Seniors Living Healthy - Episode 4

Everything You Need to Know About Medicare Advantage Plans (Medicare Part C)

Announcer: Welcome to our fireside chat with Seniors Living Healthy, the podcast that helps prepare and educate you as you enter and live out your golden years. With over 10 years of experience, Nick and Zach are experts in the senior market and are here to help you live a healthy, full life. And now fireside with your hosts, Nick Keene, and Zach Haire.

Zach: Hello, and welcome back to another episode of Seniors Living Healthy. As always, I’m your host, Zach, and beside me is Nick.

Nick: Hello, folks.

Zach: You guys, this episode we’re going to look into the different options to fill in those gaps that Medicare covers where we’ve talked about in the previous episodes, with Part A being your hospitalization, and Part B being your outpatient. There are two different options out there. One of them is Medicare Supplements, which we’re going to touch on next episode, where this episode we’re going to focus on Medicare Advantage. You may see him also called MAPD or Part C of Medicare. Especially with Annual Enrollment Period coming up, you’re going to see a lot of TV advertisements, radio advertisements, billboards, things in your mail, all of that stuff, in regards to that.

So, guys, as always, usually do a product review in our episodes, but since this whole episode is on a product, we’re just going to jump right into it and just cover the whole product as a whole. And then, as always, we’ll go into our interview, our confession section, and then wrap up the episode. So, now that we’ve talked about A and B has all these gaps, this episode—and we’re going to spill over into next episode—we’re going to talk about what covers those gaps that Medicare doesn’t. Some different options, everything out there for you. So, Nick, give me a quick rundown just to refresh everybody, what some of those gaps are?

Nick: Sure, absolutely, Zach. So, the main two parts of Medicare Part A and Part B. As you alluded to, Part A is the hospitalization, Part B is the outpatient. So, some of the major gaps under Part A of Medicare are, Medicare Part A has a $1408 deductible per 60-day benefit period. And then also beyond that, for individuals that required skilled facility care beyond hospital stays, Medicare covers all but $176 day 21 through 100, with Medicare paying 100 percent, day 1 through 20 provided that an individual is in the hospital three days or more and admitted to that facility within 30 days. Then as far as Part B, Zach, as you know, Part B of Medicare has an 80/20 coinsurance. The clients are responsible for the remaining 20 percent that Medicare does not pay, as well as a annual deductible of $198 per year.

Zach: Great, Nick. So, now we’re caught up with the different gaps and everything out there. There are two options, really, when it comes out there to filling in gaps in your Medicare. One of them is Medicare Supplements; we’re going to spend next episode talking about this one. So, this episode, we’re going to talk about Medicare Advantage Plans. You may see that also referred to as Part C, or MAPD. That’s a couple of different lingo we use in our industry. You’ll see it, especially with Annual Enrollment Period coming up. So, you’re going to see a lot of advertisements, billboards, radio ads, things like that for those products. And so, Medicare Advantage Plan, lack of better terms, it replaces A and B of Medicare.

Nick: Absolutely. Yep.


Zach: So, Nick, looking out there, there are several different types of MAPDs, you want to run through those real quick, maybe touch on the two main ones that are out there, and we’ll go from there.

Nick: Sure, absolutely. So, there’s a number of different types of Medicare Advantage Plans that are offered on the market, Zach, but the few that are the most common are going to be the HMO, which stands for Health Maintenance Organization, the PPO, which is a Preferred Provider Organization, and then SNP plans: Special Needs Plans. Those plans are specified for specific portions of the population, whether that be dual-eligible Medicare beneficiaries, institutionalized Medicare beneficiaries or Medicare beneficiaries with chronic conditions. 

But back to the main two, the HMO plans are primary care physician based. What that means, Zach, is the beneficiary’s care is all handled directly through their primary care physician, and any doctors or specialists within that network or outside, are only available to the client with a referral from that primary care physician. And their networks are typically county-based or sometimes multi-county based, but they’re for individuals that don’t do a lot of traveling. They do have set copays on a lot of services, and they typically are relatively inexpensive. 

And then the PPOs: there is no requirement for a referral on a PPO. They typically are going to have larger networks, regional, or in some cases, national networks. So, those are some options that individuals that may travel may be more appealing. And typically, they’re also pretty relatively inexpensive as well.

Zach: Great, Nick, so like I said, the plans themselves are fairly inexpensive, meaning a lot of them don’t have premiums, or they have very small premiums. So, they do, kind of, replace Medicare a little bit. What are some of the gaps still? Are there expenses out, that you are still responsible for on an HMO or a PPO plan?

Nick: Right. So, traditionally—and unlike Medicare Supplement plans that we’ve talked about on our podcast, or we will be talking about shortly—these types of plans, Zach, aren’t standardized. So, the only thing that a Medicare Advantage Plan has to do is offer benefits equivalent to original Parts A and B of Medicare. So, in most plans, you are going to have, day one through five, day one through eight, you’re going to have per day costs while you’re in the hospital, individuals are going to have copays in a lot of instances, whether it’s at the primary care, or the specialist doctor visits, copays at the emergency room, copays in some instances on lab work, CAT scans, MRIs, things of that nature. And keep in mind, folks, since these plans are network-based, in some plans more than others—HMOs for instance—if you go outside of the network, short of emergency care, and other limited instances, these plans don’t cover. So, it’s very important if you’re on one of these types of plans, or are considering taking one of these types of plans, that you consider that when you are looking to purchase one.

Zach: Great, great. So, what are some added benefits that these Advantage plans have? We talked last episode about prescription plans, and you do have MAPDs out there that—Medicare Advantage Prescription Drug Plan, as in the name itself, it does include your prescription coverage. So, one—a two-part question there touched on, the prescription component of an MAPD as well as any added benefits, whether gym memberships, things such as that, that a member client could get when enrolling in one of these plans.

Nick: Sure. So, the added benefits are something that we get asked about this constantly. The first three that come to my mind, Zach, as most people know or may not know, Medicare does not cover dental, vision, or hearing in most limited instances. So, for instance, dental insurance: Medicare covers nothing dental, most of these Medicare Advantage providers are giving individuals either a dental allowance in a given year or in some instances are actually offering them dental benefits through these plans. Vision: another thing, eye exams, lenses, frames, things of that nature, Medicare doesn’t cover. 

So, a lot of these providers are giving additional benefits in that regard on an annual basis, as I said, whether it’s their reimbursement or traditional insurance. And then to touch on your other point, Zach, I think it’s important to note that Medicare Advantage Plans wrap up and replace Part A and B, but also incorporate Part D of Medicare in the same type of plan. So, unlike Medicare, and a supplement and a stand-alone drug plan, it’s all in one card. It’s very simple for the senior market. They can take their card, whether they go to the pharmacy, the doctor, or the hospital, and know that that one card will be their coverage across the board. That’s a huge benefit, sometimes.

Zach: Oh, yeah. Yeah. Only keeping up with one card, especially in our market, that makes their life a lot easier.

Nick: Absolutely.

Zach: So, closing up this section here, we’ve hit on it here and there, we’ve talked about Annual Enrollment Period, things like that. When enrolling these plans, they are, as we’ve said, government ran, so they do have a little more restrictions, when you can enroll with those, sign up for those plans. Nick, if you want to touch on that real quickly—with AEP, in this sense, you know, it is coming up quickly—when can somebody get into one of these plans?

Nick: So, there’s three most common scenarios that an individual can purchase a Medicare Advantage Plan, or switch to another plan, or leave their current plan. The most common scenario that most people are aware of is, of course, AEP, or the Annual Enrollment Period. And that runs October 15th through December 7th of each year, so we are fastly approaching that period. But in this time, individuals that are Medicare eligible can make all three types of plan changes: they can enroll into a new Medicare Advantage Plan from original Medicare, they can switch from a Medicare Advantage Plan to a different Medicare Advantage Plan, or if they ultimately decide to leave a Medicare Advantage Plan and go back to Medicare, they can do that as well. So, all three plan changes are allowed in Medicare in AEP, and all of those changes take effect January 1 of the next year.

Zach: And of course, if you are new to Medicare, you can enroll. You have three months before and three months after, of course, when you turn 65 or take your Part B of Medicare. A lot of those occur the same time, a lot of people, but some people do delay their Part B, which gives them that enrollment period.

Next up guys, rolling into our next session here with our interview portion, we’re going to be with Tausha with Aetna. Going to be jumping on a call with us answering some questions about these Medicare Advantage Plans.

All right, guys, and so, for our next session here, again, it’s going to be our interview portion. So, as you know, this episode we’ve been talking about the Medicare Advantage Plans, Part C, MAPDs, a couple different names out there for them. And again, we are glad to welcome Tausha Mitcham from Aetna, their national sales director, getting her to join us here on the call, ask her some questions about these plans. What all is out there for him?

Nick: All right. Tausha, I want to thank you again for joining us and we know your time is money, so we’ll jump right in. What are some advantages of an individual Medicare beneficiary choosing a Medicare Advantage Plan or MAPD over traditional Medicare?

Tausha: Sure. So, Medicare Advantage Plans give you additional benefits that original Medicare does not cover. It basically Medicare Advantage Plan will pick up, like, deductibles, and coinsurance, things of that nature traditional Medicare does not cover.

Nick: So, kind of, additional benefits would be the synopsis there. Okay.

Tausha: Mm-hm. And anything above and beyond, so wherever you have your gaps. I guess, like I said, copayments, deductibles for hospitalization, office visits, prescriptions, things of that nature.

Zach: So, we touched on a little bit earlier in this episode, but what are some of the most common types of MAPDs, Advantage Plans out there on the market?

Tausha: Sure, absolutely. So, it would be HMO plans, PPO plans, and POS, which we call Point Of Service plans.

Nick: And just to follow up on that question, real quick. You know well as we do that HMO and PPO are by far the most common types. Tell us the, maybe, just two or three major differences between those two plans?

Tausha: Sure. So, HMO plans, the best way to look at it is everything’s authorized and directed through a primary care physician, and it’s generally going to be a plan that you would utilize the network and physicians within, say, the county that you live in. Some of our plans do go beyond counties, but generally, it’s always going to be within their respective state, and county, again, as I stated. And then a PPO plan, again, most often you want to be authorized and directed through a physician, of course, but it gives you more flexibility. With PPOs you generally don’t have to get any kind of authorization in advance, you have a little more flexibility as it relates to going in and out of some specialists and primary care doctors, again, without having to get any type of a pre-authorization. And then with our PPO plans, we do have national models. So, we have national networks, if you will. And depending upon, again, the state that you’re in and the county that you’re in, what plans are available to you.

Nick: Sure, okay. Maybe give us some of the types of additional benefits that some Medicare Advantage Plans cover that Medicare does not?

Tausha: Sure. So, some examples would be dental, vision, hearing, transportation, over-the-counter, meals after hospitalization, and then the case of that MAPD, which is Medicare Advantage which includes a prescription benefit, it gives you prescription drug coverage all in one package. And then Medicare Advantage over traditional Medicare has a stopgap in place that caps the amount of spending that you would do each year, which is called a max out of pocket.

Zach: Thank you for those little highlights there. So, we’re out there, a potential client looking, getting ready to choose an MAPD, what are some factors they should consider?

Tausha: Sure. So, what you want to do is consider whether you want a broad network; a specific provider; what your prescriptions that you need to be covered; your hospital system, you want to ensure that it’s in-network—again, we always want to drive the network; and if you travel, you want to make sure that it’s a portable plan, especially for emergency services. So, we just talked about portability would be those national type of plans that have a national [00:14:12 unintelligible] network so that you’ve got access to physicians outside of where you reside, especially if you’re traveling.

Nick: Very good. Thank you for that, Tausha. So, as we wrap up here, give us some information. Tell us about any exciting changes coming to Aetna CVS MAPD portfolio 2021.

Tausha: Sure. Thanks so much. So, we are extremely excited about this, and it’s just great for us, our new SmartRx low premium PDP plan. So, it’s under $8 nationally; it will vary based upon the state, but none of the plans will be over $8. 

Also, we have our Health Hubs. What Aetna CVS plans to do is have 1500 of them nationwide by the end of 2021. And our Health Hubs are there really to help for additional care in between a member’s doctor’s appointments. You’ll find them, generally, in CVS stores, and in some cases, it will also be Target where there’s a CVS within the Target facility. Also, which I think is kind of cool, CVS is now allowing PayPal for the patrons, and possibly in the future, they’re going to look to roll out Venmo which is kind of exciting. 

And then there’s 115 expansion counties for Aetna, with 1 new state, 288 DSNP expansion counties with 9 new states, which is really big for us, and we’re really trying to expand more of the DSNP opportunities. We have new HMO product offerings. And then there’s a new veteran plan nationally as well and it’s called the Eagle Plan. And just to know, 88 percent of Aetna members are in four-plus star plans. 

And then just a few other things just to know about CVS Aetna, with the integration of the company, you know, that we’ve done is we care about the whole member. So, we look at it as we’re personalizing a bundle, and that’s through our Medicare Advantage Plans which we talked about. Our HMO, PPOs, and some POS plans are SilverScript, which is our Part D PDP. DSNP specialty needs plans, Medicare Supplement, and then ancillary products, which could be hospital indemnity, cancer and heart attack, home health care, and more. 

And then lastly, one of the things that I pride myself on working for an organization that really embraced COVID-19 this year. We waived all of our COVID-related copayments, and then probably the biggest highlight is that as we had certain hotspots throughout the United States with COVID, CVS implemented testing sites to help with the testing process and to ensure that those tests were getting back fast enough to help citizens. And so that that would be the biggest highlight for us for ’21. We’re super excited about them.

Nick: Great. Thanks for that, Tausha. We are excited to see those product launches here in 2021, know those changes will be coming out soon. It’s hard to believe AEP’s about to be here again. But we certainly appreciate your time this morning and jumping on and giving us some information for our listeners.

Tausha: Great. Well, thanks for giving me the opportunity, I appreciate it.

Zach: For our next part here, as always, our Medicare confession where Nick or I will talk about how we have helped somebody in this area, especially in the product—as in, we said this episode’s product is your MAPD. Last Annual Enrollment Period, I’d had a client for several years, the wife had been on a Supplement, different options, things there, back and forth. And, as always, here at Senior Benefit, we want to find what works best for the client, meets their needs. We want to make sure the plan we put them in is the best for them. We don’t just try to put a square peg in a round hole.

So, she’d been a client for several years, hadn’t really spoke to her husband very much. He had had a plan, was happy with it. And some things came up, wasn’t very happy with his plan, and so he was ready to make a change. So, he had been on an MAPD Advantage Plan for several years. 

So, of course, during Annual Enrollment Period, we were able to review his options. Going through them there, we were able to find an MAPD that was going to really help his prescriptions more than anything. It was going to be a money saver on his prescriptions. He’d been in one for several years, never reviewed his options. He thought it just rolled over, same coverage, but as we know, unfortunately, things do change. Prices go up on prescriptions, companies may stop covering prescriptions, things like that. 

So that’s why, you guys, no matter what you have out there, we do recommend every AEP at a minimum, reviewing your options. Like I said, we were able to switch this gentleman to a different MAPD, saved him a lot of money on his prescriptions as well as got him in a better network that suited where he lived with the doctors and everything he wanted to see there.

All right guys, so in closing here, wrapping up this fourth episode on Medicare Advantage Plans, Nick and I would like to thank you for listening, tuning in. We hope this podcast answered many of the questions about your MAPDs. Remember, they are government ran, meaning you can only sign up during certain periods. And, like I said, AEP is right around the corner here, so it’s a great time to look and see what you can do for this coming year. 

As well, a lot of these plans, they do have extra benefits. They may include some type of gym membership, gym discount, vision, hearing, dental discounts, things like that, as well as a lot of them do have zero premium, things like that with them. A lot of them do have their copays and deductibles, and also want to make sure while looking at a plan that you do find something in-network. You want to make sure that the network includes the doctors, specialists that you like to see. So, Nick, again thanks for jumping on and joining us here, and breaking down some Medicare Advantage Plans.

Nick: Absolutely. Once again, folks, we thank you for tuning in, listening. Reach out to us, with AEP coming upon us, or any time of year for that matter. We’d love to work with you, answer any questions you have and go from there. Thanks again.

Zach: Again, we want to thank Tausha with Aetna for jumping on the phone with us, and answering some questions about these Medicare Advantage Plans, and breaking it down, and tell us what Aetna’s got new, coming in 2021. Again, if you ever have any questions about MAPDs or Medicare in general, you can give us a call, 844-437-4253, or email us, [email protected]. Guys, until next episode, good day and God Bless.

Nick: Take care.

Announcer: Thank you for listening, and we hope you found this episode informative. If we answered your questions, odds are you aren’t the only one wanting to know. So, please share this episode with your friends and family. If you enjoyed this episode, please subscribe and rate our show on Apple Podcasts, or wherever you listen to podcasts to catch all of our episodes. If you want more information, or want to talk directly with Nick and Zach, you can call them at 1-844-437-4253. You can also find them on Facebook at or on their website. Thanks for listening, and have a great day.

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