Medicare Advantage Prescription Drug Plans (MAPD)
Medicare Advantage Made Easy
Most Medicare beneficiaries have the option to enroll in a Medicare Advantage Prescription Drug (MAPD) plan as an alternative to their Medicare Part A and Part B (Original Medicare) benefits.
Original Medicare covers numerous hospital and medical costs but generally does NOT include prescription drug coverage.
Ashford Insurance offers Medicare Advantage Plans (Part C of Medicare) from UnitedHealthcare® Medicare Solutions.
Medicare Advantage plans, often called Medicare Part C, combine Medicare Parts A & B (Original Medicare) into one plan. However, instead of receiving the benefits of Parts A & B through Original Medicare, Medicare Advantage plans are offered through private insurers, like UnitedHealthcare®, that are approved by Medicare.
You can get your Texas Medicare benefits through Original Medicare, or you can choose a Medicare Advantage Plan. With Original Medicare, the government pays for your Medicare benefits when you get them. Medicare Advantage Plans, (the Part C of Medicare) are offered by private companies that have been approved by Medicare. Medicare pays these companies to administer your Medicare benefits.
If you join a Texas Medicare Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. They are completely different than a Medicare Supplement Insurance (Medigap) policy.
There are several types of Texas Medicare Advantage Plans:
Medicare Health Maintenance Organization (HMO) plans: With a Medicare HMO plan, you must stay within your plan’s network of providers or pharmacies. If you go outside of your plan’s network, your MA plan will not cover the costs of your care, and you are responsible for 100 percent of the costs (except for cases of emergencies and out-of-network dialysis services).
HMO-POS Plans: An HMO-POS plan has features of an HMO plan. One is a defined list of providers, often referred to as a network, that members must use for care and services. The plan may require the member to have a primary physician who coordinates care and there may be prior authorization requirements.
Preferred Provider Organization (PPO) plans: With a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You generally pay more if you use doctors, hospitals, and providers outside of the network.
Medicare Private Fee For Service (PFFS) plans: Medicare PFFS plans permit you to go to any provider in the U.S. who accepts Medicare. Some PFFS plans have a network of contracted providers. If your PFFS plan has a network, you will typically pay less out of pocket for medical care and services if you stay within your plan’s network.
Special Needs Plans (SNPs): SNP’s provide specialized and focused health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.
HMO Point-of-Service (HMO-POS) plans: These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.
Medical Savings Account (MSA) plans: These plans combine a high-deductible health plan with a bank savings account. Medicare will deposit money into the account (usually less than the deductible). You can use the money to pay for your health care services throughout the year. MSA plans do not offer any Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan, Part C of Medicare.
To be eligible to enroll in a Texas Medicare Advantage plan you must have both Medicare Parts A and B and live in the plan’s service area. People with End-Stage Renal Disease (permanent kidney failure) generally cannot enroll in a Medicare Advantage Plan.
You must continue to pay your Part B premium and generally pay one monthly premium for the services included in a Medicare Advantage Plan. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before you join. Some may have a $0 premium.
Texas Medicare Advantage Plans have to cover all of the services that Original Medicare covers except for hospice care. Original Medicare will cover hospice care even if you are in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you will always be covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.
Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for both the plan’s medical and prescription drug coverage.
What is a Medicare drug formulary?
Each Medicare Advantage Prescription Drug plan has its own drug formulary, which is a list of brand-name and generic drugs that the plan covers.
Drugs are typically organized into tiers, with drugs in higher tiers costing more than drugs in lower tiers. Your insurer can tell you which of your prescription drugs are covered by an MAPD plan.
Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.
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Sarah began working in the healthcare industry in 2001, where she worked for many years with elderly Alzheimer and Dementia patients. From there she worked as a Group Benefits Administrator with a local healthcare company in the Human Resource Department for a period of 10 years. Since then, she has decided to work in the Medicare insurance industry full time and has joined the family business, Ashford Insurance, as a Medicare Insurance Agent.
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