How to Conduct a Compelling,
Comprehensive, and Compliant
Care Improvement Plus
Appointment
Brandon Clay, Senior Director of Sales
September 30, 2010
1
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
3
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:
compliancereview@careimprovementplus.com
- 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
• 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.
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Scope of Appointment
• 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.
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Examples
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
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Important Clarification
•
An agent who is meeting with a Medicare beneficiary to discuss a nonMedicare 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
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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
• 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
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“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
C-SNP
Plan Name
Diabetes &/or Heart Failure
+
Full Dual
Silver Rx
Diabetes &/or Heart Failure
+
Not Full Dual
Gold Rx
-
Diabetes or heart failure
Dual Advantage
D-SNP
Full dual ($0 A/B cost sharing)
MA-PD
Not eligible for C-SNP or D-SNP
Not eligible for C-SNP or D-SNP
Medicare Advantage (RPPO)
+
Reside in select county
Medicare Advantage (LPPO)
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 costsharing
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
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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 Medicareapproved 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 Medicarecovered 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 noncovered 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
compliancereview@careimprovementplus.com
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!