We explain, in understandable terms, how insurance works for you.
We explain, in understandable terms, how insurance works for you.
A 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, most of the time, and an array of additional benefits such as dental, vision, etc.
Most of the time, but not always required, it's best to visit contracted network providers because services rendered under contractual conditions are pre-agreed; everyone knows what to expect. Some Plans are designed to allow visits to any providers who will accept payment from the Plan, however, the costs are higher.
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).
When using a contracted provider, your responsibility is 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.
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 which is not permissible under the Plan's contract.
If the services are submitted to the Plan have errors, the Plan will deny payment. Usually the resolution is the Provider corrects the codes and resubmits to the Plan. The Plan approves the billing and all is solved. Should there be a dispute, beneficiaries have the right 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. Depending on the drug, the Plan may require prior authorization, step therapy, limited amounts, or alternative choices.
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
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 drug plans in different companies.
This page is under revision.
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