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What is the difference between a Medicare Advantage plan and a stand-alone Medicare Part D plan?

Published on 2014-08-17 19:23:56Category: Medicare Advantage Plans

Stand-alone Medicare Part D prescription drug plans (or PDPs) only provide prescription drug coverage.

Medicare Advantage plans come in two general groups:
(1) Medicare Advantage plans with prescription drug coverage (MAPD) and
(2) Medicare Advantage plans without prescription drug coverage (MA).

Medicare Advantage plans (MAs and MAPDs) are a combination of your Medicare Part A (in-patient and hospitalization) and Medicare Part B out-patient and (Doctor visits) - plus usually some additional benefits like optical, hearing aid, fitness, and dental.

If you have a MAPD, then your Medicare Advantage plan also covers Medicare Part D prescription drugs along with your Medicare Part A and Part B coverage.

A Medicare Advantage plan is also known or referred to as Medicare Part C.

Eligibility for joining Medicare Part D or Medicare Advantage plans

You must have either Medicare Part A and/or Medicare Part B to be eligible for a Medicare Part D prescription drug plan.  Medicare Part D monthly premiums are in addition to your Medicare Part A (if any) and/or Part B premiums.

The only requirement to join a Medicare Part D plan is that you need to live in (or be a permanent resident of) the plan's service area.  A Medicare Part D plan's service area is either a state or multi-state region (such as, Pennsylvania and West Virginia being a single region and offering the same stand-alone Medicare Part D plans).

You can view all of the stand-alone Medicare Part D plans in your area using our PDP-Finder tool:
www.PDP-Finder.com (just choose your state abbreviation).  Here is an example link showing all Medicare Part D plans in Florida:  www.PDP-Finder.com/FL

There are no health-related questions when joining a stand-alone Medicare Part D plan.

On the other hand, you must be enrolled in both Medicare Part A and Medicare Part B to get into a Medicare Advantage plan.   Your Medicare Advantage plan monthly premiums (if any) are in addition to your Medicare A (if required) and Medicare B premiums.

Medicare Advantage plans require you to live in the plan's service area (usually a ZIP Code region) and you cannot suffer from End Stage Renal Disease (ESRD or kidney failure).

You can view all of the Medicare Advantage plans in your area using our online tool at MA-Finder.com - just enter your ZIP and "Click to Find Plans".

Here is an example of all of the 2015 Medicare Advantage plans in Summit County, Ohio using the ZIP 44319: http://www.q1medicare.com/PartD-SearchMA-Medicare-2015PlanFinder.php?state=OH&countyCode=39153&showCounty=SUMMIT&ZIP=44319

Like the Medicare Part D prescription drug plans, the Medicare Advantage plans are administered by private insurance carrier and compensated partially by the Federal Government.

Because of low region medical costs, some Medicare Advantage plans do not charge a monthly premium (or have a $0 premium) and a few Medicare Advantage plans actually rebate a portion of your Medicare Part B payment back to you (sometimes called a Dividend plan) - this means you do not pay anything and actually get money back for your Medicare Part A, Medicare Part B, and Medicare Part D coverage.

A Maximum Limit on your Medical Spending

One of the biggest benefits of a Medicare Advantage plan is that there is a limit to your out-of pocket medical spending that is set each year (or MOOP).

If you have original Medicare Part A and Medicare Part B, there is no limit or cap to what you can pay each year, if you have very high medical expenses, you could have very high costs.

A Medicare Advantage plan will limit your potential spending each year to some level such as $3,400, $5,000, or $6,700 - depending on your chosen plan.

The Different Structures of a Medicare Advantage plan

Medicare Advantage plans can be further defined by how the private insurance carriers choose to implement the Medicare Part A and Part B coverage.
Some Medicare Advantage plans are PPOs (Preferred Provider Organizations) - other MAs are organized as HMOs (Health Management Organizations) - and still other MAs are set up as PFFSs (Private Fee for Service Organizations).

A number of key differences exist between the organization of a PPO, HMO, and PFFS.  All three have distinct advantages and disadvantages.  When considering a MA, a Medicare beneficiary should be sure to learn about these differences and how the choice of a particular MA plan may affect  their health care.

The Private Market and Medicare Advantage Plans

From a very general perspective, Medicare Part D plans and Medicare Advantage plans were both introduced to take advantage of the competitive forces existing in a private market to help control the medical expenses.  As noted in a recent  (August 13, 2007) CMS Press Release:

"[M]any beneficiaries have access to a Medicare Advantage plan with lower prescription drug premiums. It will be important for beneficiaries to compare their coverage options for 2008 based on overall cost, coverage, and convenience in order to select the plan that best meets their needs.  MA-PD premiums continue to be lower than PDP premiums. On average, in 2007, the MA-PD premiums prior to rebates are about $7 lower than those for PDPs. In 2008, they will average $11 lower. The lower MA-PD bids and premiums reflect the effects of aggressive competition as well as lower costs resulting from better care coordination and drug benefit management techniques. In practice, many MA-PD plans also apply a portion of their rebates from Parts A and B to reduce their Part D premiums, in many cases to zero." (CMS Press Release 08/13/2007)  The entire CMS Press Release can be found as part of our Blog here.

Marketing Compliance and the Medicare Advantage Plan

On another note, as some Q1Medicare site visitors have noticed, back in 2007, PFFS Medicare Advantage plans received a great deal of press due to allegations of unethical marketing activities.  You can read more about that here: Plans Suspend PFFS Marketing;Plans adopt strict guidelines in response to deceptive marketing practices.

Doughnut Hole Coverage?

Some stand-alone Medicare Part D plans or Medicare Advantage plans offer some form of  Donut Hole (or Doughnut Hole) coverage (for either or both brand name and generic medications).  We have Donut Hole coverage details in both our PDP-Finder and MA-Finder.

: : 2015 PDP-Finder - Medicare Part D Plan Finder
The 2015 PDP-Finder is now available, displaying Medicare Part D plan information, including plan premium, deductible, type of gap coverage and if the plan qualifies for the $0 premium for those persons with a low income subsidy (LIS).

: : Click here to receive an email when the 2016 Medicare plan information becomes available.
: : Sign-up for our FREE Medicare Part D Newsletter.
: : Have a question? Click here to let us know.

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