MAPD Use

Using your plan

Best to see INN

INN (IN-Network) (aka contracted) providers are best to visit because services are rendered under contractual conditions and pre-agreed. Everyone knows what to expect. Some Plan designs (PPO or POS) allow visits to any providers who will accept payment from the Plan. However, your costs are higher.

Follow the EOB.

The Explanation of Benefits (EOB) is produced by the insurer and shows who is charging for services (the Provider), what's contractually due, what's been contractually paid (to the Provider), and, what's contractually due from the patient (the beneficiary).

Patient's Responsibility.

When using a contracted provider, your responsibility is only what the Plan shows on the EOB. The best course of action is to not pay any billings from the provider until your plan shows you what you owe.

The Provider Bills You. Nope.

At times, there are differences of opinion between what the Contracted Provider bills and the Plan pays. Some Contracted Providers then bill the patient who they see as the responsible party. Not permissible under the Plan's contract.

Not Covered Charges

The Contracted Provider, prior to services rendered must advise you and you must agree to pay, charges that will not be covered. If they do not and you do not, you are not obligated to pay.

Getting Things Correct.

If the Provider submits charges to the Plan with errors, the Plan will deny payment. Usually the resolution is, the Provider corrects and resubmits to the Plan. The Plan approves the billing and your cost share. All is solved. Further disagreements are usually settled under an appeal.

Using the Drug Coverage

Prescription Drug coverage, when included in a MAPD plan, is a separate category with separate rules. Medicare makes the rules, just as they do for medical coverage. Depending on the drug administered, the Plan may require prior authorization, step therapy, limited amounts, or alternative choices.

2025 Adjustments

Starting January 1, 2025, the rules are changing. The Out-of-Pocket Maximum is dropping to $2000. The Coverage Gap Phase is discontinued. As a result, there may be some adjustments in different plans in different companies. For most beneficiaries, 2025 annual costs will be less.

How to Use Your Medicare Advantage Plan