
Trying to figure out Medicare Advantage Prescription Drug (MAPD) plans on your own is like attempting to learn a musical instrument by yourself. It’s possible, might take a while, and it’s unlikely you will reach “first chair” anytime soon.
If you work with a knowledgeable and patient Medicare coach, you can digest the information and make the right decision.

Unless information is organized in the right format, it can be a burden and not a benefit.
The goal of this article is to spotlight general attributes of MAPD plans so people can make an educated decision on whether or not an MAPD plan is the right option for them. But before we can get into MAPD plans, it’s important to understand how Original Medicare works.
Medicare beneficiaries must be enrolled in Original Medicare part A and part B before they can enroll in a MAPD plan or a Medicare Supplement plan with a Part D prescription drug plan, which can happen as early as three months before your 65th birthday.
In 2024 the base Medicare Part B premium is $174.70 per month. Original Medicare Part A and Part B have a deductible and cover 80% of medical costs, and have no “Maximum Out of Pocket” (MOOP) protection. This means if someone gets very ill and the medical bills add up to $1,000,000 they will most likely be responsible for around $200,000 of medical bills.
Now that we have a base understanding of how Original Medicare works, let’s get into the Good, the Bad and the Confusing of Medicare Advantage Plans.

THE GOOD OF MAPD PLANS
- Built-in Maximum Out of Pocket (MOOP) : The maximum out of pocket creates a ceiling on the maximum amount a Medicare beneficiary would have to pay. This can be more beneficial than being responsible for 20% of the cost part B does not cover with no MOOP, which is Original Medicare.
- Zero-Dollar Premiums or Low Premiums : Many MAPD plans have zero dollar or low monthly premiums.
- Extra Benefits : Many MAPD plans come with extra benefits such as: Dental, vision, hearing, over the counter benefits, exercise benefits, gym membership, etc.
- Built-in Prescription Drug Plan : MAPD plans bundle in a part D prescription drug plan, the Medicare beneficiary does not have to purchase one separately to go along with Original Medicare.
- Emphasis on Proactive Health Management : The concept behind MAPD plans is to help Medicare beneficiaries proactively take better care of their health. MAPD plans encourage annual physicals, mammograms, flu shots, RSV vaccines, etc., by generally not charging a copayment for these services. Whereas with Original Medicare there could be cost sharing involved.

THE BAD OF MAPD PLANS
- Networks : MAPD plans are administered through private insurance companies who recruit medical providers, which is essentially their “network”. Each year private insurance companies negotiate with medical providers and either come to an agreement or terminate the MAPD contract with that medical provider. If the medical facility cancels the agreement with the private insurance company, the Medicare beneficiary has two options, change MAPD plans, or change medical providers.
- Rural Areas : People who reside in less populated areas typically have fewer MAPD plan options, and in some cases, no MAPD plan option. This leaves Medicare eligible beneficiaries with two options, stick with Original Medicare part A and part B for $174.70 per month and pick up a part D prescription drug plan or purchase a Medicare Supplement (AKA Medigap) plan and pick up a part D prescription drug plan.
- Prior Authorization : You need to get prior authorization for medical procedures and facilities. We had a situation last year with a client who was admitted to the hospital for a couple of weeks, they needed to go to a skilled nursing facility. We had to wait ten longsuffering days before the private insurance company approved the prior authorization. If this client had been on a Medicare Supplement, they would have been able to get right into the skilled nursing facility.
- Annual Plan Changes : MAPD plans make changes every year and typically not for the better Generally speaking, MAPD plans get less advantageous as time goes on. The extra benefits can decrease, dental benefits might get reduced, prescription drug costs can increase, and some zero-dollar plans start to require premiums. Pay close attention to the annual notice of change (ANOC) each year to understand the changes.
- Co-payments : If a Medicare beneficiary is not familiar with how MAPD plans work, they might get surprised with co-payment bills for specialist visits, EKG’s, pulmonary function tests, MRI’s, Cat Scans, outpatient surgery, and probably the most expensive copayment… Inpatient hospitalization.
- Inappropriate Denials : MAPD plans have been scrutinized by government agencies for inappropriate denials. Apparently, some private insurance companies (who also offer Medicare Supplements) had algorithms automatically declining a certain percentage of claims for medically necessary services causing a lot of frustration for the Medicare beneficiaries.
THE CONFUSING OF MAPD PLANS
- Annual Notice of Change (ANOC) : If you have nothing better to do around September, good news, you will receive about a 100-page document outlining the new changes to your MAPD plan; that is, if the plan is still being “offered in your area”. If it is not still available, you won’t receive an ANOC, you will receive an “IMPORTANCE NOTICE: Your Medicare plan won’t be offered in …”. Trying to decipher the changes can be challenging if you don’t have the skillset.
- Medicare Opinions : If you are getting opinions about Medicare from people who live in remote areas, you might not be getting the full Medicare picture. How would they know what MAPD plans are available in your area, and worse, do they understand how these plans work, what doctors you see and what medications you are on? Taking advice from someone who isn’t a licensed Medicare specialist can actually hurt you more than help.
- Misleading Commercials : If someone is not familiar with Medicare terminology, they might think the advertisement applies to their situation when it does not. For example, during the “Annual Enrollment Period” (AEP) a lot of commercials talk about “putting money back into your Social Security check” which applies to people who have lower monthly incomes when in reality a large percentage of the people who are watching the advertisement won’t qualify for the “extra help” or Medicare Savings programs tied to each state’s Medicaid department.
How is anyone supposed to make sense of the confusing Medicare circus without speaking with a knowledgeable Medicare specialist?

Bottom line, there is a lot to know about the MAPD plan system. Please work with someone who has the skillset to help you make the right decision. There are a lot of spectacular Medicare agents in this space, do not settle for mediocracy, and be open to letting people who really understand this universe help you.