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Understanding Medicare MAPD Plans: A Comprehensive Overview

MAPD plans, known as Medicare Advantage Prescription Drug plans or Medicare Part C, are available for Medicare-eligible individuals who can receive their Medicare benefits from a private insurance carrier. However, with this option comes some essential things that must be considered before deciding if it's a good choice. Below, we will discuss some of the ins and outs of MAPD plans so you can be well-informed in your decision process.

Key takeaways:

Medicare Advantage Prescriptions Drug Plans (MAPDs): What are they?

Private insurance carriers offer MAPD plans and administer your Medicare Part A (Hospital) and Part B (Medical) benefits instead of Original Medicare. These plans must be approved by the Centers for Medicare and Medicaid Services (CMS) each year and are heavily regulated. Regulation ensures all plans offered have benefits equal to Original Medicare Parts A and B.

While enrolled in a MAPD plan, Original Medicare will not administer your benefits directly; the MAPD plan takes over as your primary insurer. It may be unclear, so let’s closely examine how they work.

What types of MAPD plans are available?

Carriers offer plans in different states and counties. In addition, they provide numerous types of plans. Below, each is described.

  • Health Maintenance Organization or HMO. You must get care in the plan's network or be responsible for the total cost. Exceptions to this may include emergencies, out-of-area urgent care, and temporary out-of-area dialysis. Some plans may require referrals to see a specialist, so be sure to ask your plan's provider if you aren't sure.
  • Preferred Provider Organizations or PPO. These plans allow an individual to seek care outside the plan's network but at a higher cost than an in-network provider.
  • Special Needs Plans or SNPs. D-SNP plans provide benefits to individuals who meet specific income qualifications and/or qualify for Medicaid. C-SNP is for those diagnosed or receiving treatment for a qualifying chronic condition such as congestive heart failure or diabetes. Lastly, I-SNP plans cover individuals residing in nursing homes. Not all carriers offer plans in every area, and eligibility requirements must be met.
  • Private Fee for Service or PFFS. Sometimes, a traditional network is not in place, and the plan agrees to pay a set amount for services. This may be more like a PPO than an HMO.
  • Medicare Savings Plans or MSAs. These plans are similar to HSA plans that you would find at an employer. They combine high-deductible medical plans and medical savings accounts. Do keep in mind these plans are a bit scarce.

Who is eligible for MAPD plans?

To be eligible for a MAPD plan, an individual must have both Medicare Part A and B. Part A typically doesn't have a premium; however, Part B does, and it is $31.50 in 2023. Individuals must continue to pay the Part B premium unless they fall under income limits, even if they choose to enroll in a MAPD plan. In most situations, people age into Medicare at 65, but some are eligible earlier due to disability, end-stage renal disease (ESRD), or ALS (Lou Gehrig's disease).

How much does Medicare cost?

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The cost of a MAPD plan is typically determined by several key factors:

  • Your state, county, and zip code of residence
  • Which carrier and type of plan you choose
  • Your income level

The cost of a MAPD can come from many different places. It could be a monthly premium or a requirement to pay a cost-share for each service provided, whether it’s surgery, a hospital stay, diagnostic testing, or a physician visit. Medicare costs are broken down into four categories:

  • Deductible. The individual is responsible for 100% of the bills until this dollar amount is met. If a plan has a $500 deductible, and the bill is $3,000, the individual must pay the first $500 before the plan starts to pay.
  • Coinsurance. The individual is responsible for a fixed percentage of the bill. If the coinsurance is 80/20, the individual is responsible for 20%.
  • Copay. A fixed dollar amount the individual pays for a service or stay. An individual might have a $15 copay to see their primary care physician, a $100 copay to get an MRI, or a $250 copay for an overnight hospital stay.
  • Premium. This is a fixed monthly dollar amount an individual must pay in addition to their Part B premium to remain enrolled in the plan.

What additional benefits can come with MAPD plans?

In addition to providing medical and prescription drug benefits, MAPDs can also include the following items, most at no additional monthly cost.

  • Comprehensive dental
  • Vision
  • Over the counter medications
  • Part B premium reduction
  • Household safely items
  • Healthy food cards
  • Utility allowance
  • Service animal allowance

Who are some of the major carriers that offer MAPD plans?

Although each state and county will have regional MAPD plans locally, several large carriers offer plans nationally. Some are listed below:

  • Aetna (CVS)
  • Blue Cross Blue Shield
  • Cigna Health Group
  • Devoted Health
  • Humana
  • United Health Group
  • Wellcare (Centene)

When can individuals enroll in a MAPD plan?

Individuals can only enroll during set time frames called "enrollment periods." Several occur during the year, so let's discuss them in more detail.

Initial Enrollment Period (IEP)

This enrollment period is for individuals first eligible for Medicare Parts A and B. It begins three months prior and three months after the month of your Medicare Parts A and B effective dates.

Annual Enrollment Period (AEP)

This enrollment is for all Medicare eligibles and begins on October 15th and ends on December 7th, with the plan being effective January 1st. You have unlimited enrollments, but the last one will be the plan that takes effect on January 1st.

Open Enrollment Period (OEP)

Individuals currently on MAPD plans can choose to move to another MAPD once during this enrollment period, which begins on January 1 and ends on March 31. The new plan selected will be effective the following month of enrollment.

Special Enrollment Periods (SEPs)

These election periods are Medicare eligibles that meet certain circumstances and can be available all year. Events qualifying for a SEP could be moving, losing Medicaid, losing employer coverage, or a declared emergency in your area, to name a few of the more common ones.

How do you choose the right MAPD plan?

Choosing the right MAPD plan can be intimidating. Many states have 10 carriers offering 5-10 plans, leaving an individual searching through 50-100 plans. Each individual will have different needs that need to be factored in, including:

  • Verifying your doctors are in network.
  • Checking your medications to make sure they are covered and at what tier level.
  • Comparing the core medical and prescription benefits and cost share.
  • Comparing the added the benefits of the each plan.
  • Checking the plans star rating.

An individual can either contact a local licensed insurance broker, call the carrier, visit www.medicare.gov, or call 1-800-Medicare for further information.


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