Medicare Advantage/part D Contract And Enrollment Data
The Medicare Advantage / Part D Contract and Enrollment Data section serves as a centralized repository for publicly available data on contracts and plans, enrollment numbers, service area data, and contact information for MA, Prescription Drug Plan , cost, PACE, and demonstration organizations.
The monthly updates to these contract and enrollment reports are scheduled to be published to the web site by the 15th of each month.
An inventory of the currently available reports is provided below with a brief description of the content.
The Share Of Medicare Beneficiaries In Medicare Advantage Plans Varies Across Counties From Less Than 1% To More Than 70%
Within states, Medicare Advantage penetration varies widely across counties. For example, in Florida, 71 percent of all beneficiaries living in Miami-Dade County are enrolled in Medicare Advantage plans compared to only 14 percent of beneficiaries living in Monroe County .
In 117 counties, accounting for 5 percent of the Medicare population, more than 60% of all Medicare beneficiaries are enrolled in Medicare Advantage plans or cost plans. Many of these counties are centered around large, urban areas, such as Monroe County, NY , which includes Rochester, and Allegheny County, PA , which includes Pittsburgh.
In contrast, in 508 counties, accounting for 3 percent of Medicare beneficiaries, no more than 10 percent of beneficiaries are enrolled in Medicare private plans many of these low penetration counties are in rural parts of the country. Some urban areas, such as Baltimore City and Cook County, IL have low Medicare Advantage enrollment, compared to the national average .
What Mapd Medicare Is
As previously mentioned, MAPD is a particular kind of Medicare that is often used as an alternative to Original Medicare. It works well because it combines Medicare Part A and Part B in one. The most convenient part is that Part D coverage is also included in MAPD Medicare. In addition, prescription drugs are covered in the well-packaged plan. As the policyholder of an MAPD Medicare, you’re covered for a variety of medical services, specific hospital stays and prescription drugs.
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Enrollment In Medicare Advantage Has Doubled Over The Past Decade
Figure 1: Total Medicare Advantage Enrollment, 1999-2020
In 2020, nearly four in ten of all Medicare beneficiaries 24.1 million people out of 62.0 million Medicare beneficiaries overall are enrolled in Medicare Advantage plans this rate has steadily increased over time since the early 2000s. Between 2019 and 2020, total Medicare Advantage enrollment grew by about 2.1 million beneficiaries, or 9 percent nearly the same growth rate as the prior year. The Congressional Budget Office projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to about 51 percent by 2030.
This analysis has been updated to reflect changes in methodology in how KFF calculates the total number of Medicare beneficiaries. These changes affected the share of Medicare beneficiaries enrolled in Medicare Advantage, as well as Medicare Advantage penetration by state and county. Please see methods section for more information.
How Do I Find Out How Much Mapd Plans Cost In My Area
You can find plans in your area using the Medicare Plan Finder. The plan finder is interactive and will ask you for all the information it needs to find the best plan options for you. Youll need to enter:
- The type of plan youre interested in. You can select from Medicare Advantage plans, Medicare Part D plans, both Medicare Part D and Medigap plans, or Medigap plans. Youll select Medicare Advantage plans to search for MAPD plans.
- Your ZIP code. Entering your ZIP code will pull up plans in your area.
- Your county or parish. After you enter your ZIP code, youll need to select your specific county or parish.
- Any help to pay for Medicare you receive. You can then select if youre receiving Medicaid, Social Security Supplemental Income or assistance, or if you have a Medicare Savings Account. Select none if you are paying your Medicare costs out of pocket.
- Your current medications. Youll need to enter all the medications you take and your current pharmacy in order to see drug prices for MAPD plans. Once you enter your medications and pharmacy information, youll see plans in your area. Youll be able to click on the plans to see details, including the price youll pay for your current medications if you chose that MAPD plan.
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What Is A Pdp
A PDP, also known as a prescription drug plan or Medicare Part D, is a stand-alone prescription drug plan that is available to all Medicare-eligible individuals. PDP plans provide beneficiaries with prescription drug coverage for outpatient prescription medications and vaccines . These plans are offered by private insurance companies that work separately from your Original Medicare coverage. Costs and coverage can vary between plans, so it is best to shop multiple plans before enrolling. To enroll in a PDP, you must be enrolled in an Original Medicare plan .
Medicare Advantage Plans: Common Elements
- All plans have a contract with the Centers for Medicare and Medicaid Services .
- The plan must enroll anyone in the service area that has Part A and Part B, except for end-stage renal disease patients.
- Each plan must offer an annual enrollment period.
- You must pay your Medicare Part B premium.
- You pay any plan premium, deductibles, or copayments.
- All plans may provide additional benefits or services not covered by Medicare.
- There is usually less paperwork for you.
- The Centers for Medicare and Medicaid Services pays the plan a set amount for each month that a beneficiary is enrolled.
The Centers for Medicare and Medicaid Services monitors appeals and marketing plans. All plans, except for Private Fee-for-Service, must have a quality assurance program.
If you meet the following requirements, the Medicare Advantage plan must enroll you.
You may be under 65 and you cannot be denied coverage due to pre-existing conditions.
- You have Medicare Part A and Part B.
- You pay the Medicare Part B premium.
- You live in a county serviced by the plan.
- You pay the plan’s monthly premium.
- You are not receiving Medicare due to end-stage kidney disease.
Another type of Medicare Managed Health Maintenance Organization is a Cost Contract HMO. These plans have different requirements for enrollment.
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Disadvantages Of Ma Plans
- MA plans are annual contracts. Plans may decide not to negotiate or renew their contracts.
- Plans may change benefits, increase premiums and increase copayments at the start of each year.
- You may have higher annual out-of-pocket expenses than under Original Medicare with a Medicare supplement plan.
- Your current doctors or hospitals may not be network providers or may not agree to accept the plan’s payment terms.
- In most cases, you cannot keep your stand-alone Medicare Part D plan and the Medicare Advantage plan.
Medicare Advantage Managed Care Plans: Beneficiary Protections
- The plan cannot charge more than a $50 copayment for visits to the emergency room.
- You or your doctor can appeal a denial of service and the appeal must be handled in a “timely” way. The plan must make an initial determination within 14 days. Reconsideration of a decision must be made within 30 days. Decisions regarding urgent care must be made within 72 hours.
- The plan must have a process for identifying and evaluating persons with complex or serious medical conditions. A treatment plan must be developed within 90 days of your enrollment.
- If your treatment plan includes specialists, you must have direct access to those specialists. You do not need a referral from your primary care physician.
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Medicare Part D Coverage Is Offered Through Private Plans That Are Approved By The Federal Government Beneficiaries Who Enroll In Medicare Fee
Established in 2006 by the Medicare Modernization Act , more than 42 million, or roughly 73% of all Medicare beneficiaries, are now enrolled in Medicare Part D coverage, either through standard PDPs or Medicare Advantage Prescription Drug plans .
While Part D was considered controversial at the time of its passage, primarily due to the cost to government and the use of private plans to operate the new benefit, Part D has been a successful program. It greatly expanded coverage for prescription drugs to millions of Medicare beneficiaries, and the annual costs of the program have been below spending projections.
Most Medicare Advantage Enrollees Have Access To Some Benefits Not Covered By Traditional Medicare In 2020
Figure 9: Share of Medicare Advantage Enrollees in Plans with Extra Benefits by Benefit Type, 2020
Medicare Advantage plans may provide extra benefits that are not offered in traditional Medicare, and can use rebate dollars to help cover the cost of extra benefits. Plans can also charge additional premiums for such benefits. Beginning in 2019, Medicare Advantage plans have been able to offer additional supplemental benefits that were not offered in previous years. These supplemental benefits must still be considered primarily health related but CMS expanded this definition, so more items and services are available as supplemental benefits.
Most enrollees are in plans that provide access to eye exams or glasses , telehealth services , dental care , a fitness benefit , and hearing aids . Since 2010, the share of enrollees in plans that provide some dental care, fitness benefits, or hearing aids has increased while the share with a vision benefit has been relatively steady .
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What Are Medicare Advantage Prescription Drug Plans
A MAPD plan is a Medicare Advantage plan that includes Medicare Part D prescription drug coverage. Medicare Advantage plans offer all the coverage of original Medicare , and often include additional services.
When a Medicare Advantage plan offers prescription drug coverage, it is known as a MAPD plan. MAPD plans can be a great option for people who want to have all their coverage bundled into one plan.
Things To Consider Before You Buy A Plan
Ask your medical providers If they’ll take the MA plan.
Ask the plan if It requires a referral for you to see a specialist.
If you live in another state part of the year, find out if the plan will still cover you. Many plans require you to use regular services within the service area , which is usually the county in the state where you live.
Find out if the plan includes:
- Monthly premiums
- Any copayments for various services
- Any out-of-pocket limits
- Costs to use non-network providers
If you have Medicaid or receive long-term care, or live in a nursing home, Special Needs Plans may be available in your area. If you choose other types of MA plans, find out if:
- The plan’s in-network providers you use are certified to accept Medicaid.
- In-network providers bill the plan correctly and/or refer to Medicaid providers as needed.
- The providers’ office knows what Medicaid covers and what the plan covers.
- You’ll have monthly premiums to pay. Medicaid will not cover MA plan premiums.
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More Than 3 Million Medicare Beneficiaries Are Enrolled In Special Needs Plans In 2020
Figure 12: Number of Beneficiaries in Special Needs Plans, 2006-2020
More than three million Medicare beneficiaries are enrolled in Special Needs Plans . SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs. The majority of SNP enrollees are in plans for beneficiaries dually eligible for Medicare and Medicaid , Another 11 percent of enrollees are in plans for people with severe chronic or disabling conditions and 3 percent are in plans for beneficiaries requiring a nursing home or institutional level of care .
Enrollment in SNPs increased from 2.9 million beneficiaries in 2019 to 3.3 million beneficiaries in 2020 , accounting for about 14 percent of total Medicare Advantage enrollment in 2020, with some variation across states. In nine states, the District of Columbia, and Puerto Rico, enrollment in SNPs comprises at least one-fifth of Medicare Advantage enrollment . Most C-SNP enrollees are in plans for people with diabetes or cardiovascular disorders in 2020. Enrollment in I-SNPs has been increasing but is still fewer than 100,000 beneficiaries in 2020.
Changes for 2020 due to COVID-19: In response to the public health emergency, CMS will use discretion when enforcing certain oversight and monitoring activities relating to SNPs, including if Medicare Advantage plans do not fully comply with their approved SNP model of care or if plans experience delays in recertifying SNP eligibility.
What Is A Medicare Part D Plan
Medicare beneficiaries can receive prescription drug coverage either through a stand-alone Part D plan or through a bundled MAPD plan.
Like MA plans, Part D plans are sold by private insurance companies. These plans use a drug list called a formulary that outlines the covered prescription drugs for that plan.
The formulary organizes medicines into pricing tiers, with tier 1 generic drugs typically being the least costly. The amount you pay for medication depends on the tier. Formularies differ between plans and between the insurance providers.
It’s essential that before enrolling in any MAPD or in an independent Part D plan you review the formulary to make sure that your prescription medications are included.
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Are There Any Protections If I Enroll In A Plan And Do Not Like It
In order to enable beneficiaries to try a Medicare Advantage plan, but still have the option of returning to Original Medicare, a number of protections are in place. These protections will enable beneficiaries, in certain situations, to try a plan, but then return to Original Medicare and a Medicare Supplement policy if they want to do so.
Under these protections, beneficiaries will have guarantee issue of a Medicare Supplement policy as long as they meet one of the following criteria. For eligible beneficiaries, companies which sell supplement policies will not be able to deny coverage, charge more, or exclude benefits. However, to receive these protections, beneficiaries must apply for a supplement policy within 63 days of disenrolling from the health plan, or within 63 days of the termination of the health plan.
A beneficiary would be eligible for the Medicare Supplement protections if they meet one of the following criteria.
You are enrolled in a Medicare Advantage plan and one of the following happens:
- The contract between Medicare and the plan ends.
- The plan service area no longer covers the county where you live.
- You move out of the plan service area.
- There are violations by the plan.
Protection: In this case, you would get a guaranteed issue of a Medicare Supplement Plan A, B, C, or F from any company .
Protection: You are guaranteed to get any Medicare Supplement plan with any company .
The Share Of Medicare Beneficiaries In Medicare Advantage Plans By State Ranges From 1% To Over 40%
The share of Medicare beneficiaries in Medicare Advantage plans , varies across the country. More than 40 percent of Medicare beneficiaries are enrolled in Medicare Advantage plans in nineteen states and Puerto Rico. Medicare Advantage enrollment is relatively low in nine states, including two mostly rural states where it is virtually non-existent .
Historically, the majority of Medicare private health plan enrollment in Minnesota has been in cost plans, rather than risk-based Medicare Advantage plans, but as of 2019, most cost plans in Minnesota are no longer offered and have been replaced with risk-based HMOs and PPOs.
Changes for 2020 due to COVID-19: The COVID-19 stimulus package, the Coronavirus Aid, Relief, and Economic Security Act, includes $100 billion in new funds for hospitals and other health care entities. The Centers for Medicare and Medicaid Services has recently made $30 billion of these funds available to health care providers based on their share of total Medicare fee-for-service reimbursements in 2019, resulting in higher payments to hospitals in some states than in others. Hospitals in states with higher shares of Medicare Advantage enrollees may have lower FFS reimbursement overall. As a result, some hospitals and other health care entities may be reimbursed less that they would if the allocation of funds took into account payments received on behalf of Medicare Advantage enrollees.
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Costs For Medicare Advantage Plans
What you pay in a Medicare Advantage Plan depends on several factors. In most cases, youll need to use health care providers who participate in the plans network. Some plans wont cover services from providers outside the plans network and service area.
Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for all Part A and Part B services. Once you reach this limit, youll pay nothing for services Part A and Part B cover.
Benefits Of Mapd Medicare
So why should you go through the trouble of trying to find out if you are eligible for MAPD Medicare? What are the benefits? In fact, there are many advantages to this type of plan as compared to other plans under the Medicare packages.
First, MAPD offers a neatly bundled option to manage medical costs and coverage in the very same plan. This is far more streamlined than getting separate plans for each medical concern. In addition, MAPD plans are offered by private insurance companies so you do not have to go to another government plan. MAPD may also offer additional benefits for little or no cost.
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What Types Of Mapd And Medicare Part D Plans Are Available
Several Medicare Advantage plan types that include MAPD coverage are available. The plan you choose dictates your healthcare coverage as well as your drug coverage.
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Also, these policies may possess additional benefits that Original Medicare does not typically include. So, ensuring that your Medicare Advantage plan holistically fits your needs is crucial not just through the PDP.
Not all locations offer the same types of Medicare Advantage plans with MAPD coverage. The most common types include Health Maintenance Organizations and Preferred Provider Organizations .
HMOs are most common in the Medicare Advantage world, but they are the most restrictive, with potentially limiting provider networks. Additionally, those on HMOs may need a referral before seeing a specialist.
On the other hand, PPOs have less restrictive doctor networks. Yet, they come with higher premiums than HMO plans.
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Two additional types of Medicare Advantage plans offering MAPD coverage are Private Fee-for-Service and Special Needs Plans . Only people with specific health conditions and special financial needs can enroll in an SNP.
Several Medicare Part D PDP plans are available through multiple carriers. Unlike the different types of coverage that comes along with MAPD benefits, the basis of all Medicare Part D PDPs is the same.
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