Centene MAPD D-SNP. Sales Training. Joe Kanatzar National Sales Director

Transcription

1 Centene MAPD D-SNP Sales Training Joe Kanatzar National Sales Director

2 Agenda Module 1 Medicare 101 Myths, History, CMS and Eligibility, Marketing Guidelines Module 2 Medicare Coverage and Parts of Medicare Module 3 Medicare Part D Coverage Module 4 Medicare Advantage Plans (MAPD/PDP) Plan Types and Eligibility Module 5 Medicaid Eligibility and Coverage Module 6 Medicare Advantage Plans (MAPD HMO D-SNP) Eligibility and Coverage Module 7 Plan Specific Information Enrollment, Summary of Benefits, Provider Directory, Supplemental Benefits 2

3 Module 1: Medicare Myths, History, CMS and Eligibility, Marketing Guidelines In this module, we ll talk about the history of Medicare, its oversight, eligibility, and marketing guidelines. We ll also discuss some common myths and misconceptions. 3

4 History of Medicare First proposed by Harry Truman in 1945 Signed into law by Lyndon B. Johnson in 1965 as part of the Social Security Act Original intent was to provide health insurance to those 65 or older Medicare s first member was? 4

5 History of Medicare Under Richard Nixon in 1972, Medicare expanded to cover those under 65 with long-term disabilities and end-stage renal disease (ESRD) and provide coverage for some chiropractic services, speech therapy, and physical therapy Numerous changes and adjustments were made throughout the 80s and 90s, including changes in coverages, provider payments, and cost sharing 5

6 History of Medicare Medicare+Choiceprogram was established in 1997, bringing HMOs into the Medicare business; at the same time, assistance was provided to low-income recipients to help pay premiums In 2000, the 24-month waiting period was waived for those with amyotrophic lateral sclerosis (ALS) 6

7 History of Medicare Prescription drug coverage (Part D) passed and signed into law by President George W. Bush in 2003; became effective in 2006 The same law, the Medicare Modernization Act of 2003, rebranded Medicare+Choiceas Medicare Advantage 7

8 Medicare and the ACA The Patient Protection and Affordable Care Act of 2010 (PPACA or ACA) made a number of changes to Medicare: Reduced costs to providers and health plans Addressed donut hole, or gap, in Part D Restructured Part B premiums Strengthened anti-fraud provisions Facilitated further innovation in processes 8

9 Administration of Medicare Medicare is administered by the Centers for Medicare and Medicaid Services (CMS): Federal agency under the Department of Health and Human Services Oversees implementation of Medicare, Medicaid, Children s Health Insurance Program (CHIP), and Health Insurance Marketplace Mission is to build a better healthcare system and provide high quality care at lower cost 9

10 CMS 5-Star Rating System CMS has developed a 5-star rating system for Medicare Advantage plans to help individuals compare different plans. Plans are rated on a scale of 1 to 5 stars Medicare Advantage and Prescription Drug plans receive a separate rating Ratings are based on member survey results, the plans, and providers 10

11 CMS 5-Star Rating System The CMS 5-Star rating system is important to the success of any Medicare Advantage plan. Plans that receive 5 stars are awarded a special designation and individuals are allowed to switch to a 5-star plan throughout most of the year (Dec 8 Nov 30). 11

12 CMS 5-Star Rating System Plans that receive under three stars for three or more consecutive years receive a low performance icon. Members of such plans receive a letter from CMS advising them of their plan s status and giving them the option to switch to a higher rated plan. 12

13 CMS 5-Star Rating System In addition, plans are given financial incentives to receive a 4 or 5 star rating. Perhaps most importantly, however, is the fact that the CMS rating system lets us know how well we are serving our members. 13

14 CMS 5-Star Rating System That s it for the 5-star rating system. Now, let s clear up some common Medicare Myths and Misconceptions about Medicare 14

15 Medicare Facts and Fiction Medicare recipients pay nothing out-of-pocket for covered services Fact or Fiction? Medicare is free Medicare pays for all medical services A recipient s benefits are determine by how much they ve paid into the system over the years 15

16 Medicare Facts and Fiction Medicare recipients pay nothing out-of-pocket for covered services Fact or FICTION! Medicare is free Medicare pays for all medical services A recipient s benefits are determine by how much they ve paid into the system over the years 16

17 Eligibility To be eligible, an individual must be: 65 or older, or Under 65 with a certain disability (24 month waiting period), or Diagnosed with end-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) 17

18 Marketing and Sales As you can imagine, and may already know, marketing and sales activities for Medicare Advantage products are heavily regulated by CMS. Let s go over some of those rules and regulations. 18

19 Marketing and Sales Agent and Broker Rules CMS sets cut-off amounts each spring for amounts that a plan may pay Plans must notify CMS of their intent to use independent agents/brokers for the upcoming year and what they intend to pay them. Plans must terminate agents for serious marketing allegations and report to the department of insurance. Summary Only! This is not a comprehensive list of rules and regulations 19

20 Marketing and Sales CMS prohibits the distribution of marketing materials that are materially inaccurate, misleading, or otherwise make material misrepresentations. 20

21 Marketing and Sales Plan sponsors may not: Claim that they are recommended or endorsed by CMS, Medicare, or the Department of Health & Human Services (DHHS). Summary Only! This is not a comprehensive list of rules and regulations 21

22 Marketing and Sales Plan sponsors may not: Compare their organization/plan(s) to another organization/plan(s) by name unless they have written concurrence from all plan sponsors being compared, (e.g., studies or statistical data as described in 40.3). This documentation must be included when the material is submitted in HPMS. Summary Only! This is not a comprehensive list of rules and regulations 22

23 Marketing and Sales Plan sponsors may not: Use absolute superlatives, ( the best, highest ranked, rated number 1 ), unless they are substantiated with supporting data provided to CMS as a part of the marketing review process. If the material is submitted via the file & use program, the supporting data must be included, along with the materials that use an absolute superlative. Summary Only! This is not a comprehensive list of rules and regulations 23

24 Promotional Items Current Members Promotional Items --Plans must track and document items given to current members. Must adhere to nominal value individual item/service worth $15 or less. Rewards and Incentives --May only be offered to current members for any Medicare covered preventive service that have $0 dollar cost share SUCH AS: preventive screenings, immunizations, or Welcome to Medicare visit. $50.00 CAP NO LONGER APPLIES. 24

25 Promotional Items Prospective Members Nominal Gifts Must adhere to value of $15 or less. Do not have to track preenrollment promotional items on a per person basis, but must track event totals. However, plans must not willfully structure to give people more than $50 per year. 25

26 Educational Events Marketing Events must be filed with CMS. Plans file on the 20 th for the next month. The following information should accompany your request to file: Presentation Language Event Date and Time Facility Type Agent National Producer # Venue Name, Phone, and Address Summary Only! This is not a comprehensive list of rules and regulations 26

27 Outbound Enrollment Verification Beneficiary must be contacted within 15 days of receipt of application (receipt is date signed by applicant). Enrollment verification can be attempted by phone, letter or (if the beneficiary has opted-in for e mail). The Verification call can be integrated into existing practices, such as a welcome call. If the plan chooses to utilize telephonic contact but is unable to speak to the individual directly, the plan must continue to call attempts or follow up with written communications. Summary Only! This is not a comprehensive list of rules and regulations 27