Transcription:

Caitlin Whyte: Welcome to Hally HealthCast the wellness podcast from Hally Health, your partner in helping you live your healthiest life. Every episode on our podcast addresses a new topic, important to your health and wellbeing. Bringing in expert doctors, insurance specialists, and other healthcare experts who offer advice and answer your most pressing questions. October is national dental hygiene month. It's also an important month for everyone who's eligible for Medicare. On the 15th, the annual enrollment period begins.

It's the time of year, when you can enroll in a new Medicare Advantage plan, compare your different options and find the plan that's best for you. Which is why today we're talking about dental care on our podcast, why it's important and more specifically information about coverage for those on Medicare. Here with us is Greg Mattola. He's the consumer retention manager at Health Alliance, which offers Medicare Advantage plans for people in Illinois, Iowa, Indiana, Ohio, and Washington.

Greg has over 20 years of customer service experience and is an expert on Medicare Advantage plans and their coverage of dental care. Welcome, Greg. Thanks so much for being on the show today. Well, let's begin here, Greg, with perhaps the most simple, but still a very key question. Why is dental care so important for our health and wellbeing, especially for those of us age 65 and above?

Gregg Mottola: Well, thank you for asking that. That is a great question. So, I mean, generally speaking, right. Many people probably out there know, or maybe they don't know that inflammation is caused by gum disease is linked to heart disease. So, and that really goes for everyone of any age, obviously you're at higher risk of the older you get. But that's one of the things that I learned at my dentist early on years ago, another thing is if you have some of those more serious illnesses like diabetes and whatnot, the glucose levels or sugar levels in your Saliva kind of contribute to the growth of bacteria in your mouth.

So again, anyone of any age who has diabetes is higher risk there of gum disease and the correlation between the two, but more specifically, you asked about the over 65 population, which is our Medicare population. A couple things there. One thing, obviously, tooth loss is a common thing in older adults. I don't know if you know, but one in five adults have lost all of their teeth over the age of 65 and that's according to the CDC. So tooth loss obviously can affect nutrition, can affect what types of things seniors eat. And obviously. Which is important to everyone, but I'm sure seniors as well is, you like to be able to eat what you like.

Right. And the less, the less things that you can eat, the less likely you are to have the proper nutrition. And then of course, tooth the decay. So all the individuals tend to be on more medications and younger individual. And what that can cause is dry mouth, right? So dry mouth in your mouth can cause bacteria. And those side effects of those certain drugs that are, you know, used for things like asthma or high blood pressure and depression can all contribute to that. So really that is a couple of the points I'd like to make in terms of, why it's important for seniors, especially to have a good dental plan or to be able to keep up with their teeth.

Caitlin Whyte: Well, thank you for that. So with dental care being so important, many people might assume that Medicare just always covers it, but that's not always the case. Can you tell us more about this?

Gregg Mottola: Sure. So one of the things I'd probably like to tell you is really the differences between like original Medicare and a Medicare advantage plan, which is the plan that we offer at Health Alliance. So original Medicare covers about 80% of the costs of your medical services. So there's some perks to that. There's no dental network. It's really anyone who accepts Medicare, so you can go anywhere in the country. So that's a plus, but again, it only covers up on average, about 80% of your bills plus there's deductibles. So there's deductibles for hospitalization, there's deductibles for your outpatient care, et cetera. And there's also no out of pocket limit.

So if you have a rough year medically and you got sick frequently or hospitalized multiple times, there's no stop gap there for you. Right? So a Medicare Advantage plan and there's many benefits to a Medicare Advantage plan, but one of the major ones is it does have a stop gap there isn't out of pocket max. Now you might have to adhere to a network depending on what type of plan you're on. But the typically we can speak for ourselves. Our network is pretty vast, and usually individuals don't have issues finding a doctor that they like, a PCP or even specialist, but nonetheless, we also offer plans that gives you more flexibility. Right.

But I would say in addition to that, the out of pocket maximum where you have a worst case scenario, you're not gonna go over so many thousands of dollars in any given year. There's also a lot of those extra perks, like dental, unfortunately, original Medicare does not cover dental, for one reason or another, they don't feel like that is medically necessary if you will. I don't see how not having good healthy teeth would fall in that category. Right. But really, it doesn't. At least at this point, according to original, now there are some instances with injuries and stuff that may affect your mouth, where there could be some coverage, but that's very basic.

None of the preventative. Or what they call supplemental benefit benefits are covered by original Medicare, but on Medicare Advantage plans, many of them, including ours have coverage for dental, some more than others. And we've actually in the recent year have just enhanced that quite a bit.

Caitlin Whyte: Great explanation. Thank you so much. Now I know that you and your colleagues at Health Alliance are often out and about in the community meeting people and educating them about Medicare. I bet you hear quite a lot about the importance of dental coverage. Can you tell us more about that? Is that the case?

Gregg Mottola: Yes. I mean, it's not just out and out in the community and we do. A very active voiced group of membership, right? So they're very in tune to the things that they need. They advocate not only for themselves, but for their others. And I go out throughout the year to various locations for different retention events throughout the communities. And we always hear how, we're so happy you have a dental plan. We wish it could even be more, and we get that sort of a lot. Again, that was one of the drivers for this current year why we did such a substantial kind of increase in that coverage, but what I could also tell you is just looking at the data, I'm in retention, so I'm a data guy.

You go through many webinars, you look through the data and really dental coverage and the need, or the want for a membership in that senior demographic for some sort of dental coverage, is always in the top three. So it's very important to seniors and for those reasons that I mentioned before and it's just nice to be able to smile and have a healthy mouth, and be able to eat the things that you love to eat. So makes sense.

Caitlin Whyte: Absolutely. So it's safe to say that you and your team made a conscious choice you might say to listen to people's needs and begin offering that even more robust dental coverage. Is that correct?

Gregg Mottola: That would actu.Ally be 100% accurate. Yes

Caitlin Whyte: Well that is just so good to hear now, before we get into talking about specific benefits and costs and similar details, we need to mention an important disclaimer, Health Alliance and your colleagues in Washington at Health Alliance Northwest offer many different types of Medicare Advantage plans. These even include ones under the

popular simply

Caitlin Whyte: OSF, Med Advantage and Reid Health Alliance Medicare brands. I imagine that specific dental benefits vary based on the plan you have?

Gregg Mottola: That is correct. Yes. I would say for the most part, though, many of our plans offer for the most part, the same coverage. There are a few exceptions. You mentioned that Health Alliance Northwest market, where there is a little lower coverage, or I should say the coverage that we offer hadn't changed from the prior year to this new year. But for the complete plan that you mentioned and the OSF Med Advantage plans and all of what we call our legacy plans in our core market, which is in the Illinois counties that we serve, did increase substantially.

There is one caveat to that. One of our plans the OSF realm, it's called the OSF Enrich plan has a slightly more nuanced benefits. Instead of it being a $1,500 maximum reimbursement benefit. Its only at a thousand, but it's still much, much higher than where we were the previous year and much more competitive with those plans out in the market currently.

Caitlin Whyte: Gotcha. Okay. So digging in now, I'm excited to hear more about this robust package of enhanced dental benefits that you're offering. Can you tell us the highlights? What can members look forward to in their 2023 plans?

Gregg Mottola: Yeah, so the 2023 plan and again, we don't expect there to be anything dramatic in terms of a change. But again, we don't, in terms of our 20, 23 benefits, those are not finalized. And of course we're not allowed to kind of disclose those benefits until after October 1st. And that is a mandate by the centers for Medicare. But I can tell you about our current benefit this year, which was the first year we saw that dramatic increase.

So as I mentioned, the maximum allowance per year for most of our plans with those exceptions that I mentioned was is $1,500. And the way it works really is it's a three tiered coverage approach. So you have levels of coverage that allow for different co-insurance amounts. So when I say co-insurance people say, well, what's the difference being a co-pay and a co-insurance? A copay is a set dollar amount that you to mitigate some of that cost. Right?

So if there a $50 copay on a particular benefit, you would have to pay 50 and then Health Alliance essentially would cover the rest. And that's just an example, but with a co-insurance, you actually pay a percentage of the allowable cost. So whatever the bill might be, you might have to pay 20% or you might have to pay 50% or something of that nature. So let's start there. So there's three levels of coverage, if you will, under the umbrella of a $1,500 maximum allowance.

So for your preventative stuff like cleanings and exams and things like that, there's actually a $0 co-insurance. So we cover 100% of the costs of those level servicesin the dental field or the dental realm. So, you could have any of those services. However frequently throughout the year, you would either submit that request as a reimbursement or as I'll get into later, there's another way the reimbursement can work. But I would say most common way is people just get their bill and then they submit that to us.

And then they get reimbursed at that 100% rate, meaning $0 co-insurance now tier two levels. Things like fillings and other work like crowns or things like that, that would be your level two. And what that means is we would pay 80% and then you would be responsible for 20%. So that's a level two care. So again, the $1,500 maximum allowance per year always applies regardless of the tier, but you would have to pay 20% of those services. And then there's level three. So your dentures. Certain periodontal work that might need to be done.

That is a 50% co-insurance. So we basically pay half you pay the other half again, up to that $1,500. So that's kind of how it works. I did want to say the one other way to get reimbursed is if your dentist is able and willing, so to speak, they can submit the claim directly to us using the claims address on the back of the member's ID card. And then we would actually pay that dentist directly up to the limits of the of the program. And then of course the dentist would then turn around and bill you for the difference, much like a medical claim would work.

So the reason why that doesn't happen all the time is. We don't have a dental network. You can go to any dentist you like, which is good. Right? There's a lot of flexibility there, but again, because we don't have that contract, we can't really tell them how to that they have to submit a claim. They may just say, you know what? I need the patient to cover the cost and then you would have to submit for reimbursement on the back end. So it really just depends on your dentist. We do try to do our best with creating pieces that can be given to the dentist to let them know, Hey, listen, they have this coverage.

I know it's a Medicare plan, but they have this coverage and it's real and tangible. So a lot of times dentists will go, okay, you know what? It's a little bit easier. You don't have to cover the cost up front. I'll submit the claim. It'll get paid. And then I'll bill you the different so to speak. If that makes sense.

Yes. Yes,

Caitlin Whyte: it does. That is all so wonderful. Now I know that for other medical needs, you often can only go to certain doctors or hospitals. Is it the same with dentists on your plans or can members see any dentist they like?

Gregg Mottola: Yeah. So as I had mentioned briefly just a minute ago. Yes, you there's no dental network. That's a great part of doesn't matter if you're on an HMO or you're on one of our POS plans, which is stands for point of service, that is not relevant for the supplemental portion of the benefits and which is what dental is under. So you can go to any dentist you like in the United States.

And we will offer those same benefits with those same tier co-insurance amounts. But like I said, if the dentist is willing to submit the claim directly, that's actually best for the member because they don't have to pay upfront. They only have to pay what's not already covered by their benefit.

Caitlin Whyte: That sounds like a really great feature. So when there's cost sharing, that is when members pay a portion and the plan pays the. Can you talk more about how that reimbursement works?

Gregg Mottola: Yeah, so exactly right. So the co-insurance is the cost share if you will, it's either zero for level one, 20% for level two or 50% for level three, depending on the services that are rendered by the dentist. And how that works is if the dentist submits it directly, then we would process that like any other medical. Applying those co-insurances were applicable and then sending that payment to the dentist and then sending what they call an explanation of benefits to the member to let them know what their responsibility looks like for that particular, those particular services. Right.

And it really works somewhat similarly if the member submits the reimbursement directly. So what they would do. There's no formal reimbursement form. They have to fill out. They would simply just submit a copy of the receipt, identifying themselves with their member number, etcetera. Requesting that they'd be reimbursed for those services. And we would, again, process that just as any other claim. And then we would actually send that explanation of benefits back to the member, letting them know what we covered along with a form of payment.

A check to the member. And they will receive that. And then whatever we don't cover would likely have already been paid to the dentist anyway, because likely they would've requested that money upon receipt of the bill.

Caitlin Whyte: Great. Okay. So now let's get to perhaps the question our listeners have been waiting for. Just how, and when can they sign up for one of these Medicare Advantage plans? I bet a lot of people would love these new features.

Gregg Mottola: Yes, that's a great question. so, I mean, they can go to our website, healthalliance.org/Medicare. However, open enrollment, which is the time of year, every year that people can make a change, as most people realize when you're on a Medicare Advantage plan or most plan a Medicare plans there's a timeframe in which you can make a switch. You don't necessarily, aren't able to do it any time of year. There are some exceptions where you can do it outside of those parameters. But October 15th through December 7th is the annual election period or what we call AEP.

And that is when members can, if they like their plan. They can keep it if they want to switch to a different plan. If they may be with another carrier and they want to switch to Health Alliance, they can do that. Or maybe they wanna switch plans within Health Alliance. Maybe they had one plan and they realized their needs have changed. Maybe they travel less or whatever the situation is, maybe, they see the doctor more, they may want more coverage that has less copays or lesser copays. They can make that decision.

And of course those changes that are done between that timeframe, October 15. Through December 7th, go into effect January one of the following year. So you would make changes for 2023 effective 1/1/23, between October 15th and December 7th of this year, 2022.

Caitlin Whyte: Excellent. Well, Gregg, before I let you go, any last thoughts, any final things that you'd like to mention?

Gregg Mottola: No, just that we're happy to be of service to many of the counties in the state of Illinois and beyond we have, as you mentioned, we have Health Alliance Northwest, which is in a central Washington market. We also have plans in North Carolina and we also have some plan offerings in Iowa. So we're happy to serve all the. In counties that we serve. What I wanted to say is evaluate your plan and visit our website or call Health Alliance. Or if you have a broker, talk to them and ask them about Health Alliance and see if the, we have a plan that's a good fit for you.

Caitlin Whyte: Well, wonderful information today, Gregg. Thank you. You've simply been a pleasure to have on our podcast. Thank you so much for joining us and for the important healthcare coverage your team brings to so many people throughout our communities. That concludes today's Hally's HealthCast, tune in next time as we tackle yet another topic important for your health and wellbeing.

And remember Hally Health is your partner in helping you live your healthiest life. Visit Hally.com. That's Hally.com for resources, information, tips, and much more. Let us help keep you and your family healthy and well. Thanks for listening. We hope you tune in again.