2007 sales training presentation
DESCRIPTION
2007 Sales Training Presentation. Confidentiality Statement. - PowerPoint PPT PresentationTRANSCRIPT
1
2007Sales TrainingPresentation
2
Confidentiality Statement
The information contained herein is confidential and is the sole and exclusive property of American Progressive Life & Health Insurance Company of New York and Pyramid Life Insurance Company and may not be used, reproduced in any way, transmitted or otherwise communicated, in whole or in part, without the prior written consent of American Progressive and Pyramid Life. The information contained herein is nonpublic and requires the approval of the Centers for Medicare & Medicaid Services (“CMS”) of the United States Department of Health and Human Services and, therefore, may be inaccurate, incomplete and unreliable, but is being provided to you for your consideration as American Progressive’s and Pyramid Life’s preliminary indication of its reasonable expectation of the Medicare Advantage products, rates and commissions that will be offered in 2007 in certain counties within your territory. Your receipt of the information contained herein constitutes (i) your consent to maintain the information in strict confidence and (ii) your acknowledgement that the information is nonpublic, requires the approval of CMS and therefore may be inaccurate, incomplete and unreliable, and is the sole and exclusive property of American Progressive and Pyramid Life and may not be used, reproduced in any way, transmitted or otherwise communicated, in whole or in part, without the prior written consent of American Progressive and Pyramid Life.
3
Today’s Options Sales Agents are Supported by:
• $2 billion total assets
• $1+ billion premium inforce
• 20,000 + agents representing its
insurance subsidiaries
4
Operating Segments
Pennsylvania Life
Penncorp Life of Canada
Pyramid Life
American Pioneer Life
American Progressive Constitution Life
Union Bankers
Marquette National
WorldNet Services Corp
CHCS Services, Inc.
CHCS, Inc.
Administrative Services
Senior Market Brokerage
Career Career AgencyAgency
Managed Care
Today’s Options
Heritage Health Services
5
HMO plans Private Fee-for-Service Special Needs Plans Individual and Group
Prescription Drug Plans Individual and Group
Medicare Supplement / Select Senior Acute Care and Dental Individual and Group
3rd Party Administration: Medicare Supplement, Long Term Care, Medicare Advantage & Part D
ElderCare (non-risk)
Medicare Advantage
Medicare Part D
Senior Administrative Services
Senior Market Health Insurance
Comprehensive Portfolio ofSenior Market Products
6
UAFC is Committed toYour Success!
• Continual development of new products so that agents have the most advanced plans in the Senior Healthcare Market.
• Providing agents with an array of Medicare products and price points to offer to seniors.
• Today’s Options is a full service Medicare Healthcare Product Offering more Coverage, Benefits, Choices and Services at a Lower Premium.
• Prescription Pathway is a Medicare Approved PDP, offering competitive plan premiums, formulary and a pharmacy network of over 50,000 nationwide.
7
Today’s Goals
• Introduce Today’s Options
• Discuss marketing and sales strategies
• Review Medicare program options
• Review market conduct and compliance requirements in the sales process
8
Today’s Options
Value Propositions
9
Savings
Medicare Advantage plansresult in average beneficiarysavings of $100 a monthSource: www.cms.gov
10
Value Propositions
Private Fee-for-Service– Offer the best of both worlds!
MedicareSupplements
HMO’s
Today’s Options
(PFFS)Freedom to Choose Your own provider
$$$ Monthly Premium Savings
11
Value Propositions
• Competitive Product• Easy to sell
– Part B premium refund to beneficiaries in some areas!
• Convention Credit on Today’s Options production
• Maximize your SALES OPPORTUNITIES!
12
Value Propositions
• Guaranteed Issue• Affordable
– Monthly Premium less costly than many Medicare Supplements.
– Today’s Options prohibits providers from balance billing (beneficiary usually will not receive a bill from the medical providers).
• Low co-payments– Premier & Premier Plus = $5 for each PCP visit
and $15 for each specialty care visit.– Value & Value Plus = $15 for each PCP visit and
$30 for each specialty care visit.
13
Freedom to Choose
• Freedom to choose doctors, specialists and hospitals.– Choose any doctor, specialist or hospital.* – No referrals needed to see a specialist.– Members can get services anywhere in the U.S.– Emergency services anywhere in the world.
• Predictable out-of-pocket maximum* Who is willing to accept Today’s Options terms and conditions
14
Medicare Private Fee-For-Service (PFFS)
• For Medicare beneficiaries who:– Want freedom to make their own decisions about
doctors and hospitals– See a definite need for supplemental coverage beyond
Traditional Medicare– Believe they pay too much for Medigap– Are turning 65 and have sticker shock from Medigap
premiums– Struggle with paying Medigap premiums and living
expenses at the same time
15
Medicare Private Fee-For-Service (PFFS): Promising Future
• Industry experts predict that PFFS plans will become an increasingly viable alternative to Traditional Medicare A & B with Medicare Supplements.
• A strong middle-ground between HMOs and Supplement plans.
• Valuable Medicare health plan alternatives for rural areas or smaller metropolitan markets, where none existed before.
16
Comprehensive Benefits
• Comprehensive benefits– Covers all services under Medicare Part A and B.– Offers additional benefits (i.e. routine exams in
both plans) beyond what Medicare Parts A and B provide.
• Paperless Claims– Most claims can be handled between plan and
providers, so there is almost no paperwork for member to complete.
17
PFFS / HMO / Medigap Comparison
Description
Medicare Advantage PFFS
Medicare Advantage HMO
Medigap Insurance
•Non-network•Cost-sharing model and additional benefits beyond Original Medicare
•Network product•Cost-sharing model and additional benefits beyond Original Medicare
• Non-network filling in “gaps”•Picks up the deductibles and co-insurance of Original Medicare
18
PFFS / HMO / Medigap Comparison
Target Audience
Medicare Advantage PFFS
Medicare Advantage HMO
Medigap Insurance
•Have Medigap or are looking to buy Medigap
•Have Original Medicare only because HMO was not attractive or available
•Wants good financial protection
•Value coverage and simplicity, but willing to sacrifice choice of physicians as a trade-off
•Urban or suburban markets where providers will contract
• Wants to see their own doctors
•Wants 1st dollar coverage for out-of-pocket costs in exchange for higher premiums
19
PFFS / HMO / Medigap Comparison
Beneficiary Value Proposition
Medicare Advantage PFFS
Medicare Advantage HMO
Medigap Insurance
•Lower annual premiums than Original Medicare with Medigap•High level of financial protection•Premiums not tied to age•Guaranteed issue•Community rated premiums
•Good cost/value combination•Good benefits beyond Original Medicare•Guaranteed Issue•Community rated premiums
• Controls choice of providers•1st dollar coverage•Predictable monthly costs (premiums)
20
PFFS / HMO / Medigap Comparison
Providers
Medicare Advantage PFFS
Medicare Advantage HMO
Medigap Insurance
•Any Medicare provider who is willing to accept payment from Plan at Medicare rates
•Contracted network selected by health plan•Credentialed providers who accept payment rates and agree to plan rules
• Any Medicare Provider
21
Voluntary Care Management
• Innovative Voluntary Care Management program proactively assists members with their healthcare concerns and needs.
– Registered nurses work in collaboration with social workers and other healthcare professionals.
– Member access to “24/7 My Nurse Line” 866-549-5048.
• Today’s Options Voluntary Care Management follows inpatient admissions and provides health education and support to our members:
– Members who choose to participate will be provided with “best practice” care plans, which are shared with their physician.
– Members receive welcome home calls after an inpatient stay.– Some members will receive calls when certain outpatient procedures are planned in order to
provide support and education.
• Voluntary Care Management provides the member with coordination of their health care needs.
22
Today’s Options
Medicare
Overview
23
What is Medicare?
• Federal health insurance for:– People 65 years of age and older– Qualified disabled people under 65 (about 9% of
total beneficiaries)– People with End Stage Renal Disease (ESRD)
24
Part A: Hospital Benefits
• Pays for medical care furnished by Medicare-certified hospitals, skilled nursing facilities, home health agencies and hospices.
• Can enroll with no premium for Part A:– Must have worked and paid Medicare taxes for 40 or
more quarters (10 years).– In 2006, a patient pays an initial deductible of $952 at
the beginning of each benefit period.
25
Part B: Physicians Benefits
• Generally pays 80% of the Medicare allowed amount less a $124 (in 2006) annual deductible for:– Doctors’ services– Outpatient hospital services (including ambulance transportation
and emergency room visits)– Diagnostic tests, laboratory services– Some preventive care like mammography and pap
smears– Outpatient therapy services (PT, OT, ST)– Durable medical equipment and supplies– Some home health care services for which Part A does
not pay
26
Part C: Medicare Advantage Plans
• Medicare Advantage Plan members are still enrolled in Medicare.
• The only difference is that providers’ payments come from a Private insurance company rather than Medicare and a Supplement carrier.
• Includes HMOs, PPOs, PSOs, Medicare MSAs, PFFS.
27
Part C: PFFS Plans
• Freedom of choice / Availability– Members may go to any eligible doctor or hospital anywhere
in the U.S. that is willing to provide care and accept
Medicare PFFS terms and conditions. • PFFS includes the benefits of Parts A and B, plus
additional benefits.– Replaces the need for Medicare Supplements– Members are still enrolled in Medicare
• Eliminates most member out-of-pocket costs under Medicare A and B.
28
Part D: Prescription Drug Plans
• The Medicare Modernization Act (MMA) established PDPs
• 38 million Medicare beneficiaries have Rx Drug coverage
• 4.4 million Medicare eligibles NOT yet enrolled in part D.
• From November 15, 2006 to December 31, 2006, Medicare Beneficiaries can enroll in Prescription Drug Plans.
29
Today’s Options
2007 PRODUCT OVERVIEW
30
What is Today’s Options?
• Medicare Part C - Medicare Private Fee-For-Service Plan offered by UAFC subsidiaries:– American Progressive Life and Health
Insurance Company of NY– The Pyramid Life Insurance Company
• Today’s Options contracts with The Centers for Medicare and Medicaid Services (CMS).
31
Today’s Options Overview
• Offered in 35 states throughout the U.S.
• Four Today’s Options plans:– Value– Value Plus – includes drug coverage– Premier– Premier Plus – includes drug coverage
32
Rates for the 2007 Benefit Plan
Value Plan Premier Plan
Value Plus* Premier Plus*
(21.50)** 10.00 0.00 45.00
12.00 44.00 35.00 80.00
48.00 80.00 72.00 117.00
* Includes Prescription Drug Benefit
** Part B premium credit to enrollee
PYRAMIDSTATES FOR 2007
26 States2319 Counties
29,007,065 Medicare Eligibles
33
EligibilityWho can join Today’s Options?
• Individuals can join Today’s Options if they:– Have both Medicare Part A and Part B.– Live in a state where the plan is available. (Obtain services
anywhere in U.S.)– Do not have End-Stage Renal Disease (ESRD).
• There is NO medical underwriting – People with Medicare who meet eligibility requirements
may not be denied membership on the basis of health status.
• Only one community rate premium per county. No age rating!– 2 Premium Tiers – American Progressive– 3 Premium Tiers – Pyramid Life
34
Premiums and Other Fees
• Members pay:– Monthly Medicare Part B premiums ($88.50
in 2006)• Part B premium will vary by income in 2007
– Monthly premium directly to Today's Options, if a premium is charged
– Low co-insurance or co-payment amounts
35
VA Medical Benefits
• A Today's Options member who is also enrolled in the VA Medical Benefits Plan may use either plan. – The individual would elect to receive his or her
health care either through the VA system or through Today's Options.
– If member is enrolled in both Today’s Options and VA system:• VA will not pay Today’s Options services• Today’s Options will not pay for any VA co-pays
37
Today’s Options Highlights What’s New for 2007
SAMPLE BENEFITS VALUE PREMIER
Out-of-Pocket Limit $3000
Inpatient hospital Care $175 each day for days 1-4; $0 each day for days 5-90; no additional co-
pays; covered for unlimited days each benefit period
$150 for each Medicare covered stay; $600 maximum out-of-pocket per year
PCP Co-Pay $15 per visit $5 per visit
Specialist Co-Pay $30 per visit $15 per visit
Outpatient Surgery – Ambulatory/Hospital
$100 for each visit to an ambulatory surgical center; $200 for each visit to
an outpatient hospital facility
$25 to $50 for each visit to an ambulatory surgical center; $50 to $100 for each visit to
an outpatient hospital facility
Skilled Nursing Facility (SNF)
$0 each day for days 1-20; $100 each day for days 21-100; covered for 100 days per benefit period
Emergency Care $50 for each ER visit; Worldwide coverage
$35 for each ER visit; Worldwide coverage
Urgently Needed Care $50 for each Urgently Needed Care visit; Worldwide coverage
$35 for each Urgently Needed Care visit; Worldwide coverage
Chiropractic and Podiatry Services
$35 for each Medicare covered visit $20 for each Medicare covered visit
38
Plan Options
Let’s compare benefits for the two basic plans
VALUE PREMIER&
39
Today’s Options 2007Benefit Matrix
VALUE PREMIER
INPATIENT CARE
Inpatient hospital $175 each day for days 1-4; $0 each day for days 5-90; no additional co-pays; covered for
unlimited days each benefit period.
$150 per admission, $300 per admission if you do not notify the plan; there is a $600 max out
of pocket limit every year.
Inpatient mental health $175 each day for day(s) 1 - 5 - $0 each day for day(s) 6-90 for a Medicare-covered stay; If no notification, you pay $150 each day up to a maximum of $150 per admission;
$1,700 maximum out of pocket limit every year.
$75 each day for day(s) 1 - 5 - $0 each day for day(s) 6-90 for a Medicare-covered stay, if no notification, you pay$50 each day, up to maximum of $250 per admission; $1,250
max out of pocket limit every year.
SNF $0 each day for day(s) 1 - 20, $100 each day for days 21 - 100 for a stay in a Skilled
Nursing Facility. No prior hospital stay is required.
$0 each day for day(s) 1 - 20, $100 each day for days 21 - 100 for a stay in a Skilled Nursing Facility. No prior hospital stay is required.
Home Health 15% coinsurance 15% coinsurance
Hospice Covered by Medicare Covered by Medicare
40
Today’s Options 2007Benefit Matrix
OUTPATIENT CARE
VALUE PREMIER
PCP Office Visits $15 copay $5 copay
Specialist Office Visits
$30 copay $15 copay
Chiropractic $35 copay $20 copay
Podiatry $35 copay $20 copay
Outpatient Mental Health 50% coinsurance 50% coinsurance
Outpatient Substance Abuse
50% coinsurance 50% coinsurance
Outpatient Surgery You pay $100 for each Medicare-covered visit to an ambulatory surgical center; if no notification, you pay $200. You pay $ 200
for each Medicare-covered visit to an outpatient hospital facility; if no
notification, you pay $400.
You pay $25 for each Medicare-covered visit to an ambulatory surgical center; if no notification, you pay $50. You pay $50 for
each Medicare-covered visit to an outpatient hospital facility; if no
notification, you pay $100.
Ambulance $100 copay $50 copay
Emergency Care $50 co-pay; waived if admited within 72 hours, worldwide coverage
$35 co-pay; waived if admited within 72 hours, worldwide coverage
41
Today’s Options 2007Benefit Matrix
OutpatientCare Cont…
BASIC PREMIER
Urgent Care $50 copay $35 copay
Outpatient Rehab $30 copay $15 copay
DME & Diabetic Supplies
You pay 20% of the cost for each Medicare-covered item. If you do not notify the plan of an
equipment or device purchase over $750, you will have to pay 50% of the allowed charges.
You pay 20% of the cost for each Medicare-covered item. If you do not notify the plan of an equipment or device purchase over $750, you will have to pay 50%
of the allowed charges.
Prosthetic Devices You pay 20% of the cost for each Medicare-covered item. If you do not notify the plan of an
equipment or device purchase over $750, you will have to pay 50% of the allowed charges.
You pay 20% of the cost for each Medicare-covered item. If you do not notify the plan of an equipment or device purchase over $750, you will have to pay 50%
of the allowed charges.
Diagnostic, Lab and X-rays
You pay: - $ 0 for each Medicare-covered clinical/diagnostic lab service. - 10% for each Medicare-covered radiation therapy
service to maximum of $150 per visit. - 10% for each Medicare-covered X-ray up to $150
per visit.
You pay: - $ 0 for each Medicare-covered clinical/diagnostic lab service. - 10% for each Medicare-covered radiation therapy service to
maximum of $150 per visit. - 10% for each Medicare-covered X-ray up to $150 per visit.
42
Today’s Options 2007Benefit Matrix
Additional Benefits VALUE PREMIER
Outpatient Rx Not covered by plan (See Value PLUS) Not covered by plan (See Premier PLUS)
Part B Drugs The member pays 20% of the eligible expenses. Drugs include, but not limited
to chemotherapy medications.
The member pays 20% of the eligible expenses. Drugs include, but not limited to chemotherapy
medications.
Dental no benefit no benefit
Hearing $30 for Medicare covered benefits; $30 for 1 routine exam per year
$15 for Medicare covered benefits; $15 for 1 routine exam per year
Vision $30 for Medicare covered benefits; $30 for 1 routine exam per year
$15 for Medicare covered benefits; $15 for 1 routine exam per year
Routine Physical Exams 1 per year; $0 copay 1 per year; $0 copay
43
PLUS “Adds” Part D Benefits
Value or Premier BASIC
Value Plus Premier Plus
Part D Co-pay No Part D coverage Co-pays: $7 Tier 1; $31 Tier 2; $63 Tier 3; 30% Tier 4
Co-pays: $7 Tier 1; $31 Tier 2; $63 Tier 3; 30% Tier 4
Part D Initial Coverage Limit
N/A $2400* $2400*
Donut Hole Coverage
N/A No Yes (generics only)
Part D Deductible
N/A None None
Mail Order N/A Yes; 90-day for 2x co-pay Yes; 90-day for 2x co-pay
All the Benefits from the Premier or Value Plan, Plus:
* Does not apply to out-of-pocket maximum
44
Today’s Options:Preventative Services
• Zero Co-pay for:
– Bone Mass Measurement– Colorectal Screening Exams– Pneumonia and Flu Vaccines– Screening Mammograms– Pap Smears and Pelvic Exams– Prostate Screening
45
Today’s Options
Sales and Enrollment
46
Election Periods and2007 Effective Dates
Coverage Period When Effective Date Who
Initial Coverage Period (ICP) 3 months before, month of 65th birthday, and 3 months after entitled to Part A and B
1st day of month entitlement to Part A and Part B
T-65’s
Annual Coordinated Election Period (AEP)
2006 AEP is November 15th 2006 through December 31st
2006
January 1st, 2007 All Medicare Eligibles
Open Election Period (OEP)
ENDS MARCH 31, 2007 for Medicare Advantage
1st day of month after plan’s receipt of completed
enrollment form.
Individuals are allowed one additional change
Special Election Period (SEP)
Beneficiary moves, plan termination, etc.
Determined by CMS Depends on the situation
Lock-in Period After March 31, 2007
47
During AEP:
Beneficiaries Can Switch from the following
Changing To
MA-PD Combo
PFFS-PD Combo
Original Medicare & Stand Alone
PDPMA
OnlyPFFS Only
Original Medicare
Cu
rrently H
ave
MA-PD Combo Y Y Y Y Y Y
PFFS-PD Combo Y Y Y Y Y Y
Original Medicare & Stand Alone PDP
Y Y Y Y Y Y
MA Only Y Y Y Y Y Y
PFFS Only Y Y Y Y Y Y
Original Medicare Y Y Y Y Y Y
Medicare Advantage Lock In = After March 31, 2007 members are locked into their selected plan
Annual Enrollment Periods (AEP)
48
During OEP:
Beneficiaries Can Switch from the following
Changing To
MA-PD Combo
PFFS-PD Combo
Original Medicare & Stand Alone
PDPMA
OnlyPFFS Only
Original Medicare
Cu
rrently H
ave
MA-PD Combo Y Y Y N N N
PFFS-PD Combo Y Y Y N N N
Original Medicare & Stand Alone PDP
Y Y N N N N
MA Only N N N Y Y Y
PFFS Only N N N Y Y Y
Original Medicare N N N Y Y Y
Medicare Advantage Lock In = After March 31, 2007 members are locked into their selected plan
Open Enrollment Periods (OEP)
49
Step 1: Enrollment
Today’s Options
50
Today’s Options
51
Today’s Options
52
Today’s Options
53
Today’s Options
54
Today’s Options
55
Today’s Options
56
Today’s Options
57
Today’s Options
• Complete New Member Acknowledgement Form• Member Verification Call from Home: 1-877-275-1088 “press 1”
» Saturday 9 a.m. – 6 p.m.» Mon.-Fri. 8 a.m. – Midnight» Sunday Noon – 6 p.m.» All times Eastern
• Verification Call Center representative confirms members’ understand the items reviewed in the acknowledgement form (write in call confirmation # in top corner of acknowledgement form)
Step 2: Acknowledgement Form and Verification Call
58
Today’s Options
Step 3: Post-Enrollment
Request For Provider Information form
59
Enrollment Process:Effective Date
• Agent will write in proposed effective date on enrollment form, section 9, and advise enrollee.
• If the completed enrollment form is received at Today’s Options’ office before the end of the month, the effective date is the first of the next month.
60
DocumentationDocumentation Requested for Enrollment• Request primary residence
– Drivers license, voters registration– Ask where SSA check is sent
• Verify Medicare card information (template on enrollment form)
– Verify name – Sex– Health insurance number– Parts A and B
• Current payment options– Bank Draft
• Deduction date is approximately the 7th of each month.– Social Security Deduction– Monthly Direct Bill– Credit Card
61
Submitting Enrollment Forms
• All enrollment forms should be submitted directly to the company or to your Manager/Agency Office within 24 hours of receipt– Fax App – Mail
62
Enrollment Process:Agency Office Responsibilities
• Log applications• Check accuracy of agent number• Overnight shipping
63
New Member Welcome Process
• Welcome Call (five days after Today’s Options member is made active).
• Acknowledgement Letter - includes Today’s Options Membership ID card (within seven days).– Enrollment does not confirm that client is a member of Today’s
Options, only CMS can confirm enrollment.
• Welcome Package - includes CMS confirmation letter, EOC (policy) and sales survey (within four-six weeks).
• Health Risk Assessment (HRA) Call (Within 30 days).
64
Today’s Options
PROVIDERS
65
Provider Relations
• Accessing Benefits– To use providers anywhere in the United States,
Today’s Options members must:• Simply present Today’s Options ID card• Upon acceptance, provider will bill Today’s Options and
the member pays all applicable co-pays and co-insurance.• If provider does not accept, the provider can bill member.
The member should mail the bill to Today’s Options for payment – The bill will be paid in full, less the applicable member
co-pays and co-insurance.
66
Outreach Strategy for Educating Provider Community
• Provider Relations Outreach Strategy for 2007– Send a letter to Providers and Hospitals in our new states
• Provides information about Today’s Options (subject to CMS approval)
– Visit/contact key providers regularly regardless if they accept Terms and Conditions
• Today’s Options pays 100% of Medicare Allowable Rates (less applicable co-pays/co-insurance)– Even Medicare doesn’t pay 100%! – Providers do not have to track down balance due from Med
Supp / HMO Plan.• No contracts-because we contract with Medicare.• Provider does not have a contract with us.
67
Providers: Key
• Providers are considered “Deemed” when, prior to providing services, they:– Have knowledge that a Medicare
beneficiary is enrolled in Today’s Options;– Have a reasonable opportunity to obtain Today’s
Options Terms and Conditions; and – Subsequently provide services to the
Today’s Options member
68
Provider Relations
• A provider who does not accept the Terms and Conditions can:– Decline to treat the member.– Treat the member and accept payment from plan
(as payment in full).– Only treat members in an emergency situation.
• Contact Today’s Options Marketing Staff for a list of providers we know “do not” accept Today’s Options.
69
Provider Relations Contacts PROVIDER RELATIONS DIRECTOR: Lynn Gasorowski
Name Coverage Area Fax Number 800/Ext.
Tracey Arnold North Carolina, South Carolina
704-766-1265 800-360-5735 Ext. 8201
Robert Jeppsen Utah 801-955-5318 800-360-5735 Ext. 8202
Mary Enos Virginia, North Carolina
434-689-2169 800-360-5735 8203
Thomas Melville Oregon 503-841-5457 800-360-5735 Ext. 8204
Andrew Clark NewYork, Pennsylvania, Vermont
845-339-0220 800-332-3377 Ext 161
Susan Charczenko Maine, New Hampshire
207-892-2256 800-337-3377 Ext. 181
Kellie Hamilton Indiana 317-455-1425 800-360-5735 Ext. 8206
Anthony Girgenti Arizona 602-993-5891 800-360-5735 Ext. 8205
Jeff Schulz Wisconsin, Iowa, Minnesota
515-265-4963 800-360-5735 Ext. 8426
Kathleen Ibarguen Provider Relations Call Center Lead
800-360-5735
70
Today’s Options
Appeals,
Grievances
and Claims
71
Appeals
• Benefit Determination– Denial of payment for services member or provider
believes should have been covered.– Termination of coverage by the Plan.
• Filing The Appeal– Today’s Options– Medicare– Social Security Administration– Railroad Retirement Board
72
Grievances
• Grievance Procedure applies in instances such as:– Provider/Plan performance, such as wait times, adequacy of
facilities, staff behavior, etc.– Quality of care or access to services– Involuntary disenrollment– Sales process complaints– Administrative complaints
• Not subject to Medicare appeals process• Complaints do not involve claims determination
73
Grievances
How to Avoid Grievances:• Know and understand the product.• Properly explain all benefits and processes.• Make sure member understands that Today’s
Options is not a Medicare Supplement(Statement of Understanding).
• Be responsive to members’ inquiries.• Be professional!
74
Claims
Claims Process• Providers submit claims directly to Today's Options
using the same rule as Medicare A and B:– To the appropriate Today’s Options P.O. box– Electronic coming soon
• Today’s Options processes claims following Medicare Part A and B guidelines.
• Today’s Options pays the equivalent of Medicare allowable rates less applicable plan co-payments.
75
Voluntary Disenrollment During Election Periods
• Can disenroll through Today’s Options (Preferred way), SSA or1-800-MEDICARE.
• If the enrollee wants to cancel after an enrollment form is processed and submitted to CMS, the member must notify the plan in writing of the request to disenroll (signed and dated). Send notification to:
– Pyramid: P.O. Box 3237, Scranton, PA 18505.– American Progressive: P.O. Box 4109 Scranton, PA 18505
• The Member will return to Medicare Parts A & B, unlessthe member chooses a new MA plan
– If the member enrolls in a new MA plan while still in a MA plan, the member will be automatically disenrolled from old plan and enrolled in new plan without duplication or delay in coverage
• Non payment of premium• Disenrolled after proper notice (two notices): 90-day grace period
• Becomes effective the first of the month after theMA organization receives completed form
76
Involuntary Disenrollment
• Must disenroll if Today’s Options member:– Moves outside service area for more than six
months– Loses entitlement to either Part A or Part B– Dies (Age-out)– Plan contract is terminated or discontinues
operation• Plan can disenroll member if:
– Member is disruptive (very rare)– Member provides fraudulent information or
facilitates fraudulent use of membership card
77
Medicare Supplement availability after dropping Medicare Advantage
• Subject to Lock-in• If the member disenrolls from Today’s Options, often the
member is entitled to purchase specific Medicare Supplement policies without regard to health status. – Involuntary disenrollment: (Member moves, plan leaves service area),
member is entitled to purchase any Medicare Supplement Plan A, B, C, or F sold in state.
– First time enrolled in Medicare Part C: If it is the first time a member is enrolled in a MA plan and the member voluntarily disenrolls within 12 months, they can purchase the same Med Supp policy they had before, if it is still available from the same Med Supp insurer. If not available, member may buy any Med Supp Plan A, B, C, or F sold in state.
– Newly Medicare eligible: Eligible for Medicare at age 65, and disenrolls within 12 months–they are entitled to purchase any Medicare Supplement policy sold in the state.
• Member must apply for Medicare Supplement policy no later than 63 days after coverage terminates under Today’s Options.
78
Today’s Options
Compliance
79
Compliance
Confidentiality andProtecting Information (HIPAA)
• Information regarding Today's Options business activities is considered confidential and proprietary to the Company.
• Employees and agents are entrusted with confidential and privileged information that may not be released without proper authorization.
• Employees and agents must comply with HIPAA requirements regarding the disclosure of Protected Health Information (PHI).
• Employees and agents are responsible for properly using information stored and produced by all Today's Options information systems.
80
Compliance
Sales Audit Program
• New Member Acknowledgement form• In-home Verification Call • Welcome Call feedback• Disenrollment Trends• Sales Satisfaction Survey results • Grievance totals and trends• In-person monitoring of sales calls (ride-alongs)• Regulatory complaints
81
Medicare Advantage / PDP Deadly Sins
1. Door to door marketing / solicitation.2. Representing yourself as an agent of CMS, Social Security or
Medicaid.3. Advising consumers that they must purchase plans “as directed
by Medicare”4. Creating and using sales or marketing collateral that are have not
had prior CMS approval.5. Offering gifts or other inducements to enroll that are greater than
nominal ($15) value6. Health Screening members7. Retrospective Enrollment -- back dating enrollment forms8. Prospective enrollment – effective date is always the first day of
the month following completion of the enrollment form9. Presentations or sales in Dr's office (or anywhere health care
services are dispensed)10. Selling a Medicare supplement to a Medicare Advantage Member
82
Must Use / May Not Use / May Use Today’s Options Eligibility:
Must May Not May
•Indicate that members must be enrolled in Medicare Parts A and B.
•Say “Seniors” unless term appears or is stated with “and all other Medicare eligible Beneficiaries.”
•State that “Anyone with Medicare living in the Service Area may apply.”
•Indicate that all Medicare Beneficiaries with Parts A and B may apply.
•Say “Medicare Advantage Plan designed especially for seniors.”
•Say “Medicare entitled by age or disability.”
•Mention the ESRD exclusion when mentioning “No health screening.”
•Say “Individuals age 65 and over.” •Say “Medicare Beneficiaries or Medicare enrollees.”
•The monthly premium payment must be accompanied by a statement that Today’s Options members must continue to pay Medicare Part B premium, as well. ($88.50 in 2006)
•State that “Today’s Options is a Medicare Advantage Private Fee For Service Plan with a Medicare Contract.”
• Say “No other premium or deductibles”.•Superlatives, such as: “Highest Rated”, “Best Plan”, etc.•Make unsubstantiated comparisons with other Medicare Advantage Plans.•Say “no paperwork.”
•Say “recommended or endorsed by Medicare.”•Imply that Today’s Options has a unique or custom arrangement with the Federal Government or Medicare.•State that Today’s Options is a “special” Health Plan.”
•State “The Today’s Options premium payment per month is in addition to the monthly Medicare Part B premium.” •Say “Virtually no paperwork”, “Hardly any paperwork.”•Say “No physicals required.”
83
Fraud, Waste and Abuse
• All employees and agents are responsible to report any suspected health care fraud to the Today's Options Special Investigations Unit, Compliance Officer, General Counsel or CMS immediately upon notification.
• The Company will protect your identity as much
as reasonably possible. Report Fraud at: • UAFC fraud hotline: (800) 853-0186• Medicare: 1-800-MEDICARE
84
Corrective Actionand/or Discipline
• Agents who violate any of the Company’s Compliance requirements, violate related corporate policies or procedures, violate CMS or State Insurance regulations or anyone who knowingly fails to report violations, or any agent or manager, who fails to oversee compliance by those he or she supervises, is subject to disciplinary actions including termination of contracts and/or termination of right to sell Today’s Options.
85
Today’s Options Agent Certification Process
•Product/Compliance Overview
•Testing: 80% = Passing Grade
Online Certification Option
Annual Recertification Process•Online exam•www.PyramidLife.webce.com
86
Become licensed.
Complete training and certification.
October 1, 2006 – begin pre-selling.
November 15, 2006 – accept enrollment forms.
Your Next Steps
87
Glossary of Terms
• PDP: Prescription Drug Plan• CMS: The Centers for Medicare and Medicaid Services• Enrollee/Member: Policyholder• Enrollment Form: Application• Evidence of Coverage: Policy• MA: Medicare Advantage• MA-PD: Medicare Advantage-Prescription Drug plan• Service Area: Area where a Medicare Plan is available.• PFFS: Medicare Private Fee-For-Service Plan• DME: Durable Medical Equipment• Appeal: Applies when a payment or service is denied. • Grievance: Applies when a member is unhappy with plan services or
performance.
88
Today’s OptionsContact Numbers
PYRAMID LIFE
Pre-sales Inquiries:
800-360-5735; “press 2”
TTY 800-461-5376
Member Services:
1-866-568-8921;
TTY 1-888-844-5530
Sales Agent Support Line:
800-777-1126 ext. 9
Enrollment verification number:
1-877-275-1088 “Press 1”
Web address:
www.pyramidlife.com