What Is an MAPD Medicare Advantage Plan?

MAPD is commonly used to mean a Medicare Advantage Prescription Drug plan — a Medicare Advantage plan that also includes Medicare Part D prescription drug coverage.

Medicare Advantage is also called Medicare Part C. You still have Medicare, but instead of getting your Medicare-covered Part A and Part B services directly through Original Medicare, you receive those benefits through a private insurance company approved by Medicare.

• You generally must have both Medicare Part A and Medicare Part B   to join a Medicare Advantage plan.
• You normally must continue paying your  Medicare Part B premium
• Most Medicare Advantage plans include  Part D prescription drug coverage  although not every Medicare Advantage plan does.
• Plans may be an HMO, PPO, Special Needs Plan (SNP) or another type of Medicare Advantage plan.
• Doctors, specialists, medical groups, hospitals, pharmacies and prescription formularies can vary from one plan to another.
• Some services may require referrals or  prior authorization
• Medicare Advantage plans have an annual maximum out-of-pocket limit for covered Medicare Part A and Part B medical services.
• Plans may also include supplemental benefits such as dental, vision, hearing, fitness, transportation or other benefits. The benefits vary by plan, county and year.
• Before deciding which Medicare Advantage plan to enroll in, I think it is also important to understand the alternative:
  • Original Medicare vs. Medicare Advantage, Medigap and Part D

Resources:

• Our Medicare Guides, Forms & Reference Materials
  
• Medicare.gov — Understanding Medicare Advantage Plans #12026
  
• Medicare.gov — Compare Types of Medicare Advantage Plans
  

How I Compare Medicare Advantage Plans

Medicare Advantage plans can look very attractive. Some advertise low or $0 additional premiums, dental, vision, hearing, fitness programs, OTC allowances, transportation, meals and other extra benefits.

Those benefits may be useful — but they are not where I start.

When I help someone compare Medicare Advantage plans, I first look at the things that may matter much more when you actually need medical care.

• 1. Your Doctors, Specialists, Medical Groups & Hospitals
  • Is your primary care doctor in the plan?
  • Are your specialists in the plan?
  • Which medical group or IPA would you belong to?
    • Cedar’s Sinai Insurance Plans Accepted
      • Optum
      • Providence Little Company of Mary
      • THIPA Torrance Memorial Insurance Accepted
      • UCLA Insurance Accepted
  • Are the hospitals you would want to use available?
  • Don’t assume that because a doctor accepts one plan from an insurance company, the doctor accepts every Medicare Advantage plan offered by that company.
• 2. Your Prescription Drugs
  • Is each prescription on the plan’s formulary?
  • What drug tier is it?
  • What will your prescriptions cost?
  • Is your preferred pharmacy in the network?
  • Is prior authorization required?
  • Is there step therapy or a quantity limit?
  • Learn more about Medicare Part D Prescription Drug Coverage
    
• 3. What Will Medical Care Actually Cost?
  • Primary care visits
  • Specialist visits
  • Hospital stays
  • Outpatient surgery
  • Emergency room and urgent care
  • MRIs, CT scans and other diagnostic testing
  • Physical, occupational or speech therapy
  • Skilled Nursing Facility — SNF care
    
  • Durable medical equipment
• 4. Prior Authorization & Referrals
  • Medicare Advantage plans may require  prior authorization   before certain services, treatments, equipment or medications are covered.
  • A U.S. Department of Health & Human Services Office of Inspector General review found that 13% of the denied Medicare Advantage prior-authorization requests it reviewed met Medicare coverage rules and likely would have been approved under Original Medicare.
  • HHS Office of Inspector General — Medicare Advantage Prior Authorization Denials
    
• 5. Your Maximum Out-of-Pocket Exposure
  • Don’t compare plans based only on the monthly premium.
  • Review the copays and coinsurance you might actually pay during the year.
  • Look at the plan’s annual maximum out-of-pocket limit for covered Medicare Part A and Part B services.
  • A $0 additional plan premium does not mean your medical care is free.
• 6. What Happens When You Travel or Are Away From Home?
  • Emergency care
  • Urgent care
  • Routine care outside the service area
  • Out-of-network benefits, if any
  • Medicare Advantage Coverage When Traveling or Outside Your Area
    
• 7. Is Medicare Advantage the Right Type of Coverage for You?
  • Sometimes Medicare Advantage makes a lot of sense.
  • Sometimes Original Medicare with a Medicare Supplement and Part D may be a better fit.
  • Compare Original Medicare vs. Medicare Advantage
    
  • Learn about Medicare Supplement / Medigap Plans
    
• 8. Then I Look at the Extra Benefits
  • Dental
  • Vision
  • Hearing
  • Fitness or gym programs
  • OTC allowances
  • Transportation
  • Meal benefits
  • Other supplemental benefits

Extra benefits aren’t worthless. If you are actually going to use a benefit, it belongs in the comparison. But I don’t believe a gym benefit, dental allowance or other advertised extra should outweigh your doctors, hospitals, prescriptions, prior authorization requirements or potential medical expenses.

Should You Have Medicare Advantage at All?

Before comparing one Medicare Advantage plan with another, I think it is worth asking a more basic question:
Is Medicare Advantage the right way for you to receive your Medicare benefits?

• Medicare Advantage
  • Provides your Medicare Part A and Part B benefits through a private Medicare-approved plan.
  • Most plans include Part D prescription drug coverage.
  • May have a low or $0 additional plan premium.
  • May include dental, vision, hearing, fitness and other supplemental benefits.
  • Usually requires paying close attention to provider networks.
  • May require referrals or prior authorization.
  • Has an annual out-of-pocket limit for covered Medicare Part A and Part B services.
• Original Medicare + Medigap + Part D
  • Original Medicare generally lets you use any doctor or hospital in the United States that accepts Medicare.
  • A  Medicare Supplement / Medigap plan   can help pay some of the deductibles, copays and coinsurance left by Original Medicare.
  • Part D prescription coverage   is generally purchased separately.
  • Monthly premiums are usually higher than with a $0-premium Medicare Advantage plan.
  • Your ability to change to a Medigap policy later can depend on California rules, guaranteed-issue rights, timing and underwriting.

There is no one answer that is best for everybody.

• Compare Original Medicare, Medicare Advantage, Medigap & Part D
  
• California Medicare Supplement / Medigap Plans
  

Medicare Advantage Topics & Enrollment Rules

Looking for more detail?

These pages cover specific Medicare Advantage questions, enrollment rules and special situations.

• Medicare Advantage & Part D Enrollment Dates — AEP, MA Open Enrollment, ICEP and Special Enrollment Periods
  
• Medicare Star Ratings — What Do the Ratings Mean?
  
• Medicare Advantage Marketing Rules — CMS Rules & Consumer Protections
  
• Scope of Appointment — Permission to Discuss Medicare Advantage & Part D
  
• Medicare Special Needs Plans — SNPs
  
• Medicare + Medi-Cal / Medi-Medi — Dual Eligible Special Needs Plans (D-SNPs)
  
• Prior Authorization — What It Means and What to Do If Care Is Delayed or Denied
  
• Medicare Coverage When Traveling — Medicare Advantage, Original Medicare & Medigap
  
• Medicare Guides, Forms & Reference Materials
  

Medicare Advantage Plan Information in California

Medicare Advantage plans are local. Plan availability, provider networks, prescriptions, premiums, copays and supplemental benefits can vary by ZIP code, county and plan year.

You can review more detailed information for the Medicare Advantage companies below:

• Anthem Blue Cross Medicare Advantage
  
• Blue Shield of California Medicare Advantage
  
• SCAN Medicare Advantage
  
• UnitedHealthcare Medicare Advantage
  

Important: Don’t assume the company name alone tells you whether the plan will work for you. Different plans from the same company can have different doctors, medical groups, hospitals, prescription coverage and benefits.

Want Help Comparing Medicare Advantage Plans?

A Medicare Advantage comparison is much more useful when we compare your actual situation rather than simply looking at which plan advertises the most extra benefits.

Please send me:

• Your ZIP code and county
• Your primary care doctor
• Your specialists
• Your medical group or IPA, if applicable
• Your preferred hospitals
• Your prescription medications
• Your preferred pharmacy, if important
• Your current Medicare coverage
• Whether you also have Medi-Cal
• Any medical, prescription or supplemental benefits that are particularly important to you

I can then help you compare the Medicare Advantage plans I represent, we do have the research tools to compare ALL MAPD plans  and look at the items that actually matter for your situation.

• Email [email protected]
• Schedule a Zoom Meeting
  
  
• Scope of Appointment
• When Can I Enroll or Change Plans?
  

Always Verify the Current Plan Information

Medicare Advantage plans can change from one year to the next. Premiums, copays, provider networks, prescription formularies, prior authorization requirements and supplemental benefits may change.

Before enrolling or renewing, check the current year’s information for the exact plan in your ZIP code and county.

Important documents and information to review may include:

• Summary of Benefits
• Evidence of Coverage
• Annual Notice of Change
• Prescription Drug Formulary
• Pharmacy Directory
• Provider / Doctor Directory
• Referral and prior authorization requirements
• Maximum out-of-pocket limit

That is also why I provide links to source material throughout this website. If something on one of my pages has not yet been updated for a new plan year, use the link to check the current official information before making a decision.

Resources:

• Our Medicare Guides, Forms & Reference Materials
  
• Medicare.gov Plan Compare — Check Current Plans
  
• Understanding Medicare Advantage Plans — Medicare Publication #12026
  
• Medicare.gov — Current Medicare Publications
  
• Medicare.gov — Compare Types of Medicare Advantage Plans