Another name for an MAPD plan is called an Advantage plan. They are
provided by insurance companies and represent a replacement for Original
Original Medicare is anyone having Part A & B who gets their coverage
directly through the government. You are also required to have a standalone
drug plan. With Original Medicare you have an 80/20 plan where the
government pays the 80% and you pay the 20%. To keep this explanation
simple, Medicare is the only insurance without a maximum out of pocket. So,
you have medical bills in the several hundred thousand range, and you pay
20% of that bill with no maximum out of pocket. To most seniors that is
scary, and many are retired without a lot of income or living on a fixed
pension and Social Security. Regardless, Medicare is the only insurance in
the country without a maximum out of pocket.
These MAPD plans replace Original Medicare meaning if you sign up for one
of these plans, it replaces Original Medicare, and the insurance company
pays the 80% of your future medical bills. These MAPD plans also include,
for the most part, a drug plan with a specific formulary. So, when reviewing
these plans consider the medications you take, your doctors and hospitals
you want to use in the event you need their services.
Typically, these MAPD plans come in several different types; HMO (Health
Maintenance Organization), PPO (Preferred Provider Organization, & PFFS
(Private Fee for Service).
We will review both the HMO and PPO as there are not many PFFS plans
These plans require you to get a referral from you Primary Care Physician to
see any specialist in their plan. Restrictive as to who you can see and usually
means within the geographic area where you live. There is a trend with a
couple of these HMOs to allow you to see specialists without a referral.
Hopefully other insurance carriers will adopt that policy in the future. (In an
emergency you can see any doctor anywhere in the country and the copays
with be as if you are in network.)
These plans usually have a larger network of doctors than the HMO and
there is no referral to see any doctor in that network. They usually have
doctors across the country so going out of state is allowed. The copays
typically are somewhat higher than the HMO, but the inherent benefits are
the larger national network. You can also see any doctor who takes
Medicare, but the copays will be higher than using in network doctors and
Perhaps an explanation on how these plans came about with help seniors to
understand them better. The government annually does an evaluation by
county to determine what Medicare costs. In Clark County Nevada, which is
basically southern Nevada, the government estimates their costs per
Medicare recipient is around $1100 per month. So, they give the insurance
company $900 per month saving $200 per Medicare recipient. There are
about 140,000 seniors in Clark County with MAPD plans so the savings are
significant. Multiply that by the 6000 counties in the country and those
savings are very significant.
The insurance company has very flexible plans that many seniors want, and
these companies usually offer many additional benefits over Original
Medicare making these plans very attractive to seniors. Some of the
additional benefits include, gym membership, and services like hearing,
vision and dental, which vary by insurance company and plan but are not
available on Original Medicare.
The MAPD marketplace in Clark County represents 82 different plans from
multiple insurance carriers. How does one decide which plan is best for
them? Using a Medicare insurance broker really makes sense not because I
happen to be one but because of the may choices you have and trying to
decide which one will take you forever to figure out.
As a Medicare broker I have at my disposal all the carrier’s plans and must
complete training on these plans annually to maintain my ability to sell
Medicare plans to the public. So, we are specifically trained on all the plans
available and have the tools to determine which plans would work best for
our clients by reviewing their medications, their doctors, and any other bits
of information about the client so we can help them find the best plan for
In review, these MAPD plans offer services not available under Original
Medicare and have typically low costs of usage making them very desirable
The Barend Agency Inc.
Len Barend, broker