the-counter medications, including vitamins and allergy medications. They may also include transportation to and from doctor’s offices, meal delivery, and gym memberships. (The most common fitness benefit is the Silver Sneakers program.)
Medicare Advantage Prescription Drug Plan Limitations and Disadvantages
We’ve mentioned that every Medicare Advantage plan must include the same benefits as those found in Original Medicare. This will include coverage for cancer treatment and dementia. However, Medicare Advantage plans do not have hospice benefits.
MAPD plans always have a deductible, as well as copayment and coinsurance expenses. There will be a separate deductible for the prescription drug portion. These plans also have a high out-of-pocket maximum, so if a beneficiary is very sick, they may pay somewhere in the ballpark of $5000 per year before their coverage is paid for at 100%.
Scheduling Prescription Drugs for Medicare Advantage
Medicare Advantage Prescription Drug Plans (MAPDs) deliver various options. Filtering among all of your options might be time-consuming and challenging. Reviewing the material offered here will equip you with the knowledge needed to begin going.
The most crucial thing to grasp is that you have to abide by the insurance carrier’s policies when registered in a MAPD plan. The federal government will now handle your prescription claims and any other medical claims through the private insurance company that supplied the plan.
Your benefits from Original Medicare – Parts A and B – are replaced when you sign up for a Medicare Advantage Prescription Drug plan by the MAPD plan. Your Medicare Part B premium still needs to be paid; the MAPD plan may also have a monthly premium. The insurance carrier and the features of the plan will determine that premium.
How effective are MAPD plans?
Private insurance firms, as noted, provide Medicare Advantage Prescription Drug programs. The Medicare program has allowed these companies to provide insurance. They have to offer the same advantages as Medicare Parts A and B and the most minimal prescription drug coverage permitted. Most MAPD plans go beyond that.
Specific networks of doctors and facilities negotiated with the insurance insurer providing the Medicare Advantage plan define the plans. Claims are filed not through the federal government but to the insurance company.
Because MAPD plan members choose to pay a larger cost share of the charges, Medicare Advantage Prescription Drug plans sometimes have cheaper rates than Medicare supplement equivalents.
Maps of Provider Networks for MAPD Plans
Usually, MAPD plans are linked with a network. A MAPD can belong to three different kinds of networks.
A patient enrolling in a Medicare Advantage Prescription Drug (MAPD) plan must decide which plan type they want and may select from a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Special Needs Plans (SNP), and Private Fee-For-Service.
Organizational Health Maintenance (HMO)
A Medicare Advantage HMO plan offers patients a network of practices and healthcare providers they may visit. Patients under this Medicare Advantage plan must have a primary care physician organizing their treatment. Patients should also ask for referrals should they wish or need to see an out-of-network specialist. HMO plans offer a certain advantage as their monthly rates are often lower than others.
Preferential Provider Organization (PPO)
MAPD wanted Plans for provider organizations to feature a network of physicians who have agreed to negotiate a fee. Members utilizing an in-network provider will have maximum coverage. Although coverage outside the network is still available, it will be lessened, and the subscriber will pay more out-of-pocket. PPO networks are often bigger than HMO networks, generally speaking.
SPECIAL NEEDS PLANS
Special Needs Plans differ from others mentioned here because they limit membership to serve only specific groups of people with certain conditions. What are considered to be qualifying membership factors and qualified individuals for an SNP are those living in certain institutions such as nursing homes and those eligible for Medicare and Medicaid Services. Individuals who are also considered to be eligible for this plan are the ones who have chronic disabling conditions such as diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia.
Additionally, like an HMO plan, SNPs require their patients to have a primary care doctor or care coordinator, and it’s common for patients to require referrals for certain specialists.
Personal Fee-for-Service (PFFS)
PFFS Medicare Advantage programs give consumers a network of practices and doctors they can attend, on the one hand. Conversely, unlike an HMO plan, a PPO plan does not call for a primary care physician. Patients have more freedom to choose who they will visit when they see them and the reason behind their choice about their health care services.
Evaluating Medicare Advantage Plans Against Medicare Advantage Prescription Drug Plans
Unless named Prescription, Medicare Advantage plans do not cover prescription drugs. You must also enroll in a stand-alone Part D plan if you join a Medicare Advantage plan without prescription drug coverage.
MAPD Expenses
Regarding MAPD plans, the particular insurance provider, network, and coverage choices will affect the healthcare expenditures. Usually, however, expenses consist of premiums, deductibles, copayments, and coinsurance. Paying the Part B premium—$164.90 in 2023—is needed.
Medicare Advantage Prescription Drug Plan Awards
As we have already covered, MAPD plans incorporate a prescription drug benefit. These strategies offer some other advantages as well.
Many MAPD plans cover dental, optical, and hearing aids. Coverage for dental checkups, cleanings, and treatments falls here. It might also cover some payment for contact lenses, prescription eyeglasses, and annual eye checkups. This applies also to hearing tests and hearing aids.
Apart from prescriptions, some MAPD programs allow over-the-counter drugs, including vitamins and allergy treatments. They include gym memberships, meal delivery, and travel to and from doctor’s offices. (The Silver Sneakers program is the most often used fitness benefit.)
Limits and Drawbacks of Medicare Advantage Prescription Drug Plans
Every Medicare Advantage plan, as we have noted, has to offer the same advantages as Original Medicare. This will include dementia as well as cancer treatments. Medicare Advantage plans lack hospice benefits, though.
MAPD plans always include coinsurance, copayments, and a deductible. The section about prescription drugs will have a separate deductible. These plans also have a large out-of-pocket maximum; hence, if a beneficiary is severely sick, they could pay somewhere to the tune of $5000 annually before their coverage is paid for at 100%.
Finding the
BEST POLICY
A licensed agent can help you choose the best type of Medicare policy. We’ll ask you some questions about your lifestyle and health, and then can give you options that will fit those needs. We’ll be able to look at different plans across many carriers, so you can choose the best possible plan. After you choose, we’ll help you through the enrollment process and will file all the necessary paperwork. Our work doesn’t end there. We’ll reach out during important enrollment periods and make sure you still have the best plan available. All of these services come at no cost to you.
Medicare Advantage Prescription Drug Plan Enrollment
Any Medicare beneficiary who has already enrolled in Medicare Parts A and B is eligible to apply for a Medicare Advantage Prescription Drug plan, with one exception. Individuals who have already been diagnosed with End-Stage Renal Disease (ESRD) are not eligible for any Medicare Advantage plan. Otherwise, an individual can enroll during their Initial Enrollment Period or during the Annual Enrollment Period. Some individuals may even qualify for a Special Enrollment Period.
Medicare Advantage Prescription Drug plans are not available in all areas. Work with a licensed agent to find out which plans are available in your area.
