2015 Medicare Product Training Instructions

Transcription

1 2015 Medicare Product Training Instructions Review the training content contained in this presentation. You can advance the slides by using the arrows on your keyboard. Once you have reviewed and feel comfortable with the content, please proceed to the test by clicking on the icon below. The icon will appear throughout the training materials for your convenience. If you have already attended one of our in-person trainings, you may proceed directly to the testing portion. To the pass the test, you need at least an 85%. You can test up to three times. You will receive a test grade once you have completed your test and scores will automatically be recorded. Agent writing numbers will be communicated once your appointment/certification is complete. 1

2 User Agreement I hereby certify that I am acting on my own behalf. Responses to all information contained herein, and responses to any test or training questions or modules were not developed with any assistance, consultation, or review of or by a third party or resource. I understand that I may print a copy of the information contained for my personal use only. I may not reproduce or distribute the text or graphics, digitally, in hard-copy, or in any other medium, to others or substantially copy the information without prior written permission from MedStar Medicare Choice. I shall abide by all applicable laws, regulations, and rules, including, but not limited to, those of the Centers for Medicare & Medicaid Services (CMS). I understand that this information is being provided for training purposes only and that I may not solicit or accept applications from beneficiaries for the 2015 annual election period (AEP) prior to October 15,2014. My failure to adhere to the above certifications may result in termination of my broker agreement with MedStar Medicare Choice. 2

3 2015 Medicare Product Training 3

4 MedStar Medicare Choice 2015 Medicare Product Training Agenda Section 1: MedStar Health Overview Section 2: Original Medicare Updates Section 3: 2015 MedStar Medicare Choice Plan Section 4: 2015 MedStar Medicare Choice Dual Advantage Benefits Section 5: 2015 MedStar Medicare Choice Care Advantage Benefits Section 6: Our Model of Care Section 7: Enrollment Applications and Management Section 8: Enrollment Kit Materials Section 9: Broker Responsibility and Compliance Section 10: Broker Resources 4

5 Section 1: MedStar Health Overview 5

6 Values Service We strive to anticipate and meet the needs of our patients, physicians and co-workers. Patient first We strive to deliver the best to every patient every day. The patient is the first priority in everything we do. Integrity We communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards. Respect We treat each individual, those we serve and those with whom we work, with the highest professionalism and dignity. Innovation We embrace change and work to improve all we do in a fiscally responsible manner. Teamwork System effectiveness is built on the collective strength and cultural diversity of everyone, working with open communication and mutual respect. August 29,

7 The MedStar Medicare Choice Difference The same expert and caring professionals and leadership that put patients first every day Revolutionize care for seniors Integrating care and coverage Harness MedStar Health s clinical expertise and ability to provide those that need the most help them navigating through the health system Consolidate information from stakeholders throughout the health care system to tailor health care to individuals needs Predict who is at risk before a crisis occurs August 29,

8 Facts & Figures 205,252 inpatient and observation cases 3.78M outpatient visits 551,292 ER visits 223,333 home health visits 1,033 clinical trials 30,000 associates 1,600 employed physicians and 6,000 affiliated doctors 8,000 nurses $309.7M in community contributions 8

9 MedStar Family Choice Care for over 100K individuals in MD and D.C. Top rated Medicaid plan in Maryland in 2013 August 29,

10 Network Philosophy Narrow network with strategic additions Integrate care for members Contract with providers and facilities that: Are employed or owned by MedStar Health Will work to integrate care Are required to meet access requirements We want to hear from you: August 29,

11 Section 2: Medicare Review 11

12 Medicare Part A Overview What is Medicare Part A? Medicare Part A is part of original Medicare, which generally includes coverage for hospital care, skilled nursing facility care, nursing home care, hospice and home health services. Medicare Part A Eligibility? Medicare Part A eligibility is determined if a person is 65 years or older, a citizen or permanent resident of the United States, and they or a spouse worked for at least 10 years in Medicare-covered employment. Medicare Part A Costs? In most cases, there is no premium for Medicare Part A. However, there are costs that may be associated with coverage under Medicare Part A including, deductibles for inpatient hospital care, co-pays for skilled nursing, and payments for long-term custodial care. 12

13 Medicare Part B Overview What is Medicare Part B? Medicare Part B is part of original Medicare, which is generally medical and preventative care insurance, and covers services such as outpatient and professional medical services. Outpatient services, surgery, labs, x-rays, ambulance, durable medical equipment and supplies, and preventive services are also typically covered expenses. Medicare Part B Eligibility? Medicare Part B eligibility is determined if a person is 65 years or older, a citizen or permanent resident of the United States, and they or a spouse worked for at least 10 years in Medicare-covered employment. Those with a disability or those who have been diagnosed with End-Stage Renal Kidney disease may also be eligible. Medicare Part B Costs? Medicare Part B provides insurance to partially cover the costs of medically necessary care, for which most people pay a monthly premium. In addition to the Part B monthly premium, there is a required annual deductible. Also, individuals with Part B coverage are responsible for a percentage of the cost (co-insurance) that part B does not cover. 13

14 Medicare Part C Overview What is Medicare Part C? Medicare Advantage, also known as Medicare Part C, is a type of Medicare health coverage offered by private companies, such as MedStar Health. Medicare Advantage also provides all of the services and benefits of original Medicare (Part A and Part B). These plans may also offer additional health coverage and benefits not included in Original Medicare, which is why many eligible individuals enroll in these types of plans. Medicare Part C Eligibility? In order to enroll in a Medicare Part C plan, a Medicare Advantage plan, a beneficiary will need to be currently enrolled in a original Medicare (Part A and Part B). The beneficiary must also reside in one of the plan s service areas. Unlike original Medicare, it is less likely that you will qualify for Medicare Advantage if you have been diagnosed with End-Stage Renal Disease. Medicare Part C Costs? Depending on your health care needs and budget, the monthly premium, deductibles, and copays associated with your Medicare Advantage plan may vary. 14

15 Medicare Part D Overview What is Medicare Part D? Medicare Part D, also known as Prescription Drug Plans (PDP), provides prescription drug coverage for people enrolled in original Medicare (Part A and Part B) through private insurance companies like MedStar Health. Medicare Part D Eligibility: In order to enroll in a Medicare Part D plan, a Prescription Drug Plan, a beneficiary will need to be currently enrolled in a original Medicare (Part A and Part B). The beneficiary must also reside in one of the plan s service areas in order to be eligible. Medicare Part D Costs: The cost of Medicare Part D Plan varies from plan to plan. Depending on a beneficiaries prescription(s) and budget, the monthly premium, deductibles and copays associated with their Medicare Prescription Drug Plan or Medicare Advantage Drug Plan may differ. 15

16 Section 3: MedStar Health Medicare Choice Plan (MAPD) 16 The following slides include plan benefit information that is pending CMS contract approval.

17 MedStar Medicare Choice At MedStar Health we ve created a comprehensive approach to your health, designed by doctors and backed by local healthcare leaders in your community. Member Focused Our Medicare Choice plan is built to deliver great coverage for when members are sick, plus a complete plan to help keep them well. Imagine a health plan, created by doctors and focused on helping members live better. Enhancing Wellness Comprehensive tools and resources to help members improve and maintain a healthy life. Care When It s Needed Built to give the best care possible when and where members need it. 17

18 2015 HMO Choice Plan $0 monthly plan premium. Medical and prescription drug coverage. Referrals are not required to obtain care from a specialist, but we encourage members to coordinate their care through their PCP. Care Advising Services that support, no matter where the beneficiaries PATH (Personal Approach to Health) take them: $0 Monthly Premium A comprehensive and integrated approach to patient care. We involve patients most trusted advisor their primary care doctor to help coordinate and improve the quality of care and help members manage medical costs. The care team is led by the patient s doctor and includes a registered nurse Care Advisor, a registered dietician, licensed pharmacist, and a clinical social worker. 18

19 2015 MedStar Service Area The service area for MedStar Medicare Choice: Washington D.C. Maryland: Anne Arundel County Baltimore County Baltimore City Charles County Howard County Prince George s County St. Mary s County 19

20 Nationally Recognized Hospitals Maryland Hospitals MedStar Franklin Square Medical Center MedStar Good Samaritan Hospital MedStar Harbor Hospital MedStar Montgomery Medical Center MedStar Southern Maryland Hospital Center MedStar St. Mary's Hospital MedStar Union Memorial Hospital Washington D.C. Hospitals MedStar Georgetown University Hospital MedStar National Rehabilitation Network MedStar Washington Hospital Center 20

21 In the Community MedStar Family Choice MedStar Health Research Institute MedStar NRH Rehabilitation Network MedStar Pharmacy MedStar Physician Partner MedStar PromptCare MedStar Surgery Center MedStar Visiting Nurse Association Multispecialty Care Centers RadAmerica 21

22 MedStar Medicare Choice 2015 Benefit Grid NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 22

23 MedStar Medicare Choice 2015 Benefit Grid (continued) NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 23

24 MedStar Medicare Choice 2015 Benefit Grid (continued) NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 24

25 2015 Prescription Drug Benefit The prescription drug benefit will have five drug tiers as follows: Tier 1: Preferred generic drugs Tier 2: Non-preferred generic drugs Tier 3: Preferred brand drugs Tier 4: Non-preferred brand drugs Tier 5: Specialty drugs 25

26 2015 MedStar Medicare Choice NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 26

27 2015 Additional Benefits Our MedStar Medicare Choice plan provides the following additional benefits: Vision Benefit Dental Benefit Fitness Benefit Nurse Line 27

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29 Personalized Approach to Care: Fitness We are committed to helping member feel their best throughout every phase of life, giving them tools to help maintain their health. Members will have access to a wide range of tools and resources to help them achieve and maintain good health, including: A fitness membership through Silver&Fit The Silver&Fit Program includes membership at a local participating fitness facility or home exercise kits, website resources, and support from Silver&Fit s toll-free member services hotline and website. *D-SNP members are not eligible 29

30 MedStar Health Preventative Care We help patients stay well with preventive services available at no additional cost. Some of our preventive services include: Abdominal aortic aneurysm screening exam (one-per lifetime) Annual wellness exam or Welcome to Medicare exam Bone mass measurement Mammogram Pap test and pelvic exam (including clinical breast exam) Colorectal screening exam (screening colonoscopy/sigmoidoscopy) Prostate exam (PSA test only not the exam) Mental Health and Substance Abuse Screening Glaucoma screening test (for those at risk) Diabetic retinal eye exam Flu, pneumonia, and Hepatitis B immunizations HIV screening and sexually transmitted infections and counseling Smoking cessation counseling Cardiovascular, diabetic and obesity screening tests and behavioral therapy A separate copay may apply if you receive additional non-preventative medical services during the same visit as your screening exam. 30

31 Section 4: MedStar Medicare Choice Dual Advantage Dual Eligible Special Needs Plan (D-SNP) 31

32 Types of Dual Eligible Beneficiaries Qualified Medicare Beneficiaries: Premiums and cost share paid by Medicaid. Providers cannot balance-bill. Not qualified for Medicaid benefits Full Benefit Dual Eligible: Medicare beneficiary that has all Medicaid benefits 32

33 Key Highlights of Selling to Full Benefit Dual Eligible (FBDE) Beneficiaries and QMBs $0 premium plan MedStar Health are uniquely qualified to care for the dual eligible population D.C. Medicaid pays 1,2 : Part A deductible and coinsurance: full amount Part B deductible and coinsurance up to state plan rates FBDE and QMBs not responsible for cost share amounts and cannot be balance-billed by providers 3 1. D.C. Medicaid Plan (DHCF) Section 4.19B, Part 1, Item 16 (Payment of Title XVIII Part A and Part B Deductible/Coinsurance 2. Provider must participate in Medicaid or be enrolled with D.C. Medicaid to bill Medicare crossover claims 3. QMBs: Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing 33

34 Full DUAL-MD Full Dual-DC Identifying a FBDE beneficiary or QMB August 29,

35 2015 MedStar Medicare Choice Dual Advantage Benefit Grid NOTE: Depending on Medicaid eligibility, member may not have any cost-sharing responsibility for original Medicare services. If the member looses full status, they may be subject to cost sharing. This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 35

36 2015 MedStar Medicare Choice Advantage Benefit Grid (continued) NOTE: Depending on Medicaid eligibility, member may not have any cost-sharing responsibility for original Medicare services. If the member looses full status, they may be subject to cost sharing. This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 36

37 2015 MedStar Medicare Choice Dual Advantage Benefit Grid (continued) NOTE: Depending on Medicaid eligibility, member may not have any cost-sharing responsibility for original Medicare services. If the member looses full status, they may be subject to cost sharing. This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 37

38 2015 MedStar Medicare Choice Dual Advantage Prescription Drug Benefits Grid NOTE: Depending on Medicaid eligibility, member may not have any cost-sharing responsibility for original Medicare services. If the member looses full status, they may be subject to cost sharing. This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 38

39 2015 MedStar Medicare Choice Dual Advantage Prescription Drug Benefits Grid (continued) NOTE: Depending on Medicaid eligibility, member may not have any cost-sharing responsibility for original Medicare services. If the member looses full status, they may be subject to cost sharing. This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 39

40 2015 Additional Benefits Our MedStar Medicare Choice Dual Advantage plan provides the following additional benefits: Vision Benefit Dental Benefit Transportation Benefit Nurse Line OTC 40

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43 Section 5: MedStar Medicare Choice Care Advantage Chronic Condition Special Needs Plan (C-SNP) 43

44 2015 MedStar Medicare Choice Care Advantage Benefit Grid NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 44

45 2015 MedStar Medicare Choice Care Advantage Benefit Grid (continued) NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 45

46 2015 MedStar Medicare Choice Care Advantage Benefit Grid (continued) NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 46

47 2015 Prescription Drug Benefit The prescription drug benefit will have five drug tiers as follows: Tier 1: Preferred generic drugs Tier 2: Non-preferred generic drugs Tier 3: Preferred brand drugs Tier 4: Non-preferred brand drugs Tier 5: Specialty drugs Tier 6: Preferred Diabetic drugs 47

48 2015 MedStar Medicare Choice Care Advantage Prescription Drug Benefits Grid NOTE: This grid is for training purposes do NOT distribute to beneficiaries. Grids are not submitted to CMS for approval. A CMS tracking number must be on member materials in order to distribute them. 48

49 2015 Additional Benefits Our MedStar Medicare Choice Care Advantage plan provides the following additional benefits: Vision Benefit Dental Benefit Fitness Nurse Line Transportation Benefit Benefit 49

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52 Personalized Approach to Care: Fitness We are committed to helping member feel their best throughout every phase of life, giving them tools to help maintain their health. Members will have access to a wide range of tools and resources to help them achieve and maintain good health, including: A fitness membership through Silver&Fit The Silver&Fit Program includes membership at a local participating fitness facility or home exercise kits, website resources, and support from Silver&Fit s toll-free member services hotline and website. *D-SNP members are not eligible 52

53 Section 6: Our Model of Care Kate Rollins, Sr. Director, Clinical Operations 53

54 Personalized Approach to Care: Integration Tools to help members maintain their health: Integrated Medical Record System: Digitized medical and health information is securely shared across a centralized system, making it easy for doctors to see your entire medical history including prescriptions, test results, treatment regimens and collaborate with other medical professionals in the MedStar Health system. 24/7 nurse hotline: Get health information from experienced, registered nurses 24 hours a day, seven days a week. 54

55 Model of Care Identify Patient Population and Subpopulations using Stratification and Modeling Organize into work streams based on acuity/need MedStar Medicare Choice Outreach and Engagement Continuous Quality Improvement Health of a Population Better Care Reduce Disparities Better Outcomes Reassess Regular progress evaluation Develop coordinated plan of care with patient and provider Assess needs and level of motivation Reporting Analytics Experience of Care Safe Effective Patient-centered Efficient Timely IHI Triple Aim Maximize Utilization The right care The right time The right place 55

56 Section 7: 2015 Enrollment: Applications and Management 56

57 New, User-Friendly CRM We are pleased to introduce: Cloud-based solution Real-time, broker level user access Enhanced Lead Management Tools Streamlined Enrollment and Tracking Fulfillment Storefront Broker training schedule now available! Reserve your spot now. Click here to register 57

58 2015 Annual Election Period (AEP) Enrollments Plans cannot begin to market 2015 Medicare Advantage Plans until October 1, In 2015, the AEP election will be from October 15 to December 7. The enrollee s coverage will begin on January 1, An individual can make an election during this time. If he or she signs up for multiple plans, the last application date submitted is considered to be the election. Plans cannot solicit applications from an enrollee prior to October 15. Brokers/agents should remind beneficiaries that they cannot submit enrollment requests prior to the start of the Annual Election Period (AEP). CMS may asses beneficiaries with a late enrollment penalty (LEP). If the enrollees select the electronic fund transfer (EFT) option box on the application, they will receive the payment election form with the enrollment confirmation letter for completion and returning it in the envelope provided for electronic payments to begin. The individual MUST pay the LEP by check until the electronic withholding is set up. 58

59 2015 Enrollment Application Submissions Electronic Paper 59

60 Cavulus rules of the road Lead Management As of October 1, leads will be distributed and assigned through the Cavulus Lead Management system. Lead outreach within 48 hours of initial assignment. Lead dispositions within 72 hours of initial outreach. Electronic Enrollment MedStar Health requires electronic enrollment applications be submitted through the Cavulus CRM system*. Application status updates and confirmation checks will be available through the Cavulus CRM system at the broker level. System Training and Access Cavulus system training will be available via webinar, more details including a list of training sessions will be available soon and distributed from your FMO. System access including User ID and Password will be provided following appointment and/or appointment renewal. Access will be through the following link, Note: FMO application handling and management process options will also be available. Please see your select FMO for guidance. 60

61 2015 Commission Schedule 2015 AEP commission payments will be will be paid at 100% of the current Full Market Value (FMV): Compensation Type 2015 FMV Maryland Initial Year $408 $461 Renewal Years $204 $ FMV Washington D.C. Enrollments effective on January 1, 2015 and after are subject to the new compensation requirements, even if the beneficiary signed up for the plan during the CY2015 AEP (October 15, 2014 through December 7, 2014). Per new CMS regulations, commission payments will be made to brokers in January 2015 for January 1, 2015 effective dates. Outside of AEP, commissions will be paid monthly in the month of the enrollment effective date. 61

62 Section 8: Enrollment Kit and Materials 62

63 2015 Summary of Benefits 2015 MedStar Medicare Choice Summary of Benefits (SOB): 2015 MedStar Medicare Choice Summary of Benefits (SOB): The Summary of Benefits is a CMS template document that all Medicare Advantage plans must include in the enrollment kit. Section 1- Introduction Contains information about MedStar Medicare Choice and Medicare Advantage plan requirements. Section 2 Premium and Benefits section Section 2 provides a high level description of the medical and prescription drug benefits/premiums and provides a comparison to original Medicare benefits. The benefit plans will span across the left and right page of the booklet for each benefit category. 63

64 2015 Provider Directory The provider directory lists network facilities, providers and pharmacies in the MedStar Medicare Choice Network and is included in the enrollment kit. The following provider sections are included in the directory: Participating Hospitals Services and Facilities Including home health, rehabilitation facilities, skilled nursing facilities, durable medical equipment providers. Primary Care Providers (PCP) This section will be used to select a PCP that must be entered onto the enrollment application. Obstetrics and Gynecology Providers Specialists Behavioral Health Facilities and Providers Participating Pharmacies Members can also use our online provider search at: 64

65 2015 Formularies Network Pharmacies Retail Pharmacies Home Infusion Pharmacies Long-Term Care Pharmacies Mail-Order Pharmacy via Express Scripts 65

66 2015 Member Welcome Kit Evidence of Coverage (EOC) The EOC is our contract with the member and provides detailed information on Medicare Advantage plan guidelines and appeals and grievance procedures. The Evidence of Coverage is mailed to the enrollee, is available on-line and by request. Member ID Card Membership ID cards will be mailed to the members in mid-december, in advance of January 1, There is one ID card for both medical services and prescription drug services. 66

67 Section 9: Agent Responsibility and Compliance 67

68 Fraud, Waste, and Abuse (FWA) You have a responsibility to report FWA. Contact our confidential hotline at (855) Fraud: Requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and Abuse: May involve obtaining an improper payment, but does not require the same intent and knowledge. 68

69 2015 Broker Oversight and Compliance Secret Shopping CMS have set specific regulations on how insurance companies and their broker agents can market to potential health plan enrollees with the goal of protecting beneficiaries from deceptive or high-pressure marketing tactics by private insurance companies. CMS conducts regular compliance audits to identify organizations that are in violation of CMS Chapter 3 guidelines throughout AEP. Ride Along Audits Your dedicated Field Marketing Organization (FMO) and/or the General Agency is responsible for conducting marketing oversight and ride-along audits with you as a contracted writing agent. The FMO and/or General Agency representative will meet with you at the specified time and location of the member appointment with a copy of an enrollment kit. The broker s presentation of MedStar Medicare Choice information at the sales appointment will be evaluated and the required Medicare Ride-Along Audit Form completed. 69

70 Section 10: Broker Resources 70

71 2015 Agent Tools Cavulus CRM System: Fulfillment: Broker Storefront for Enrollment Kits and Sales Brochures Application Submission and Tracking Seminar Management: Reservations, Capacity and CMS reporting compliance Lead Management: Real-time access for broker agents to respond to an inquiring beneficiary lead. Web-sites and On-line Tools: Broker Sales Support Line:

72 2015 Fulfillment Orders Enrollment Kits and Sales Brochures Enrollment kits available after today s session. Additional AEP fulfillment orders will be available to brokers through the Cavulus CRM Storefront. Fulfillment order confirmations are viewed real-time in the Cavulus CRM system. 72

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75 Opportunity: By the numbers Washington DC 77,500 Medicare Eligible 25,640 Dual population 19,927 Full Benefit Dual population 75

76 Opportunity: By the numbers Maryland 796,500 Medicare Eligible 119,760 Dual population 79,917 Full Benefit Dual population 76

77 Congratulations, you have completed the training Click here to begin your test 77