MAPD Plans: What They Are, How They Work, & More

• Before breaking down the details of an MAPD plan, it’s important for a patient to understand what an MAPD plan is and what it stands for. 
• When enrolling in any kind of Medicare Advantage plan, patients must decide which plan type to select (HMO, PPO, SNP, etc.). 
• There are different options when it comes to enrollment periods for MA plans. 
• Cost is an important factor when it comes to selecting an insurance plan. 

Deciding which medical insurance to pick can be difficult. And when it comes time to enroll in Medicare, there are plenty of options to choose from. In addition to Original Medicare, there is also Medicare Advantage, a type of Medicare plan that provides all the coverage of Original medicare but with additional benefits such as prescription drug coverage. 

This article will discuss MAPD plans specifically. 

Simply put, an MAPD plan is a Medicare Advantage plan that includes Part D coverage or prescription drug coverage. Medicare Advantage plans are separate from Original Medicare plans as they are sold through private insurance companies since they are considered Medicare supplement insurance. MA plans automatically include Part A and Part B coverage, and as of 2017, many Medicare Advantage Plans (88%) already have Part D coverage included. 

When a patient enrolls in a Medicare Advantage Prescription Drug plan, they must decide which plan type they desire. The Federal Medicare Program lists various plan types including: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Special Needs Plans (SNP), and Private Fee-For-Service (PFFS).

Note: Less common plans include HMO Point of Service (HMOPOS) plans and Medicare Medical Savings Account (MSA) plans. To learn more about these Medicare Advantage plan types, visit this source.

Health Maintenance Organizations (HMO) Plan

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 (PCP) that coordinates their care. Due to this PCP stipulation, it’s also necessary for patients to request referrals if they want or need to see an out-of-network specialist. One of the advantages of an HMO plan is that they often have lower monthly premiums in comparison to competing plan types.

Note: To learn more about HMO plans, visit this source.

Preferred Provider Organizations (PPO) Plan

Similar to an HMO plan, a PPO Medicare Advantage plan provides patients with a network of providers and practices they can visit. However, unlike an HMO plan, a PPO plan does not require a PCP. Due to this, patients have more flexibility when it comes to care as they are in charge of who they see, when they see them, and why. 

Note: To learn more about PPO plans, visit this source.

Special Needs Plans (SNPs)

SNPs are different from their counterparts because they limit membership to serve specific groups of people with certain conditions or diseases. These qualifying membership factors include those that live in certain institutions such as nursing homes, those eligible for Medicare and Medicaid services, or those who have chronic disabling conditions (e.g., diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). In addition, like an HMO plan, SNPs require their patients to have a PCP or care coordinator, and it’s common for patients to require referrals for certain specialists.

Note: To learn more about Special Needs Plans, visit this source.

Private Fee-for-Service (PFFS) Plans

PFFS Medicare Advantage plans come with the most flexibility as they typically come with a network, but not always. This MAPD plan independently determines how much to pay providers and hospitals when their patients desire health care and how much the patient must pay. Similar to a PPO plan, a primary care physician is not required for patients with a PFFS plan.

Note: To learn more about PFFS plans, visit this source.

When it comes to MAPD enrollment, there are various options to look at and factors to consider.

Initial Enrollment Period (IEP)

The initial enrollment period is the most standard option for enrolling in original Medicare or MA plans. The timeframe for an IEP is a seven-month stretch: the three months before a patient turns 65, the month of their 65^th birthday, and the three months after they turn 65. Most patients are automatically enrolled in Medicare Part A at this time and will receive a welcome packet that guides them through the enrollment process. However, it’s the patient’s responsibility to further enroll in Medicare Part B or an all-inclusive MA plan at this point; if they delay enrollment, there could be impending penalty charges.

Note: To learn more about the Initial Enrollment Period, visit this source.

General Enrollment Period (GEP)

For individuals that missed the IEP, they are welcome to join during the general enrollment period. For standard Medicare coverage, the GEP timeframe is from January 1^st to March 31^st, and for Medicare Advantage plans, it’s April 1^st to June 31^st. For both of these timeframes, a patient’s coverage will begin starting July 1^st.

Note: To learn more about the General Enrollment Period (GEP), visit this source.

Fall Open Enrollment 

Patients who are looking to switch their plan (e.g., MA to standard Medicare or vice versa) can do so during Fall Open Enrollment. This timeframe is from October 15^th to December 7^th, with coverage beginning on January 1^st.

Note: To learn more about Fall Open Enrollment, visit this source.

Those eligible for MAPD enrollment include those 65 and older who have worked for at least ten years and have paid Medicare taxes during their career. It also includes individuals who are younger than 65 and have received social security for at least 24 months or have recently been diagnosed with ALS or kidney failure.

Note: Other eligible groups include spouses and those who are still working after the age of 65. To learn more about the specifications of these groups or overall MAPD eligibility, visit this source.

When it comes to MAPD plans, health care costs may vary depending on one’s insurance provider, network, and coverage options. However, costs usually break down into premiums, deductibles, copayments, and coinsurance.

Premiums

For MAPD plans, individuals must pay the Medicare Part B premium. In 2023, the average premium cost is $164.90, depending on one’s income. Paying a premium for Part B is standard when it comes to any kind of Medicare plan.

Deductibles

One’s deductible is the amount they must pay for health care or prescription drugs before their insurance begins to step in and cover costs. Deductible costs vary depending on the patient’s MAPD plan type (i.e., HMO, PPO, etc.).

Copayments

A copayment is the share a patient must pay for any health care service such as a doctor’s visit, prescription drug allocation, or outpatient care. Copayment costs vary depending on the MAPD plan type a patient chooses (i.e., HMO, PPO, etc.).

Coinsurance

Coinsurance refers to the percentage a patient must pay for certain services once their deductible is paid off. The rate of coinsurance cost varies depending on the MAPD plan type a patient selects (i.e., HMO, PPO, etc.).

Note: To learn more about the costs associated with an MAPD plan, visit this source.

Medicare Advantage plans are often referred to as Medicare Part C as they cover many expenses that standard Medicare does not cover. Only Medicare-covered expenses count Part A coverage as premium-free, with the option for patients to add Part B and Part D insurance. Meanwhile, most Medicare Advantage plans or MAPD plans specifically include Part A, Part B, and Part D coverage along with additional care services such as dental, vision, and hearing protection. To learn the details of what a specific Medicare supplement plan (like MAPD) insures, be sure to reach out to an insurance agent and discuss which services are covered.

Note: To learn more about the covered services of an MAPD plan or the medical services it includes, visit the federal government website at this source.