MAPD Plans & PDPs: The Differences You Should Know

Are you new to selling Medicare and considering adding it to your existing agency services? This article will help you understand MAPD and demystify some of the common confusion.

The first point of confusion lies within MAPD and Medicare Part D plans (PDPs), which is prescription drug coverage.

Below is a summary of each type of plan. Reference the FAQ towards the bottom of the article for more detail.

What is an MAPD plan?

At it’s core, it’s medical insurance.

An MAPD plan is health insurance coverage offered by private insurance companies approved by Medicare that provide the primary services for Medicare Parts A, Medicare Part B and Medicare Part D consolidated into one plan which is called Medicare Part C.

Medicare Part A + Medicare Part B + Medicare Part D = Medicare Part C

A good way to remember the parts of Medicare are as follows:

• Part A = Hospital
• Part B = Medical
• Part C = Combination
• Part D = Prescription Drugs.

The order isn’t perfect, but that’s an easy way to remember.

MAPD plans are offered by private insurers who contract with Medicare. In addition to prescription drug coverage, MAPDs often offer additional benefits that are not currently covered by Medicare.

What does MAPD mean?

MAPD is short for Medicare Advantage prescription drug plan. These plans are available as both HMO and PPO plans to offer network flexibility to customer. This is the most common type of Part C plan sold.

What does MA mean?

MA is Medicare Advantage only which doesn’t include prescription drugs.

What is a PDP?

A PDP, or Prescription Drug Plan, is also commonly referred to as Medicare Part D. It covers prescription drugs for beneficiaries who purchase it as a separate plan in addition to their other Medicare coverage. Those who have already enrolled in Original Medicare (Parts A and B) can also choose to enroll in a Part D plan.

Frequently Asked Questions

Are prescription drugs covered under Medicare Advantage Plans (MAPD)?

Yes, prescription drug coverage is included with MAPD plans, however, benefits vary and must be thoroughly reviewed prior to enrollment.

What is the difference between MA and MAPD?

• MA is Medicare Advantage only and does NOT include Medicare part d prescription drug coverage.
• MAPD is Medicare Advantage that also includes prescription coverage.

Open enrollment periods are the same for both types.

What are the benefits of enrolling in an MAPD plan?

Benefits of enrollment in an MAPD plan can often be different for different people, but here are some of the common benefits.

• Network Flexibility through health maintenance organizations (HMO plans) and preferred provider organization (PPO), the two most common types of Medicare Advantage plans. These varying plan options allow Medicare beneficiaries more choices for how to access their healthcare providers in a specific plan’s network as well as out-of-network. The biggest difference is HMO require referrals for specialist and PPOs do not while PPO have more robust out-of-network flexibility.
• Potential cost savings. Many of these plans are zero premium which means they do not have a monthly premium, and instead, have a schedule of copays and coinsurance when they use their plan at the doctor or hospital.
• Additional benefits not covered by Original Medicare. Not all health plans offer the same additional benefits, but those commonly found are fitness plans, some levels of dental, vision, and hearing, and wellness services. Additional information on extra benefits should always be confirmed with each plan.
• Special needs plans (SNPS) are available for individuals who meet certain qualifying factors such as living with a chronic condition or actively receiving Medicaid benefits. These plans are custom tailored for those individuals.
• Cover deductibles. Part A and Part B deductibles are covered.

Does Original Medicare go away with an MAPD?

No. In order to be eligible to enroll in an MAPD, a consumer must first have Original Medicare which is Parts A and B.

They will continue to pay their Medicare part B premium which is most commonly deducted from their monthly social security check.

Once enrolled in a Part C plan, the private insurance companies become primary to Medicare which is why someone people are often confused. Yes, they still have Medicare, but it’s just not primary when they elect for enrollment in an advantage plan.

Can you have an MAPD and Medigap plan at the same time.

No. Medicare beneficiaries may not have both types of plans and must choose the plan that is best fit for their needs.

What is a formulary?

The formulary is a list of all drugs that will be covered on a specific plan. In some cases, beneficiaries can ask their insurer to cover a drug that is not listed. Insurers will typically cover additional drugs that are medically necessary, but not others. In that case, beneficiaries can almost always find a similar drug on their formulary to replace the one they were prescribed but they’ll probably need a new prescription.

What’s Best For The Client?

This all depends on the consumer.

Medicare Advantage plan is usually the better choice over an Original Medicare plan with a Prescription Drug plan as it sometimes offers more coverage and financial protection via a maximum out of pocket cap.

Clients who are in more of a financial bind may opt for a Medicare Advantage plan.

However, if a beneficiary needs full network flexibility, they’ll need a Medicare Supplement plan, also known as Medigap. Med Supp plans won’t include prescription drug coverage, but they’ll help to cover copayments and coinsurance along with other out-of-pocket costs.

The more clients you speak with and the more plans you sell, the clearer this will become.

You’ll learn to better serve your clients with plans that best suit their needs. If you’re looking for training services and help with your marketing efforts and lead generation, SMA may be the FMO for you.

Get started by speaking with one of our advisors today at 1-844-452-5020.