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What is MAPD?

March 30, 2022

What is MAPD?

Medicare Advantage Prescription Drug (MAPD) plans are a specific type of Medicare Advantage option. Many Medicare Advantage plans include prescription drug coverage, so they are MAPDs.

This guide will help you understand the different types of MAPD plans that are available. Keep in mind that the availability of these plans will depend on your local area, as Advantage plans are sold by private insurers in specific localities.

Let’s get started!

How Do MAPD Plans Work?

What is a Medicare MAPD plan and how does it work? This is a common question we hear, and fortunately, the answer is fairly simple.

Medicare Advantage plans are full replacements for Original Medicare and often include discounts on fitness centers or the availability of vision and dental coverage. An MAPD plan goes one step further and also includes prescription drug coverage.

In Original Medicare, you’d have to have Medicare Part A (hospital coverage) and Part B (medical coverage), and then pay an additional premium for a Part D plan to get prescription drug coverage. With an MAPD Medicare plan, you get all of that in one package for a single price.

Types of MAPD Plans

There are many different kinds of MAPD plans, and the differences involve the medical provider network and whether you can access care outside of the network.

Remember, every Medicare Advantage plan has to offer at least as much coverage as Original Medicare does. The prices, extra benefits, and medical provider networks are where the plans differ.

Health Maintenance Organization (HMO) Plans

An HMO is a health insurance plan with a set provider network. You generally cannot get coverage for non-emergency care outside of the provider network.

An HMO also requires you to designate a primary care physician (PCP) as your first point of care. If you need anything further, including specialist care, your PCP must provide a referral.

As a result of using a limited network, you’ll pay less for an HMO than other plans that allow more choice. Before you choose an HMO, make sure your preferred doctors and specialists are part of the network. You’ll also need to compare the monthly premium and the out-of-pocket costs to the benefits you get before you make your decision.

Preferred Provider Organization (PPO) Plans

A Preferred Provider Organization (PPO) plan has a medical provider network, like other insurance plans, but generally, you can also get care outside of the network. However, you’ll pay more out-of-pocket if you do go out of network.

In-network doctors and specialists will be called preferred providers. You’ll pay less to see them, so it’s best to ensure that your preferred doctors are part of the network before you choose a PPO. You won’t need a PCP and you can choose to see a specialist if you feel it’s necessary, without a referral.

Because you have more choice of providers with a PPO, they tend to be more expensive. You’ll pay a higher monthly premium and out-of-pocket costs, but you’ll have the ability to see any doctor you choose — as long as you’re willing to pay the higher fees for out-of-network care.

Special Needs Plans (SNP)

A Special Needs Plan (SNP) is a Medicare Advantage plan that is tailored to people who have specific medical conditions. These plans will have doctors and specialists who are highly qualified to treat the medical condition the plan focuses on.

You can also get general medical care from the doctors in the SNP network. Some SNPs allow you to get coverage for care outside the network and others do not. These plans also generally require a PCP to coordinate your care and provide referrals to specialists.

SNPs have specific eligibility requirements, so be sure you research the availability of a plan that fits your needs before you decide on this type of coverage.

Private Fee-for-Service (PFFS) Plans

Medicare PFFS plans aren’t available in all areas, but they have some similarities with an HMO and other similarities with a PPO. For example, there is usually a defined provider network and you generally cannot get non-emergency care covered outside the network.

However, you don’t need a PCP or referrals to see a specialist, which gives you more freedom than an HMO.

The plan will decide how much you’ll pay for services each year, so keep your eyes open for the Annual Notice of Change and Evidence of Coverage documents each year.

What Is The Difference Between MA and MAPD Plans?

Medicare Advantage (MA) and MAPD plans are similar, except that an MA plan won’t include coverage for prescription drugs. The good news is many Medicare Advantage plans are MAPD plans.

As you compare the Medicare plan options available to you, be sure you understand all of the benefits and costs associated with each plan. If you find an MA plan that doesn’t include prescription drugs, it may not be a good fit if you have prescription drug needs.

Who is Eligible For MAPD?

Usually, MAPD plans are available to anyone who is eligible for Medicare and lives in the plan coverage area. For some MAPD plans, like a SNP, you’ll need to meet other criteria as well.

Most of the time, however, you simply need to be a Medicare beneficiary in the right geographic area to sign up.

This means that many Medicare beneficiaries have a lot more options for Medicare plans than they realize. That’s why talking to a licensed agent can help you compare all plan options and choose the one that’s right for you.

How Much Do MAPD Plans Cost?

Every MAPD has its own costs and benefits. Some plans will cost the same as your Part B premium, which means that you get Part D (prescription drug) coverage for free. Others will have an additional premium. Learn more about the latest changes to Medicare costs and premiums in this guide.

Be sure you look at the deductibles and copayments as well, not just the monthly premium. If you pay less per month but the out-of-pocket costs are unaffordable when you need care, you aren’t truly saving money.

Many Advantage plans offer additional benefits that Original Medicare does not, which makes them an important option to consider each year as you review your insurance coverage.

Learn More About Medicare Advantage Plans

After reading this guide, you have the answers to many of the most common questions about MAPD plans. However, you might have additional questions about your specific situation, or perhaps you want help comparing coverage options.

Either way, we’re here to help. Contact us today!

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