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1 Optimum HealthCare Sales Video Script - H5594_14SalesVideo_CMS Approved Thank you for joining us for this special presentation on Optimum HealthCare s Medicare Advantage Plans. Today we will explain the tremendous value of an Optimum HealthCare plan which offers benefits and savings you can use every day! At the end of this presentation one of our skilled Benefit Consultants will be available to answer any questions you may have or sign you up for an Optimum HealthCare plan today. Thank you for joining us today to learn about Optimum HealthCare s Medicare Advantage H-M-O Point of Service H-M-O Special Needs and H-M-O Point of Service Special Needs Plans. This is also an opportunity to review your current coverage and compare Medicare Advantage plans to Original Medicare. During this presentation you will learn about the variety of Optimum HealthCare s benefit plan options to determine what best fits YOU and your lifestyle. And if you like what you hear today one of our benefit consultants can help you enroll in an Optimum HealthCare Medicare Advantage H-M-O Point of Service H-M-O Special Needs or H-M-O Point of Service Special Needs Plan. Optimum HealthCare is an H-M-O Plan with a Medicare contract and a contract with the Florida Medicaid Program. Your enrollment in Optimum HealthCare depends on contract renewal. The benefit information you hear today is just a brief summary, not a complete description of benefits but you can always contact the Plan for more information. Benefits may vary by Plan and County and limitations, co-payments and restrictions may apply. As with all Medicare Advantage Plans benefits formulary pharmacy network premium and-or copayments/co-insurance may change on January 1st of each year. Please hold any questions you may have for the end of this presentation when one of our benefit consultants will be happy to assist you. We ll begin by explaining Medicare. As you probably already know Medicare is federal health insurance for people 65 and older younger people with certain disabilities and people with end stage renal disease with limited exceptions. Medicare is divided into several parts. Part A is hospital insurance.

2 It helps cover the care of patients in hospitals skilled nursing facilities hospice or even home health care. Part B is medical insurance which helps cover doctor s services outpatient care or some preventive services. Part C is Medicare Advantage which is a health coverage option that is run by a private insurance company and may offer extra coverage. Medicare Advantage Plans are approved and under contract with Medicare. They include Parts A B and usually prescription drug coverage which is known as Part D. Part D is also an option run by private companies approved by and under contract with Medicare to help cover the cost of prescription drugs. To be eligible for Medicare Advantage you must have both Medicare Parts A and B. You must be a permanent resident in the area where the plan is offered. People with End Stage Renal Disease are not eligible for Medicare Advantage with limited exceptions. If you are eligible you may enroll in an H-M-O plan only during specific times of the year. If you are eligible for an H-M-O Special Needs Plan or S-N-P you can enroll at any time of the year. You can always contact the Plan for more information but here is a brief description of the different Medicare Enrollment Periods. From October 15th through December 7th each year All Medicare beneficiaries may enroll or disenroll in a Plan. Coverage begins January 1st of each year. From January 1st through February 14th of each year you may switch back to Original Medicare and choose a Part D Plan. The Initial Coverage Enrollment Period is when newly eligible beneficiaries can enroll in a Medicare Advantage Plan. The time frame is based on their individual circumstances and allows for a 7 month period of eligibility. An agent is available to assist you with any questions on your eligibility. The Special Enrollment Period is when you may enroll or disenroll in a plan due to a qualifying condition. Qualifying conditions are listed on the last page of our enrollment application. There are many reasons to choose Optimum HealthCare. It is owned and operated by doctors who are focused on preventive care they don t just see you when you are sick or have a health problem. Optimum HealthCare has its headquarters in Tampa Florida with convenient concierge centers across the entire state.

3 Optimum HealthCare is accredited by The National Committee for Quality Assurance N-C-Q-A and received a Commendable rating and was re-awarded a three year accreditation from December 26th to December 26th Optimum HealthCare has also been approved by N-C-Q-A to operate a Special Needs Plan or S-N-P until December 2014 based on a review of Optimum HealthCare s Model of Care. N-C-Q-A accredits and certifies a wide range of health care organizations and manages the evolution of HEDIS the performance measurement tool used by more than 90 percent of the nation s health plans. Optimum HealthCare passes these rigorous standards and reported their performance in dozens of clinical areas to earn the N-C-Q-A seal of approval. You will also find a Medicare Plan Ratings sheet in the Plan enrollment kit. The Plan rating is given by Medicare and shows how well a plan is performing in different categories. Medicare evaluates Plans based on a 5 star rating system. For 2013 Optimum HealthCare was awarded a 5 star rating in Customer Service and 5 stars in Member Overall Rating of Drug Coverage. Optimum s Overall Star Plan Rating was an above average 4 stars. Star Ratings are calculated each year and may change from one year to the next. For more information on Plan Star Ratings go to w-w-w dot Medicare dot gov. It is really easy to find an Optimum HealthCare plan to fit your needs and lifestyle. There are Medicare Advantage H-M-O Plans with prescription drug coverage and a Point of Service benefit. These include the Optimum Gold Rewards Plan and the Optimum Platinum Plan (H-M-O P-O-S). Optimum HealthCare also offers full and partial dual eligible Special Needs Plans with drug coverage including the Optimum Emerald Partial and Optimum Emerald Full (H-M-O S-N-P). There are also Chronic Condition Special Needs Plans with drug coverage and a Point of Service benefit including the Optimum Diamond Rewards and Optimum Diamond Rewards C-O-P-D (H-M-O P-O-S S-N-P) These are designed for people with Cardiovascular Disorders Chronic Heart Failure Diabetes Mellitus or Chronic Lung Disorders. Dual Eligible H-M-O Special Needs Plans are available to anyone who has both Medical Assistance from the state and Medicare. Premiums co-pays co-insurance and deductibles may vary based on the level of Extra Help that you receive. Here are what just some of our satisfied members have to say about Optimum HealthCare (Member Testimony) It s awesome. It really is, you know, to not have to, there s some nights I can t sleep but it s not because of worrying about my health insurance. You know, I m totally confident in the plan, in the service, in my doctor.

4 Earlier in this presentation we mentioned Medicare Special Needs Plans or S-N-Ps which are a type of Medicare Advantage coordinated care plan that is focused on individuals with special needs. Optimum HealthCare S-N-Ps are limited to people with specific chronic conditions or people eligible for both Medicare and Medicaid. If you qualify to join a Medicare S-N-P you get all of your Medicare hospital and medical health care services through that plan including Medicare prescription drug coverage. Optimum HealthCare offers two types of S-N-Ps. Chronic Care Special Needs Plans or C-S-N-Ps are for people with one or more of the following chronic or disabling conditions: Cardiovascular Disorders Chronic Heart Failure Diabetes Mellitus and Chronic Lung Disorders. To join an Optimum HealthCare C-S-N-P the Plan will need to obtain verification of the chronic condition from your doctor. A response from your doctor s office is required within 30 days of enrollment. The second type of S-N-P offered by Optimum HealthCare is a Dual Eligible Special Needs Plan or D-S-N- P. These plans are for people who are eligible for both Medicare and Medicaid. You can contact the Plan to confirm your eligibility or get your questions answered. If you lose eligibility or there are changes to your eligibility or qualifying condition you will be disenrolled from your Special Needs Plan but you will be eligible for a Special Election Period that will allow you to enroll in another plan. The bottom line is Optimum HealthCare offers benefits and savings you can use every day and that is a true value for its members! For instance, there are $0 cost Primary Care Visits $0 cost Preventive and even $0 cost Plan Premiums on most plans! You can also save with Medicare Advantage Prescription Drug Savings Plans. Members can receive up to $80 of their Part B Premium back each month on the Gold Rewards Plan that s up to $960 each year! And there are savings with Optimum Chronic Condition Special Needs Savings Plans too. Members can receive up to $86 of their Part B Premium back each month on the Diamond Rewards Plans that s up to $1032 each year! All these savings vary by Plan and County and are based on a 12 month enrollment. You must continue to pay your Medicare Part B Premium. The Part B Premium is covered for full benefit dual members of Special Needs Plans.

5 Another exciting Optimum HealthCare benefit is the O-T-C Allowance. (Member Testimony This covers over the counter health related items and supplies that most people buy regularly and Optimum HealthCare members love it! That over the counter plan! Who came up with that? That s, I mean, who even would think of offering that. That in itself is just an amazing benefit. And you think right away, well $15 a month, that s not much. Well it really is because the things on the list are very low cost. They ll be $2, $3, $4 and $5 at the most so you could get three $5 things where you d walk into the drug store and pay double that. Plan participants can receive between $15 and $50 each month depending on Plan selection and where you live. Over the course of a year this could mean between $180 and $600 in savings! Plus members can order these supplies on-line or over the phone and have them delivered directly to their homes at no cost! It s easy and hassle free. Specifics vary by plan and county and limitations and restrictions may apply. When it comes to prescription drugs there are four cost sharing tiers. Every drug on the Plan s list can be found in one of these tiers. Cost sharing tier one covers preferred generic prescription drugs. Cost sharing tier two covers preferred brand prescription drugs. Cost sharing tier three is for non-preferred brand prescription drugs. And cost sharing tier four is dedicated to specialty prescription drugs. In general, cost sharing Tier 1 drugs are the lowest tier and includes some Generic Drugs and some Brand Drugs. Tier 2 Drugs include Preferred Brand Drugs and some Non-Preferred Generic Drugs. Tier 3 Drugs include Non-Preferred Brand Drugs and Non-Preferred Generic Drugs and Tier 4 Drugs are the highest tier and include Specialty Tier Drugs. To find out which cost sharing tier your drug is in look it up in the Plan s formulary and then refer to the benefits section for specific cost sharing. Eligible beneficiaries must use network pharmacies to take advantage of their prescription drug benefit except in non-routine circumstances. Quantity limits and restrictions may apply.

6 You may also receive a Late Enrollment Penalty or L-E-P which is an amount that Medicare adds to your Part D Premium. You may owe the L-E-P if after your initial enrollment period is over there is a period of more than 63 days in a row when you don t have Part D or other creditable prescription drug coverage. There are exceptions. If you get Extra Help then you will not owe a L-E-P. Beneficiaries can find out at enrollment if they owe a L-E-P and if so how much. If you are presented with an L-E-P but disagree you may request a reconsideration request form from the Plan. There are two ways to find a drug within the Formulary. You can look it up depending on the type of medical conditions it is used to treat. For example drugs used to treat a heart condition can be found under the category Cardiovascular Agents. The index of the Formulary also provides an alphabetical listing of all the drugs along with the page number where you can find coverage information. Any drug restrictions will also be noted in the formulary. Some drugs require Prior Authorization P-A. Quantity limits Q-L and or step therapy S-T requirements. If your drug is indicated as P-A your doctor will need to contact the plan to request authorization. If your drug is indicated as Q-L your doctor will need to prescribe the Plan approved amount or contact the Plan for an exception. If your drug indicates S-T the Plan will want you to try certain drugs to treat your medical condition before covering another drug. If you doctor already has you on a step drug they may ask the Plan for an exception. If you are newly eligible switching Plans or have a change in your level of healthcare you can receive a one-time 31 day supply of your current medications within the first 90 days of membership. This is called the Formulary Transition Process. You can ask the Plan to make an exception to the coverage rules by asking for a Formulary Exception. How much you pay for your prescription drugs depends on your coverage stage. Stage 1 is the initial coverage stage and the Plan will pay its share of the cost of your drugs and you are responsible for your share. You remain in Stage 1 until your payments for the year PLUS the Plan s payments equal two thousand- 850 dollars. Stage 2 is the Coverage Gap stage many of you may know it as the Donut Hole. In Stage 2 you pay 25 percent of generic drug costs as well as discounted costs for brand drugs until your yearly out of pocket drug costs reach four thousand-550 dollars. This total may be different if you are already getting Medicare Extra Help. For certain plans, you may pay zero or ten dollars for drugs in Tier 1 during the Coverage Gap or Donut Hole.

7 You can contact the Plan for more information. The third stage is the Catastrophic Coverage Stage. Once you have paid enough for your drugs to move into this last payment stage the Plan will pay most of the cost of your drugs for the rest of the year. You will pay the greater of five percent or two dollars 55 cents for generic or preferred multi-source drugs and the greater of five percent or six dollars 35 cents for all other drugs. Another great feature of Optimum HealthCare plans is the Medical Home. Here your Primary Care Provider or P-C-P acts as your personal physician and coordinates all your health care needs. Your P-C-P focuses on prevention and your overall wellness not just treating you when you are sick and this allows for a higher quality of overall service. (Provider Testimony) It s important for them to be seen frequently so we do make the calls and we also try to get them to set appointments before they leave and then call and change it if it doesn t work out just so that we re on top of being on the right schedule with them. You must use Optimum HealthCare providers except in emergent or urgent care situations out of area renal dialysis or other services. If you choose to get routine care from an out of network provider neither Medicare nor Optimum HealthCare will be responsible for the cost. The bottom line is Optimum HealthCare offers its members more benefits for less money than Original Medicare. For example there are no plan premiums on most plans. Some Optimum HealthCare plans even provide a Part B Premium refund. In fact, the Optimum Gold Rewards Plan (H-M-O P-O-S) provides a refund of up to $80 each month. And the Optimum Diamond Rewards Plan (H-M-O S-N-P P-O-S) provides a refund of up to $86 each month. Plus there s an O-T-C benefit! Optimum members can receive from $15 to $50 dollars each month to purchase Over The Counter health related items. That s between $180 and $600 in savings each year! There s also brand and generic prescription drug coverage available on plans that offer Part D coverage.

8 And all Optimum HealthCare plans offer supplemental benefits like dental vision hearing and health club or fitness memberships. But probably most importantly for people on a budget Optimum HealthCare members can expect predictable costs and low out of pocket maximums. Yeah, it was quite a surprise that I could get so much coverage and so many benefits with zero premium per month. It s just, it s fantastic. And I was doing a little happy dance here when I found out. There are more than a dozen preventive services available to Optimum HealthCare at zero cost. These include bone mass measurements cardiovascular colorectal and diabetes screenings flu shots glaucoma tests mammograms and more. Benefit limitations may apply so be sure to review your Evidence of Coverage or ask your benefit consultant for complete details of your coverage. So you may be asking when you can enroll in an Optimum HealthCare plan it s called the Annual Enrollment Period or A-E-P. During the A-E-P people eligible for Medicare Advantage may enroll or end their enrollment in a Medicare Advantage Plan. The AEP starts October 15th and goes through December 7th. Most enrollments submitted during this time will have an effective date of January 1st, If you have a special enrollment period or initial coverage election period you may be able to enroll with an earlier effective date. If you have questions please call our Member Services department for more information or refer to the Medicare and You handbook for more information on enrollment periods. After you enroll you will receive some important items from Optimum HealthCare including your I-D card and evidence of coverage a provider directory and if your plan offers Part D coverage a pharmacy directory and the formulary which is the list of covered drugs as well as other member materials. This is what the Optimum HealthCare I-D card looks like and the information it provides. On the front you ll find your plan benefits for your pharmacist if you have Part D coverage your Optimum HealthCare identification number the year you joined Optimum HealthCare the name of your Optimum Medicare Advantage Plan and your plan number. On the back are the up-front payments or co-pays for your plan benefits Member Services contact information and information for your doctor pharmacist or hospital. If you ever have a question that you would like answered face to face you can always stop by one of our concierge centers conveniently located around the state. These centers are open Monday through Friday from eight in the morning until five in the evening. You ll find concierge centers in Casselberry Bradenton Spring Hill Tampa and Ocala. Each location has helpful staff licensed agents and a one hour resolution time. To find a concierge center close to you go to our website at w-w-w dot your optimum healthcare dot com.

9 Optimum HealthCare believes your health is important and it changes on a daily basis. Optimum can help you stay on top of these changes with their Health Assessment Tool or HAT. Once you submit a HAT Optimum HealthCare uses it to coordinate any care that you may need or to qualify you for any specialized health wellness program or education available. The HAT will not be used to disqualify you and will not impact your enrollment with Optimum HealthCare. You may have questions about what you have learned here today. Optimum HealthCare wants to make finding those answers as easy as possible. To start you can meet with the benefit consultant who is with you now. Or you can always go to our website w-w-w dot your optimum healthcare dot com. You can also call Member Services at T-T-Y T-D-D users should call These numbers are available seven days a week from eight in the morning until eight at night October 1st through February 14th From February 15th through September 30th the lines are open Monday through Friday from eight in the morning until eight in the evening. And from October 1st through December 31st you can reach someone seven days a week from eight in the morning until eight in the evening. Thank you for your time today. Remember Optimum HealthCare is Care You Can Trust.

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