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Question: MA and MAPD: What is the difference between a Medicare Advantage MA and a Medicare Advantage MAPD?
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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.
Important: If you join an MA plan (without prescription drug coverage), you may not be allowed to also add a stand-alone Medicare Part D prescription drug plan. If you want prescription drug coverage and want to join a Medicare Advantage plan, then you probably should choose an MAPD. You can read more here: "Can I enroll in an HMO and then add prescription drug coverage through a stand-alone Medicare Part D plan?"
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.
Types of Medicare Advantage Plans (MA and MAPD)
You can use our Medicare Advantage Plan Finder to browse through the Medicare Advantage plans. As you review plan in your ZIP Code region, you might notice some common types of Medicare Advantage plans .
- 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,”
(www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html.)
MMPs only serve full benefit dual (Medicare/Medicaid) eligible beneficiaries and some additional limitations may apply.
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