This week, listen in as Kumar answers your more pressing questions about Medicare and Medicare Advantage plans. From breaking down the difference between Part A and Part D, to explaining the financial and clinical benefits of different plan types, this is the perfect episode to tune in to before the Medicare Annual Enrollment Period comes to a close this December 7.
This week, listen in as Kumar answers your more pressing questions about Medicare and Medicare Advantage plans. From breaking down the difference between Part A and Part D, to explaining the financial and clinical benefits of different plan types, this is the perfect episode to tune in to before the Medicare Annual Enrollment Period comes to a close this December 7.
This is the Healthy Aging Podcast from Clover Health, exploring a wide variety of medical and wellness issues for older adults and their families.
Lauren:Hi everyone. Welcome to Clover's Healthy Aging Podcast. I'm Lauren Volkmann from Clover Health and I'm here with Dr. Kumar Dharmarajan, the Chief Scientific Officer at Clover. Welcome Kumar.
:So today we're talking Medicare. Medicare is super confusing, let's be real, but it's open enrollment season so that's what we're going to talk about today. We'd like to help answer your most pressing questions. Let's start with the different parts. It's really an alphabet soup-- there's A, B, C, and D. Can you give us a basic description of each of those?
Kumar:Sure. And I wish it was only A, B, C, and D. There's a lot more alphabets in Medicare. So let me take you through really briefly. So Medicare Part A, think about that as hospital and institutional insurance. So Part A generally covers inpatient hospital stays, skilled nursing care, hospice care, and some limited home health services. And for patients, you typically pay a deductible or coinsurance or copayments for even the things that are covered by Medicare Part A like a hospital stay. Most people are automatically eligible for part a when they turn 65 although others may get eligible sooner-- let's say if you have bad kidney disease or bad neurological disease such as ALS. Part B is different. It's medical insurance, that's how I like to think about it. It generally covers services and items like doctors visits, preventive care, medications you might get in a doctor's office like chemotherapy, durable medical equipment-- that's like a cane or a walker or wheelchair. In Part B, in most cases, folks pay 20% of the Medicare approved amount for each item and there also might be a deductible, so again, people are paying out of pocket in addition to what Medicare covers. Then there is a Part B premium in many cases and that might be higher based on your income. I'm going to go to Part D next and then I'm going to end with Part C. So Part D is an optional prescription drug program-- it's simply insurance for your medication needs. There's a monthly premium you pay and you go with an insurance carrier to get your Pard D benefits and you use that insurance carrier's network of pharmacies for prescription medications you have. There usually is an annual deductible for Part D and then it gets complicated...With Part D there's initial coverage you get, then there's something called, it used to be called the donut hole but now it's called the coverage gap, where you end up paying more and then what's called a catastrophic coverage area where you then pay less. It gets complicated but that's what it is in a nutshell. And I'm going to end with Part C which is what Clover Health is, which is Medicare Advantage or managed Medicare. What is managed Medicare? So what is Clover Health? It is Medicare administered by a private insurance company and it covers everything that original Medicare, that Part A and B that I talked about covers, plus it can give you extra benefits. Unlike original Medicare, Part C generally does offer coverage for prescription drugs that you take at home, and so there is a formulary. And you may get extra benefits like routine dental care, like cleanings, x-rays, routine vision care, like eyeglasses, routine hearing care in some places like hearing aids and fitness benefits, like a gym membership. Not all Medicare part C plans have the same benefits, so it's really important to figure out what each plan offers. So that was a lot, but it is complicated, but there's a way through all that, you know, ABC's mess.
Lauren:That was super informative and I had no idea that you didn't have prescription drug coverage just as part of your traditional Medicare. Same with hearing and vision. Those seem like super obvious benefits, at least for someone coming from like traditional workplace insurance.
Kumar:Yeah, and I think that's one of the things that has driven a lot of folks to Medicare Advantage or Medicare Part C. You know, in the early 2000s there was just a few million Americans who got their Medicare benefits through Part C or through a private insurance company. You know that number now, it goes up every year, every year, and about a third of Medicare beneficiaries now get insurance Advantage plan and those supplemental benefits, the gym memberships, the vision, the hearing, you know, they're a big reason why.
:That definitely makes sense. I mean those are the types of benefits that I would want if I were to lose my employer sponsored coverage. So if you're in a Medicare Advantage plan, can you see whatever doctor you want because most doctors take Medicare I think, but it's just not clear to me if I'll be able to see my doctor.
Kumar:Yeah, I think it's a little complicated. So for many Medicare Advantage plans, they have what's called a restricted network, meaning that they have some doctors that are in network and some that are out of network. For the in network doctors you pay a certain amount. And for out of network, you will usually pay substantially more. Traditional Medicare lets you essentially see anyone who takes Medicare insurance so people have more choice. Clover has really taken a philosophy in this case that's more akin to traditional Medicare, we're what's called a PPO, a preferred provider network. We don't have a restrictive network like many Medicare Advantage plans do because we really think it's important for older adults to have choice as to who they want to see and so this is unique to many Medicare Advantage plans in terms of having options for folks who want to get a wide network, like they would have a traditional Medicare but still get some of those additional supplemental benefits that they won't get through Medicare.
:Definitely. I feel like, I mean a lot of people have been seeing their doctor for many years and don't necessarily want to give that up just because they turn 65. With Medicare Advantage, there's also a cap on out of pocket expenses, which I know can be a huge deal, especially if you're on a fixed income. So traditional Medicare patients are going to be responsible for 20% of treatment costs-- but that can be really expensive, especially if you're in the hospital for a week or you fall, something like that. How does Medicare Advantage differ in that respect?
Kumar:Most Medicare Advantage plans, really all of them, have an annual out of pocket maximum. It differs by plan, but I think for folks who are signing up with a Medicare Advantage plan, they know that there's some cap on what they will spend. So they're not necessarily going to be hit with bills for$50,000,$100k, or even$10-$15,000 so many Medicare Advantage plans cap at something like, four, five or$6,000 a year. That can still be a lot of money, but there's a big difference between having to pay$6,000 versus$60,000 and I think for folks particularly who are sick and frequently use medical care, having that peace of mind that there is an out of pocket maximum that you will hit, I think can be a differentiator for folks and a big reason why they might choose to be with Medicare Advantage rather than traditional Medicare.
Lauren:Totally. In addition to the financial benefits such as that, and I know that a lot of plans have$0 million premiums and$0 copays and things like that that can be really helpful for folks, are there medical or clinical reasons that you might want to be in an MA plan over Medicare?
Kumar:So, so first off, you know, as we said, some Medicare Advantage plans offer additional supplemental benefits. So whether it's vision care, dental care, hearing aids, etc. The other thing that many Medicare Advantage plans offer, not all but many do, is extra benefits, let's say around care coordination or care management. You can call someone who can help you find a service that you might need, whether it's someone, a sub- specialist to take care of a particular medical condition, whether it's a local resource from your local area agency on aging, whether it's a community resource, or an adult take care center or things like that that might be relevant. You know, I think MA plans are generally incentivized to keep people healthier and so they often offer better care navigation resources than traditional Medicare offers.
:So say I'm a senior and I want to join a Medicare Advantage plan-- how do I do that?
Kumar:There are a number of ways to do it. One of the ways is to go directly to the Medicare website, put in information about yourself, especially where you live because you know folks sign up for Medicare Advantage plans that operate in the area where they live. So you can do it directly through the Medicare website. You can contact plans directly-- usually health plans on their own websites have the ability to enroll, and then are brokers. So there are folks who are out there who are trying to give information to older adults about what their options are. And there are a lot of options. A recent study came out that said on average across the United States, seniors can choose this year from about 28 different MA plan options, and so it can be difficult. So sometimes I think having a broker to talk to can be helpful in understanding what the options are.
Lauren:Yeah, that's wild. 28 choices for plans is, especially when you don't know exactly what the differences are. So I'm sure a broker could be helpful in those situations.
Kumar:And I think that's where PPO can be helpful. Because to your point, Lauren, a lot of people have had doctors for many years and then to arbitrarily feel like you have to change at age 65 someone you've known and knows you well and has provided care for you for a long time. And I think that, you know, choosing an MA plan with a PPO structure with a wide network becomes really important. So I think for folks especially who have a number of different providers looking to that network choice ultimately is a big differentiator.
Lauren:Can you sign up for a Medicare or Medicare advantage whenever you want or is there a specific timeline around it?
Kumar:So there's something called the annual enrollment period, which happens every year from October, middle of October to let's say middle of December where folks can sign up for a Medicare Advantage plan. So if they're already with a Medicare Advantage plan, they will continue with that plan unless they do something active to say they want to be with a different plan or you know, they want to move to traditional Medicare. For folks who are in traditional Medicare, the end of the year is that period of time where you can look to what are your other options and sign up. Now it is more complicated than that. There are folks let's say, who have both Medicare and Medicaid, which is a program to help folks with, I would say a lower socioeconomic means, additional healthcare benefits. Folks who are dual eligible, they're eligible for both Medicare and Medicaid, they have greater flexibility to change their plans in the course of the year, not just the annual enrollment period. And increasingly the government is allowing folks who are moving to a new plan to in January and February and the beginning of the year saying, was that the right decision for me? Do I need to move from my plan back to traditional Medicare? And so increasingly there are more options for seniors to change their plans during the year. But at the end of the year for everybody is the big, big push to figure out what's the best match.
Lauren:Great. So as we're in mid November, if you haven't started thinking about it, it's probably time. I think that's it, that was a helpful overview of Medicare. There are obviously a million questions to be had, but that was a great starting point.