We explain, in understandable terms, how insurance works for you.
We explain, in understandable terms, how insurance works for you.
iA MAPD is a (M)edicare (A)dvantage (P)rescription (D)rug plan. It's different than a Medicare Supplement Plan. It's a cost co-share plan which includes drug coverage and, most of the time, an array of additional benefits, approved by Medicare, that are included.
Most of the time, but not always, it's best to visit contracted network providers. Some plans allow visits to any providers. Services are rendered under contractual conditions and treatment is advised.
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). Nothing else is due.
Amounts due are determined by the Plan. All parties (Plan, Providers and Beneficiaries) pre-agree as to the amounts. The Provider is to bill the beneficiary only allowed amounts.
As shown on the EOB, you, as the beneficiary, owe only the amount shown as your share as determined by the plan. The Provider has a contract with the Plan to provide services at an agreed price. The Plan has a contract with you, the patient, to pay your share. Your only responsibility is what the Plan determines is your share.
At times, there are differences between what the Provider bills and the Plan pays. Some Providers resort to billing the differences (aka Balance Billing) to the patient who they see as the responsible party. Not permissible under the Plan's contract.
Usually, the error is resubmitted by the Provider, the Plan revises the billing and all is solved. Should there actually be a dispute, there is a provision to appeal.
Prescription Drug coverage, in a MAPD plan, is a separate category with separate rules. Medicare makes the rules, just as they do for medical coverage.
Drugs encompass a range of treatment effects., and a range of availability from freely available to not so freely available. Same situation with pricing. Your physician prescribes what is expected to help you in your situation.
Usually drugs are prescribed with function in mind. Human beings are one-off organisms where sometimes the inexpensive formulation does not work but the brandname formulation will. A process is in place for the physician to petition the plan on behalf of the patient. The plan is not obligated to cover drugs not on the formulary.
The short version of payment under the PDP rules is the beneficiary pays 100 percent of the cost until the deductble is met. Then, the Plan and the Beneficiary share the cost until the first trigger, the Initial Coverage Phase, is met. Then, the Plan, the Beneficiary and the Drug Manufacturer share the cost until the Coverage Gap Phase is met. At that trigger point, the Plan steps in and pays 100 percent for the balance of the year. On January 1st, the Plan resets and everything starts over
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