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.
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.
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).
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.
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 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.
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.
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.
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.
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.)
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%.
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.