Question: MA and MAPD: What is the difference between a Medicare Advantage MA and a Medicare Advantage MAPD?
Answer: In general, a Medicare Advantage plan is a health plan option approved by the Centers for Medicare & Medicaid Services and operated by private company. A Medicare Advantage plan may also be called a Medicare Part C. plan or a Medicare Health Plan. Medicare Advantage Plans provide a combination of your Medicare Part A (hospital coverage) and Medicare Part B (out-patient or medical coverage) and may also include other service such as vision coverage, dental coverage, and recreational coverage (such as a "Silver Sneakers" membership).
If the Medicare Advantage plan also includes Medicare Part D
prescription drug coverage, then the Medicare Advantage plan is know as an MAPD.
If the Medicare Advantage plan does not includes Medicare Part D
prescription drug coverage, then the Medicare Advantage plan is know as an MA.
Most MAs and MAPD have healthcare networks and you may need to visit doctors (or other healthcare providers) who are part of the Medicare Advantage plan network - or be prepared to pay a higher coverage cost.
HMO - Health Maintenance Organizations: HMOs
are wellness based Medicare Advantage plans and usually have the
most-restrictive healthcare provider network, meaning that your
healthcare costs may be considerably higher if you go outside of your
plan’s established network. Also, depending on your HMO plan, you may
only be allowed outside of your plan network with a referral from your
doctor. Local HMOs are often very affordable compared to other Medicare
Advantage plans because the restrictive network and focus on wellness
helps to control healthcare costs. The majority of Medicare
Advantage plans will be HMOs (Health Maintenance Organizations).
HMO POS - Health Maintenance Organizations
Point-of-Service: These Medicare Advantage HMO’s have a more flexible
healthcare network allowing you to seek care outside of your plan’s
network by paying a higher cost-sharing rate. This type of HMO is
chosen often for people who travel part of the year, but still return
home for the majority of their healthcare needs. For instance, you may
have a $30 co-payment when you visit a healthcare provider in-network
(at home) and pay $60 when you visit a provider outside of the plan’s
network (while traveling). Important: Sometimes an HMO
POS plans will convert to HMOs (without the POS option) in the following year. Please
note, depending on your HMO POS, you may find that out-of-network costs
do not apply to your plan's that your Maximum Out of Pocket (MOOP)
limit - check with your plan's Member Services for more details.
PPO - Preferred Provider Organization:
Medicare Advantage PPOs have a less-restrictive provider network, but
again, you probably will pay a higher cost-sharing rate when you visit a
healthcare provider outside of your plan’s network.
PFFS - Private Fee for Service plans:
Although popular several years ago, fewer Medicare Advantage PFFS plans
are now available (for instance, only 57 PFFS plans were available in 2016). PFFS
plans have the most flexible network, meaning that you can go to any
health care provider as long as they accept Medicare and the terms and
conditions of your PFFS plan. As noted, PFFS plans are becoming rare, but some people still find PFFS plans as a flexible and economic
alternative to other Medicare Advantage plans.
SNPs - Special Needs Plans: SNPs are Medicare
Advantage plans designed for a people with specific conditions or
financial needs. Certain SNPs are available only to diabetics, people
with chronic cardiac conditions, nursing home residents, or people
eligible for both Medicare and Medicaid (D-SNPs). If you do not have
the plan’s “special need”, you will not be allowed to join (or stay in) the SNP.
MSAs - Medical Savings Accounts: MSAs are
like Health Savings Accounts (or HSAs) or a high-deductible health plan
combined with a spending account that you can use to pay for your health
care costs. MSAs do not provide prescription drug coverage and you
would need to join a separate Medicare Part D plan for your prescription
needs. Unfortunately, few MSAs are available.
MMPs - Medicare-Medicaid Plans: MMP plans were
introduced in 2014 and are only offered in a few locations across the
country. As noted by CMS: "A Medicare-Medicaid Plan (MMP) [like a
D-SNP] is a private health plan that has been competitively selected and
approved to provide integrated care to eligible full-benefit
Medicare-Medicaid enrollees under the CMS Financial Alignment
Demonstration." (CMS, “Financial Alignment Initiative,”
MMPs only serve full benefit dual (Medicare/Medicaid) eligible beneficiaries and some additional limitations may apply.
The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
Medicare has neither reviewed nor endorsed the information on our site.
We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information.
However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist.
For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.
Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
Limitations, copayments, and restrictions may apply.
We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area.
However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service
area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048),
24 hours a day/7 days a week or consult www.medicare.gov.
Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare.
Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits
money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible.
The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll
during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the
Beneficiaries can appoint a representative by submitting CMS Form-1696.