How do Medicare Advantage Plans (MAPD) work?

If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare, plus you’ll usually get Medicare drug coverage (Part D) as well.

MAPD plans have provider networks, so it is important to find a plan for where you live that gives you access to the providers you want to be able to get services from. If you choose an HMO MAPD plan, there is no cost sharing available for services from providers outside of the network. If you choose a POS or PPO plan, your costs may be higher if you get services out of network.

What’s covered by MAPD?

These plans must provide coverage for everything Original Medicare covers (but perhaps at a different cost sharing and subject to seeing providers in network) but they may also have coverage for things Original Medicare doesn’t cover such as

  • fitness programs (gym memberships or discounts)
  • Vision, hearing, and dental services (like routine check ups or cleanings)
  • Transportation to doctor visits
  • Over-the-counter drugs
  • Services that promote your health and wellness.

Why are so many of these plans available for $0?

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. Sometimes the company determines they don’t need additional premiums from you to offer those benefits.

Even with the $0 plans, all MAPD plans have an annual out of pocket limit. Once you reach this limit, you’ll pay nothing for services Part A and Part B cover.

Other considerations

Each Medicare Advantage Plan can charge different  out-of-pocket costs.

They can also have different rules for how you get services, like:

  • Whether you need a referral to see a specialist
  • If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
  • These rules can change each year.

What about Medicare Supplement Insurance (Medigap) policies ?

You can’t buy (and don’t need) Medigap while you’re in a Medicare Advantage Plan. You can’t use Medigap to pay for any costs (copayments, deductibles, and premiums) you have under a Medicare Advantage Plan. MediGap only supplements Original Medicare. With MediGap, you’ll need a standalone Part D Presciption Drug Plan.

“We do not offer every Medicare plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”