1 How to Conduct a Compelling, Comprehensive, and Compliant Care Improvement Plus Appointment Brandon Clay, Senior Director of Sales September 30, 2010.

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How to Conduct a Compelling, Comprehensive, and Compliant

Care Improvement Plus Appointment

Brandon Clay, Senior Director of Sales

September 30, 2010

Compelling, Comprehensive, and Compliant

• Compelling—a unique Medicare Advantage plan that provides specialized care based upon personal needs

• Comprehensive—providing a complete and thorough review of the plan’s benefits and rules

• Compliant—regulatory environment requires deep understanding and consistent obeyance of the laws/rules set forth by all Federal (CMS) and State (DOI) entities

Care Improvement Plus Appointment

1. Generating a “lead”/Setting an appointment

2. Conducting an appointment

3. “Best practices” for enrollment follow up

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Generating a (Compliant!) Lead

• CMS, DOIs, and Care Improvement Plus are focused on how a lead/appointment is secured– You are personally responsible for every

lead/appointment– During the course of an audit or investigation

you likely will be asked to provide documentation as to the source of the lead

Permissible Lead Generation

• CMS/Plan approved marketing materials– CMS/Plan-approved, plan-specific materials– Plan-approved generic materials

• These materials may take the form of:– Direct mail– Advertising– Phone scripts

• Contact with Existing Customers– Sold into and currently enrolled in another Medicare

health plan– Sold non-health related insurance product (e.g. life,

burial, dental)

ALL Marketing Materials

- All marketing materials (even those approved for use by other health plans and/or CMS) must be submitted to Care Improvement Plus for prior review and approval if their use may result in a Care Improvement Plus enrollment. Examples include: business reply cards, fliers, print ads, scripts, etc. - All materials must be submitted by email to the

following address: [email protected]

- Plan mention or benefit-specific information will require filing with CMS

Prohibited Lead Generation

• Unsolicited contact- Calls can only be made to prospects who initiate

the contact (e.g. via reply card or inbound telephonic inquiry)

- This includes electronic voicemail messages, or answering machine messages

Prohibited Lead Generation

Sales Agents are NOT permitted to:– Call former members who have voluntarily

disenrolled or current members in the process of disenrolling to market plans or products.

– Call beneficiaries to confirm receipt of mailed information.

– Approach beneficiaries in common areas (e.g. parking lots, hallways, lobbies, etc.).

– Call or visit beneficiaries who attended a sales event, unless the beneficiary gives express permission at the event for a follow-up call or visit.

Third-Party Lead Generation

• If you are obtaining sales leads from a third party and they cannot produce documentation to confirm that the lead was produced in a compliant manner, do not follow up to the lead if you believe it to be gathered in a non-compliant fashion.

Pre-Appointment• Calling a beneficiary who has requested

contact to set/confirm an appointment is compliant and Care Improvement Plus would recommend it as a best practice

• If a Scope of Appointment has not been secured already, gather a Scope of Appointment at this time

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Scope of Appointment

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• The scope of the appointment must be agreed upon by the prospective enrollee either in writing or recorded call at least 48 hours prior to the appointment. - The agreement must be documented by the Sales Agent or

health plan when scheduling the appointment. Sales Agents can document the scope of appointment in writing via a signed scope of appointment form

- If the scope of appointment is being documented by recording a phone call in advance of the appointment, the call must be placed by the plan sponsor and Not the agent/broker

- If it is not feasible for the Scope of Appointment form to be completed prior to the appointment, the sales agent may have the beneficiary sign the form at the beginning of the appointment.

• If it is not feasible for the Scope of Appointment form to be obtained prior to the appointment, you may have the prospect sign the form at the beginning of the appointment; however you are required to submit documentation to Care Improvement Plus as to why it was not feasible to obtain the Scope prior to the appointment.

Scope of Appointment

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• In a case where the beneficiary has agreed to an appointment to discuss a PDP product, an agent cannot discuss an MA product during that same meeting unless the beneficiary requests it.

• When a beneficiary asks to discuss another (MA) product type, the agent must have the beneficiary sign a new Scope of Appointment form for the new product type and then may continue the marketing appointment.  – A new separate appointment is not required and

the 48 hour waiting period does not apply.

Examples

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The following is an example of an unacceptable process:– A Sales Agent purchases a list of Medicare beneficiaries. The

Sales Agent then calls each beneficiary on the list to see if they are interested in seeing what Medicare Advantage health plans are available to them.

The following is an example of an acceptable process:– Mrs. Jones schedules an appointment with a Sales Agent/Broker

to discuss MA-PD products. During the appointment, Mrs. Jones states that she would also like to purchase life insurance. The Sales Agent/Broker explains to Mrs. Jones that he can assist her with purchasing a life insurance policy but that he will have to schedule a separate appointment to come back and discuss life insurance options with her.

• Only if Mrs. Jones insists that the non-MA product is represented at that time is it permissible to proceed with review of the non-MA product

Important Clarification

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• An agent who is meeting with a Medicare beneficiary to discuss a non-Medicare Advantage product or service may establish a sales appointment for a Medicare Advantage product if the beneficiary or a caregiver initiates the request for information and if the  agent's and the lead generation organization's motivation for the original appointment was solely to market the non-Medicare Advantage product.

– CMS policy is clear that an agent's motivation for the initial appointment, and any preceding contact arranging the appointment such as an outbound call, needs to be to market the non-MAPD product.

• If the beneficiary requests information on Care Improvement Plus, the agent (1) must obtain a signed scope of appointment form and (2) schedule the Medicare Advantage appointment at least 48 hours after the non-MAPD appointment.– Only if the beneficiary insists that Care Improvement Plus is

represented at that time is it permissible to proceed with review of the plan

The Appointment

• Introduction• Eligibility• Assessing the “Best Fit” plan option• Coverage Review

– Care Improvement Plus’ unique selling proposition– Benefits– Rules

• Enrollment Application– Other administrative

• Wrap up

Introduction

• Sales presentation introduction- Provide name- The organization represented- Reminder of the purpose of the appointment

- Do not:- Communicate or imply that you are a representative

of—or affiliated with—Medicare (CMS)

Eligibility

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• General eligibility requirements to enroll a Medicare beneficiary:• Must be enrolled in Medicare Part A and enrolled in Medicare Part B• Must continue to pay the monthly Medicare Part B premium, unless it is otherwise paid for under Medicaid or by a third party. • Must live in the plan’s service area• Must complete the enrollment form during an applicable enrollment period

• C-SNP Must have one of the qualifying chronic conditions: Diabetes and/or Heart Failure• D-SNP Full dual - $0 A/B cost-share

• Best practice: If uncertain of member’s Medicaid status, call the Broker Advocate Team to check Medicaid eligibility

“Best Fit” Plan• Assess the prospective member’s needs

- Review existing coverage

- Financial situation - Medicaid- LIS

- Healthcare needs - Chronic conditions diabetes and/or heart failure- Medical needs- Prescription drug needs

– Review of Rx drug needs against formulary

“Best Fit” Plan

Coverage Review—Benefits• Monthly premium

– Many of our plans are $0 premium• Be sure to account for subsidy level when quoting monthly

premium

– Out of pocket maximum• Out of pocket maximum should not be of concern to a full dual

beneficiary (as they do not accumulate A/B cost sharing)

– A/B benefits and any associated cost-sharing• Deductibles, copays/co-insurance associated with A/B

coverage are covered by State Medicaid for full duals– Be sure to account for subsidy level when quoting A/B cost-

sharing

Coverage Review—Benefits• Prescription Drug (Part D) benefit

– Formulary review• Best practice: have the beneficiary provide a list, or pull out all

of their Rx drugs• Be sure to account for Low Income Subsidy (LIS) level when

quoting Part D cost sharing

– Review of Coverage Gap• Remember: those with LIS do not encounter the Coverage

Gap—they continue to pay their LIS co-pay levels• For those without LIS

– 7% discount on generics in the Coverage Gap

– 50% discount on brands in the Coverage Gap

Coverage Review—Benefits• Additional Care Improvement Plus Benefits

and Services– NOT offered by Original Medicare– NOT offered by most other Medicare

Advantage plans

Coverage Review—Benefits• Additional Benefits and Services

– Benefits• Vision

– Routine eye exam– Glasses/contacts ($150-$200 annually)

• Dental– Preventive dental (exams, x-rays, etc.)– Dentures (available in our plans for full duals)

• Transportation (12-60 one-way rides)• OTC (available in our Silver Rx plan)• 24/7 Nurse Hotline

Coverage Review• Care Management Programs

– HouseCalls• Offers members an in-person visit with a physician or nurse

practitioner who performs a health assessment to:- Gather information to help us provide additional health education

and care coordination- Identify urgent health problems or risks- Provide advice on topics to discuss at the next appointment with

their regular doctor

• Occurs annually or more frequently upon need

Within the past year, Care Improvement Plus has conducted more than 45,000 HouseCalls visits – more than any other Medicare health plan.

Coverage Review• Care Management Programs

– PharmAssist- Specialist Pharmacists provide:

– Personalized, private counseling

– Review of medications

– Education and support

– Many Care Improvement Plus members regularly take between 8-11 different medications – for these individuals, the PharmAssist program helps make managing medications more effective, safer, easier and less costly.

Coverage Review• Care Management Programs

– Social Service Coordinators (SSC)• Conducts outreach to members to determine eligibility for

state, local, and federal programs that can assist with expenses, such as:

- Medicare Savings Programs (Medicaid)

- “Extra Help” or Low Income Subsidy (LIS)

- “Golden Touch” with local programs» Pharmaceutical Assistance Program » Telephone, heating and electric bills» Meals» Transportation

Coverage Review• Care Management Programs

– Social Service Coordinators provides significant savings and valuable programs to our members.

– Social Service Coordinators:• Will save Care Improvement Plus members more than $4 million in

Part B premiums in 2010

• Has enrolled or helped maintain more than 3,500 Care Improvement Plus members into State Medicaid programs whereby they will no longer have to pay their A/B cost sharing

• Enrolled more than 1,500 Care Improvement Plus members in LIS, saving them more than $6 million in prescription drug costs annually

• Enrolled Care Improvement Plus members in more than 25,000 community-based programs through its GoldenTouch outreach – bringing Care Improvement Plus members more than $30 million in valuable services annually

Coverage Review—Rules• Open Access Network—go to any Medicare-approved provider

who accepts payment from the plan– With an open access network, members may go to any Medicare-

approved provider that accepts payment from the plan.- For DSNP, providers must accept both Medicare & Medicaid

– The plan will pay current Medicare rates to any Medicare provider with only a few exceptions (for example, transportation and pharmacy) where benefits are limited to a contracted network. 

– There are some providers who refuse to accept assignment from health plans, particularly Medicare Advantage plans.  These providers are generally not singling out Care Improvement Plus members, but have taken the position that they do not work with certain types of programs. 

– If a Sales Agent learns that a provider will not accept Care Improvement Plus, they are asked to bring this to the attention of the plan by calling Agent Support Hotline.

– Agents must emphasize that not all health care providers accept the health plan.  Care Improvement Plus will conduct outreach to providers who do not accept the plan—and, can provide the beneficiary with alternative health care providers if necessary.

Coverage Review—Rules• Care Improvement Plus does not require referrals for

access to specialists or other providers for Medicare-covered services.– Members may always self-refer to a provider, without a referral or

approval in advance for Medicare-covered benefits.

• Review of non-covered services (e.g. those not covered by Original Medicare unless covered by the plan, not “medically necessary”, etc.)– The beneficiary is responsible for charges associated with non-

covered services• Review of services that require prior authorization (e.g.

Inpatient hospital, SNF, etc.)

Marketing/Sales Events

- Webinar has focused on the Personal/Individual Marketing Appointment

- Separate set of rules govern Marketing/Sales events

- If you have questions re: Marketing/Sales events, ask your Sales Manager or email [email protected]

Important Reminders

– Individuals who currently have Medicare Advantage (MA), Medicare Advantage Part D (MA-PD) or Part D coverage are AUTOMATICALLY dis-enrolled from their plan by CMS upon their effective date with Care Improvement Plus.

– Individuals who currently have a Medicare Supplement (Medigap) coverage may keep it, but they CANNOT use it once they join Care Improvement Plus.

– Care Improvement Plus is NOT a Medicare Supplement (Medigap) plan.

– Care Improvement Plus is NOT a “stand-alone” Part D Plan.

Questions?

Thank you in advance for representing Care Improvement Plus’ 2011 plan

options in a compelling, comprehensive, and compliant

manner!