Annual Agent Medicare
Training Program
November 2009
Presented by:
Jan Getty
Resource Link
Agent Medicare Training Program
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Medicare Marketing Regulations
Overview
 Medicare Marketing Guidelines are for use by:
o
o
o
o
Medicare Advantage Plans (MAs)
Medicare Advantage Prescription Drug Plans (MA-PDP)
Prescription Drug Plans (PDPs)
1876 Cost Plans
 CMS reviews & approves plan marketing materials to ensure
that they:
o Are consistent with the Medicare Marketing Guidelines, accurate,
not misleading, and with no material misrepresentations.
o Agents must use plan-approved materials – they cannot create or
utilize other materials in sales presentations.
 Marketing by a sales agent on behalf of plans is considered
marketing by plans
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Medicare Marketing Regulations
Use of Plan Sales Agents
 Plans must ensure that sales agents:
o Comply with all applicable MA and/or Part D laws, Federal health
care laws, and CMS rules and regulations (including CMS marketing
guidelines) and plan policies
o Are monitored to ensure compliance with all applicable MA and/or
Part D laws, Federal health care laws, and CMS rules and regulations
(including CMS marketing guidelines) and plan policies
o Are licensed, registered or certified by a state to perform marketing
activities in that state
o Have been appointed by the plan, consistent with the appointment
process in that state
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Medicare Marketing Regulations:
Plan Oversight of Sales Agents
 Plan oversight of sales agents include:
o Plans must comply with requests from state insurance department
or other state agency investigating sales agents licensed by that
agency
o Plans must report sales agents whom the plan suspects is violating
state licensing, registration, certification or insurance laws
o Plans must report termination of sales agents and reasons for
termination to the State if required under state law
o Plans must implement a strategy to prevent and detect prohibited
marketing practices
o If aggressive or prohibited marketing practices are identified, plans
must take immediate corrective action
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Medicare Marketing Regulations:
Plan Oversight of Sales Agents (cont’d)
 Plan oversight of sales agents include (cont’d):
o If plans verify misconduct, they must take action including:
 Withholding or withdrawing commission
 Retraining
 Suspension of marketing
 Termination
 Reporting of misconduct to Department of Insurance
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Medicare Marketing Regulations:
Sales Agent Training & Testing
 All sales agents (both employed & contracted) must
complete training on Medicare rules, regulations, and
compliance-related information on the product they intend
to sell
 On an annual basis, Sales Agents must be tested and must
achieve a score of at least 85 percent prior to selling
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Medicare
101
CMS Training Module Customized by Resource Link for
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HealthPlusMedicarePlus 2010 Agent Training Program
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Medicare 101
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Introduction to Medicare
Original Medicare
Medicare Supplement Insurance (Medigap)
Medicare Advantage and Other Plans
Medicare Prescription Drug Coverage
Medicaid and Medicare Savings Programs
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What Is Medicare?

A health insurance program for people
– 65 years of age and older
– Under age 65 with certain disabilities
– With End-Stage Renal Disease (ESRD)
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Administered by the Centers for Medicare
& Medicaid Services (CMS)
Enrollment
– Social Security (SSA)
– Railroad Retirement Board (RRB)
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Applying for Medicare

Apply 3 months before age 65
– Don’t have to be retired
– Contact the Social Security Administration

Enrollment automatic if receiving
– Social Security
– Railroad Retirement benefits
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Medicare Coverage Basics
Part A (Hospital Insurance) helps cover inpatient care in hospitals. Part A also
helps cover skilled nursing facility, hospice, and home health care under certain conditions.
Premium free to most. Deductibles for most services.
Part B (Medical Insurance) helps cover medically-necessary services like doctors’
services and outpatient care. Part B also helps cover some preventive services to help
maintain health and to keep certain illnesses from getting worse. 2010 premium is $96.40 for
most. 2010 annual deductible is $155 & 20% coinsurance.
Part C (Medicare Advantage Plans) It combines Part A, Part B, and,
sometimes, Part D (prescription drug) coverage. These plans must cover medically-necessary
services that original Medicare covers. However, plans can charge different premiums, copayments, coinsurance, or deductibles for these services.
Part D (Medicare Prescription Drug Coverage) helps cover prescription
drugs. This coverage may help lower prescription drug costs and help protect against higher
costs in the future.
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Medicare Part A
 Most people receive Part A premium free
 People with less than 10 years of
Medicare- covered employment
– Can still get Part A
• Will pay a premium
 Hospital inpatient care
 Skilled nursing facility (SNF) care
 Home health care
 Hospice care
 Blood
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Part B Coverage
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Doctors’ services
Outpatient medical/surgical services &
supplies
Diagnostic tests
Outpatient therapy
Outpatient mental health services
Some preventive health care services
Other medical services
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Enrolling in Medicare Part B
 Automatic Enrollment
– Must opt out if not wanted
 Initial Enrollment Period (IEP)
– 7 months starting 3 months before month of eligibility
 General Enrollment Period (GEP)
– January 1 through March 31 each year
– Coverage effective July 1
– Premium penalty
• 10% for each 12-month period eligible
but not enrolled
• Paid for as long as the person has Part B
• Limited exceptions
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Enrolling in Medicare Part B
 May delay enrolling in Part B with no
penalty if
– Covered under employer or union group health plan
• Based on current employment
– Person or spouse
• Will get a Special Enrollment Period (SEP)
– Sign up within 8 months after coverage ends
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Paying the Part B Premium
 Pay monthly Part B premium
– Most pay $96.40 in 2010
– Higher income may pay more
 Taken out of monthly payments
– Social Security
– Railroad retirement
– Federal government retirement
 For information about premiums
– Call SSA, RRB, or Office of Personnel Management
 If no monthly payments
– Billed every 3 months
– Medicare Easy Pay
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Part C & D Benefits
Part C - Medicare Advantage Added
Benefits
– Additional benefits beyond Part A & B benefits (i.e. vision,
hearing, dental)
– Offered as part of a Medicare Advantage Product Option
Part D – Prescription Drug Benefit
– Coverage began January 1, 2006
– Available to all people with Medicare
– Provided through
• Medicare Prescription Drug Plans
• Medicare Advantage and other Medicare plans
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Medicare Past & Present
“Original Medicare”
Part A
Hospital
Inpatient
Insurance
Part B Physician
and Outpatient
Services
Added in 1992
Part C added
Medicare+Choice
MMA added in 2003
Part D added
•RX Coverage (“PDP”)
•Renamed to “Medicare
Advantage”
Medicare Modernization Act (MMA) provided new opportunities for
Beneficiaries to select new coverage model with added incentives.
i.e. MA-PD plans will offer Part A, Part B and Part D benefits whereas
PDPs offer only Part D benefits
-or- Beneficiary may maintain traditional Part A and Part B and then
select a PDP.
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Medicare Program Choices
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Original Medicare - Part A, B, & D Benefits
Medicare Advantage Plans - Part A, B, C, & D
Other Medicare Plans – Part A, B, C & D
Medicare Prescription Drug Plans
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Original Medicare
 Beneficiary can go to any provider that
accepts Medicare
 People are responsible for
– Part A in 2010
• $1,100 deductible for hospital stays up to 60 days
– Additional costs after 60 days
• Different costs for other Part A services
– Part B in 2010
• $155 annual deductible
• 20% coinsurance for most Part B services
 Some programs may help with costs
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The Medicare Card
Jane Doe
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Medigap
 Health insurance policy
–
–
–
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Sold by private insurance companies
Costs vary by plan, company and location
Must say “Medicare Supplement Insurance”
Covers “gaps” in Original Medicare
• Deductibles, coinsurance, copayments
• Does not work with Medicare Advantage Plans
– Up to 12 standardized plans A – L
• Except in Massachusetts, Minnesota, Wisconsin
• So people can compare easily
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How Medigap Works
 People can buy a Medigap policy
– Within 6 months of enrolling in Part B
• Must be age 65 or older
– If they lose certain kinds of health coverage
• Through no fault of their own
– If they leave MA Plan under certain circumstances
– Whenever the company will sell them one
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Medicare Advantage Definition
Medicare Advantage Organization (MA
Organization) – A public or private entity organized
and licensed by the State as a risk-bearing entity that is
certified by CMS as meeting MA contract requirements.
Medicare Advantage Plan (MA Plan) – A
health plan offered by an MA Organization that
includes all Medicare covered benefits offered at
a uniform premium and cost-sharing
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Who is Eligible to Join a MA Plan?
 Live in plan’s service area
 Entitled to Medicare Part A
 Enrolled in Medicare Part B
– Continue to pay Part B premium
– May also pay monthly premium to plan
 Don’t have ESRD at enrollment
– Some exceptions
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How MA Plans Work
 Usually get all Part A and B services through plan
– May have to use providers in plan’s network
– Benefits and cost sharing may differ from Original Medicare
– Generally must still pay Part B premium
• Some plans may pay all or part
 May get extra benefits
– Vision, hearing, dental services
– Prescription drug coverage
 Still in Medicare program
– Get all Part A and Part B services
– Have Medicare rights and protections
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Medicare Advantage Plans
Medicare
Part A
Medicare Pays
Part A & Part B Claims
Medicare
Part B
Medicare
Advantage
Plans
Medicare
Part C
Medicare Advantage
Plans Pay All
Medicare Claims
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Types of
Medicare Advantage (MA) Plans
 Health Maintenance Organization (HMO)
Plans
– Some have Point-of-Service option
 Preferred Provider Organization (PPO) Plans
 Private Fee-for-Service (PFFS) Plans
 Special Needs Plans
 Medicare Medical Savings Account (MSA)
Plans
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Other Medicare Plans
 Medicare Cost Plans
 Demonstrations/Pilot Programs
 Programs of All-inclusive Care for the
Elderly (PACE)
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Health Maintenance Organization (HMO)
• Includes a network of providers
• Member must stay in network or may pay full cost of services
(except for emergency care, out-of-area urgent care, and out-ofarea dialysis)
• Member must select a primary care physician
• Member generally needs a referral to see a specialist
• Plan covers Medicare Part A & B services
• Plan sometimes covers prescription drug coverage
• Additional covered services may include extra days in the
hospital
• POS option allows members to go outside of network but for a
higher cost
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PPO Summary
• Includes a network of providers
• Member can go outside of the network - costs may be
higher
• Member does not need to select a primary care physician
• Member does need a referral to see a specialist
• Plan covers Medicare Part A & B services
• Plan sometimes covers Rx coverage
• Additional covered services include extra days in the
hospital
• Plan premiums usually include the Original Medicare Part
B premium plus an additional amount set by plan
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PFFS Summary
• Members can see any doctor in any service area
• Note, however, members should ensure that the
provider will accept the plan’s terms and conditions
• Members do not need a referral to see a specialist
• Medicare pays a set amount every month to the health plan
for the member’s care
• Plan determines how much members must pay for care
• Plan covers Medicare Part A & B services
• Plan usually covers Part D prescription drug coverage
• Additional benefits may include extra days in the hospital
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Special Needs Plan (SNP)
Summary
• Plan provides focused care management, special expertise of
providers, & benefits that meet the needs of the special enrollee
population
• Plan includes a network of providers
• Members must get care from the providers in the network
• Members usually need a primary care physician or a care coordinator
to coordinate their care
• Plan is available in limited areas
• Members usually need a referral to see a specialist
• Plan covers Medicare Part A & B services and Part D drug coverage
• Plan limits membership to people with certain special needs
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Special Needs Plans (SNPs)
 “Special Needs” Medicare beneficiaries - Definitions
– Institutionalized Beneficiaries – Those who reside are
expected to reside in long-term care (LTC) facility for 90
days or longer or individuals living in the community that
require a level of care equivalent to that of individuals in a
LTC.
– Dual Eligible Beneficiaries – Beneficiaries that have both
Medicare and Medicaid coverage at the time of enrollment.
– Beneficiaries with Chronic Conditions – A target population
with a severe and disabling chronic condition as determined
appropriate by CMS (i.e. Cardiovascular disease, diabetes,
congestive heart failure, HIV/AIDS, ESRD)
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MSA Summary
• Members can see any doctor in any service area.
• Members do not need a referral to see a specialist.
• Medicare gives the plan an amount of money for the member’s
care.
• The plan sends a portion of money to a savings account.
• Members can use money from the savings account to pay for
services before the deductible is met.
• Plan covers Medicare Part A & B services after the deductible is
met.
• There is no monthly plan premium, but members must pay the
Part B premium.
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Medicare Prescription Drug Coverage
 Medicare Part D
 Available to all people with Medicare
 Provided through
– Medicare Prescription Drug Plans
– Medicare Advantage and other
Medicare plans
– Some employers and unions
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How Do I Receive Medicare Part D
Prescription Drug Benefits?
Instead, Medicare Contracts
With Private Companies to
Provide Part D Coverage
Medicare Does Not
Directly Pay For Part D
Prescription Drug Claims
Stand-Alone
Prescription Drug Plans
(PDPs)
or
Medicare AdvantagePrescription Drug Plans
(MA-PDs)
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Standard Part D Coverage*
How Does
The
Medicare
Part D
Benefit
Work?
*Medicare also provides
“extra help” for Medicare
beneficiaries who are
eligible.
“Catastrophic Coverage”
Medicare Covers
Approximately 95%
“Coverage Gap”
You Pay 100% Of All
Prescription Drug Costs
You Pay
Approx.
25%
“Interim Coverage”
Medicare Covers
Approximately
75%
You Pay $310 Deductible
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$4,650
This is your total
“out-of-pocket”
Part D cost
$2,830
This is what you
and the plan
pays for Part D
drug costs
$310
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What is a Part D Drug?
 A covered Part D drug is a Part D drug that is
included in a Part D sponsor’s formulary, or treated
as being included in a Part D plan’s formulary as a
result of a coverage determination or appeal.
– Cost of plan drugs may vary.
– Beneficiaries need to check the cost of their
particular drugs.
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Prescription Drug Plan Costs
 Costs vary by plan
– In 2010, members may pay:
• Monthly premiums
• Annual deductible, no more than $310
• Copayments or coinsurance
• Very little after $4,550 out-of-pocket
 May offer supplemental benefits
 Plan information and costs available
– www.medicare.gov
– 1-800-MEDICARE (1-800-633-4227)
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Extra Help With Drug Costs
 For many with limited income and resources
– Income limit in 2009
• $1,300/month (individual)
• $1,750/month (married couple)
– Resource limit 2009
• $12,510 (individual)
• $25,010 (married couple)
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Extra Help With Drug Costs
 People with lowest income and resources
– Pay no premiums or deductibles
– Have small or no copayments
 Those with slightly higher income and
resources
– Pay no or a reduced premium
– Have a reduced deductible
– Pay a little more out of pocket
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Eligibility for Extra Help
 Who may automatically qualify
– People with Medicare who get
• Full Medicaid benefits (Duals)
• Supplemental Security Income (SSI)
• Help from Medicaid paying Medicare premiums
(Medicare Savings)
 Others must apply and qualify
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Medicaid
 Joint Federal and state program
– For some people with limited income and resources
 If eligible, most health care costs covered
 Eligibility determined by state
 Application processes vary
 Office names vary
– Social Services
– Public Assistance
– Human Services
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Enrollment Periods
 Initial Enrollment Period (IEP)
– 7 months
– Starts 3 months before month of eligibility
 Annual Coordinated Election Period (AEP)
– November 15 through December 31 each year
– Can join, drop, or switch coverage
• Effective January 1 of following year
 Special Enrollment Period (SEP)
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Annual Coordinated
Election Period (AEP)
Nov. 15 – Dec. 31 every year
Can enroll, switch, or drop
coverage
– Medicare Prescription Drug Plan
– Original Medicare
– Medicare Advantage Plan
Nov. 15
thru
Dec. 31
New plan starts Jan. 1
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Special Enrollment Periods (SEP)
 Involuntary loss of creditable coverage
– Loss of other creditable drug coverage
 Continuous SEP for people who
– Receiving extra help (low-income subsidy/LIS)
– Move to, live in, or move from a long-term care
facility
 Change in residence
– Move out of plan’s service area
 Others
– See CMS PDP enrollment guidance
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Late Enrollment Penalty

Pay penalty
– Most people who enroll after IEP
• 63 days or more without creditable coverage
• Pay penalty as long as enrolled in drug plan

No penalty
– People with extra help
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Late Enrollment
 People who wait to enroll may pay penalty
– Add 1% of national base premium ($30.36 in 2009) for
each month eligible but not enrolled
– Must pay the penalty as long as enrolled in a Medicare
drug plan
 Unless they have other coverage at least as
good as Medicare drug coverage
– “Creditable coverage”
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Creditable Drug Coverage
 Prescription drug coverage that meets
Medicare’s minimum standards
 Will get information from other plan each year
– Employer group plans
– Retiree plans
– VA
– TRICARE
– FEHB
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Other Savings Programs
 Medicare Savings Programs
– Help from Medicaid paying Medicare expenses
• QMB, SLMB, and QI
– For people with limited income and resources
– May also pay deductibles and coinsurance
 State-specific programs
 PACE
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Summary
 Medicare coverage
 Original Medicare
 Medicare Supplement Insurance (Medigap)
 Medicare Advantage and other plans
 Medicare prescription drug coverage
 Medicaid and Medicare Savings Programs
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Marketing Materials
Overview
 Several types of marketing materials:
1.
2.
3.
Advertising materials
Pre-enrollment materials
Post-enrollment materials
 Marketing materials are designed for Medicare beneficiaries
to:
o Promote a health or drug plan
o Provide enrollment information
o Explain benefits and how services are provided
 Marketing material not only include advertising materials
but also include enrollment and disenrollment forms and
letters
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Marketing Materials
Overview (cont’d)
 Only CMS-approved, plan-approved marketing materials
may be used to market health and drug plans
 Forbidden to use words or symbols including Medicare,
Centers for Medicare & Medicaid Services, Department of
Health and Human Services that would convey the
impression that the product is approved, endorsed or
authorized by Medicare.
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Types of Medicare Events
 There are two basic types of Medicare events that Medicare
beneficiaries and other may attend or utilize:
1.
2.
Sales/Marketing Events
Educational Events
 Each of these events has a specific set of rules and
guidelines determined by Medicare
 All events must be registered with CMS prior to the event
occurring
Agents must notify HealthPlus of any planned
marketing events in advance of the event.
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Sales and Marketing Events
 A sales/marketing event is an event sponsored by an MA or
MA-PD, PDP plan or other entity (on behalf of the
MA/MAPD/PDP plan)
 May not use the term “educational” to describe a
sales/marketing event
 Purpose of a sales/marketing event is to:
o Market a specific, limited number of plans to potential members
o Steer or attempt to steer potential members to a specific or limited
number of plans
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Sales and Marketing Events (cont’d)
 Sales agent must:
o Use only CMS-approved plan marketing materials, including scripts
and sales presentations or CMS marketing materials
o Comply with rules regarding gifts or prizes (cannot exceed $15 in
retail value)
o Prior to any sales event or presentation, announce all products that
will be covered during the event or presentation at the beginning
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Sales and Marketing Events
Meals
 Meals are prohibited at marketing events, even for current
members. Plans may not allow meals to be subsidized for
prospective enrollees
 Marketing representative may not allow any other entity to
provide meals at any event where plan benefits are being
discussed or materials distributed
 Marketing representatives may not give gift cards or gift
certificates to a restaurant or any place where food is
served
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Cross-Selling
 Sales agents may not cross-sell or market non-health care
related products (such as annuities or life insurance) during
sales presentations
 Dental coverage is considered health-related and may be
marketed during sales activities
 Plans may sell non-related products on inbound calls where
the beneficiary requests information about non-health
related products
 Marketing to current plan members of non-health MA plan
covered health care products, and/or non-health care
products, is subject to HIPAA rules
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Educational Events
 An educational event provides objective information about
Medicare and/or health improvement and wellness
o If the event is advertised as “educational,” it is considered an
educational event and sales activities may not be conducted
o If not advertised as “educational,” sales activities are permitted
 Educational events are not used to provide plan specific
information or steer an enrollee towards a specific or limited
number of plans
 CMS requires that sales agents use the following disclaimer
when an educational event is organized, sponsored or
promoted by a plan:
o “This event is only for educational purposed and no plan specific
benefits or details will be shared.”
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Educational Events
Acceptable Activities/Restrictions
 Educational events can:
o Have multiple vendors
o Receive sponsorship from the plan or an outside entity
o Promote the event as educational
 Educational events cannot:
o
o
o
o
Include sales activities
Distribute marketing materials
Distribute or collect enrollment applications
Conduct unsolicited contact with beneficiaries
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Educational Events
Prohibited Educational Event Practices
 During an educational event, sales agents may not:
Conduct sales presentations
Discuss plan-specific premiums and/or benefits
Compare benefits to other health or drug plans
Distribute or collect enrollment applications
Collect names/addresses of potential enrollees
Distribute or display business reply cards, scope of appointment
forms or sign-up sheets
o Attach business cards or contact information to educational
materials
o Provide marketing materials generated by the plan or a third party
o
o
o
o
o
o
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Educational Events
Permitted Activities
 During an educational event, sales agents may:
o Distribute educational materials that are free of plan-specific
information
o Display a banner with the plan name and/or logo
o Distribute promotional items, include items with the plan name,
logo, or contact information
o Distribute a business card (that is free of plan marketing or benefit
information) if the beneficiary requests information on how to
contact the sales agent for additional information
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Educational Events:
Meals
 Sales agents may provide refreshments and light snacks to
prospective enrollees
 Plans must use their best judgment on the appropriateness
of the food products provided and ensure that the items
provided could not be reasonably considered a meal
 Examples:
o
o
o
o
o
Fruit
Raw vegetables
Cookies
Nuts
Chips
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Health Fairs & Promotional Events
 Health fairs and promotional events can have the following
sponsorship:
o Sole sponsor: single sponsor for an event
o Multiple sponsors: more than one sponsor for an event
o Both: single and multiple sponsor events
 For sole sponsor events: door prizes or raffles cannot exceed
the $15 limit
 For multi-sponsor events: door prizes or raffles can exceed
the $15 limit if a plan sponsor contributes to a pool
o Plan must not be individually identified and must be listed along
with other contributors
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Health Fairs & Promotional Events
(cont’d)
 For both sole and multi-sponsor events:
o Should not include a sales presentation
o Advertisements and pre-enrollment materials may be distributed
o Organization representatives may answer questions at the event but
no enrollment forms should be accepted at the event
o Value of giveaways or free items should not exceed $15 per
attending person, based on the retail purchase price of all items
provided by the plan sponsor
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CMS-sponsored Health Fairs
 CMS is required to conduct an outreach and education
campaign to inform potential enrollees on health and drug
plans
 Plans may do the following:
o
o
o
o
Assist in planning local health fairs
Distribute health plan brochures and application forms
Have a booth at the health fair
Value of giveaways or free items should not exceed $15
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Promotional Activities
Nominal Gifts
 Plans may offer gifts to potential enrollees, if:
o Of a nominal value ($15 or less based on retail purchase price of the
item)
o If more than one item is at the event, the combined value of all
items must not exceed $15
o May not be in the form of cash, including charitable contributions on
behalf of the potential enrollee, gift certificates or cards that can be
readily converted into cash, regardless of dollar amount
o Must be offered to all eligible enrollees without discrimination
o Must state that there is no obligation to join plan
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Promotional Activities:
Drawing, Prizes & Giveaways
 Plans may offer drawings, prizes & giveaways to potential
enrollees:
o May offer a prize over $15 to the general public as long as the prize is
not offered only to Medicare beneficiaries and it is not routinely
awarded
o May not use prizes and drawings to induce enrollment
o Must include a disclaimer stating that there is not an obligation to
enroll in the plan
o For example:
 “Eligible for a free drawing and prizes with no obligation”
 “Free drawing without obligation”
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Promotional Activities
Referral Programs
 Referral programs may be used by plans to solicit leads from
members for potential enrollees:
o Thank you gifts (less than $15 based on retail price) must be
available to all members and cannot depend on actual enrollment of
the person being referred
o May not use cash promotions
o A letter sent from the plans to members cannot say that a gift will be
offered for a referral
o May ask for referrals from current enrollees, including name and
address, but not telephone numbers
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Provider Promotional Activities:
Overview
 Providers include but not limited to: pharmacists,
physicians, hospitals, and long-term care facilities
 Plans must ensure that contracted providers will not steer or
attempt to steer an undecided enrollee toward a plan for
the providers’ financial benefit
 Providers must not be involved in the following:
o Offering sales or appointment forms
o Mailing marketing materials on behalf of the plans
o Making phone calls or potentially steering enrollees to certain plans
 Providers may display or distribute plan materials, but must
do so for all plans with which they contract
 Providers cannot accept enrollment applications
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Plan Activities in a Health Care Setting
 Sales agents may conduct marketing activities (such as sales
presentations or accepting enrollment applications) in
healthcare settings
 Plans may not market in areas where beneficiaries receive
health care including waiting rooms, exam rooms, patient
rooms, dialysis centers, pharmacy counter areas
 Some marketing may be held in a common area of a health
care setting including hospital or nursing home cafeterias,
community or recreational rooms, and conference rooms
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Unsolicited Marketing
Prohibited Activities
 Door-to-door solicitation is prohibited & extends to other
instances of unsolicited contact that may occur outside of
sales or educational events
 Prohibited activities include:
o Outbound marketing calls, unless the beneficiary requests the call
o Exception for Medigap outbound marketing calls: If during an
outbound call about Medigap a beneficiary is interested in an MA or
PDP, the MA or PDP product may be discussed as long as the call is
recorded (also to include beneficiary-initiated request)
o Requesting private, identification numbers such as Social Security
Numbers, bank accounts or credit cards, or any statement that
implies the plan is endorsed by Medicare, or calling on behalf of
Medicare
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Unsolicited Marketing
Prohibited Activities (cont’d)
 Prohibited activities include:
o Calls to former members who have disenrolled, or to current
members who are in the process of voluntarily disenrolling; except
to conduct disenrollment survey for quality improvement purposes
o Calls to beneficiaries to confirm receipt of mailing
o Approaching beneficiaries in common areas such as parking lots,
hallways, or lobbies
o Calls or visits to beneficiaries who attend sales events, unless the
beneficiary gives permission at the event for a follow-up call or visit
o Use of old lists or consents to contact beneficiaries for sales activities
o Short-term or event-specific consent may not be treated as openended consent
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Unsolicited Marketing
Prohibited Activities (cont’d)
 Prohibited activities include:
o Referrals of beneficiaries resulting from an unsolicited contact (such
as call was based initially on a non-MA or non-PDP product)
o Conducting marketing under the guise of selling a non-MA or nonPDP product (such as a discount prescription drug card, Medicare
Supplement, or review of general Medicare coverage options) and
then presenting MA or PDP plans
o Calls to beneficiaries to confirm acceptance of appointments made
by third parties or independent agents
o Unsolicited e-mails
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Unsolicited Marketing
Permitted Activities
 Plans, sales agents are allowed to conduct the following
activities:
o Conduct outbound calls to existing members to conduct normal
business related to enrollment in the plan or discuss other products
that the plan offers
o Sales agents who enrolled a beneficiary in a plan may call that
member to discuss plan issues & market other plan options, but
cannot conduct unsolicited phone calls to other beneficiaries or plan
members; agents are not required to set-up an appointment
o Sales agents may initiate a call to confirm an appointment that has
been agreed to by a beneficiary
o Call former members to conduct a disenrollment survey
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Unsolicited Marketing
Permitted Activities (cont’d)
 Plans, sales agents are allowed to conduct the following
activities:
o Call beneficiaries who have expressly given permission for a sales
agent to contact them
o Market using mailing, Web sites, advertising, and sales events
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Scope of Appointment Form
 Must be completed in advance - Prior to any marketing
appointment, potential enrollee must agree to the scope of
the appointment
 Must document agreed upon scope in writing - Sales agent
must document the scope of the appointment agreed upon
in writing and signed in advance prior to the appointment
 Must clearly identify types of products(s) to be discussed Sales agent should clearly identify the types of product(s)
that will be discussed, obtain agreement from the potential
enrollee and document that agreement
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Scope of Appointment Form (cont’d)
 To discuss other products not originally covered in the preappointment documentation:
o If the beneficiary requests information on the additional product(s),
the sales agent must have the beneficiary sign a new scope of
appointment form for the new product type
o Marketing appointment may continue
 Sales presentations that are open to the public do not
require documentation that attendees consented to the
scope of the presentation
o The advertising of the event however must indicate the products
being covered during the event
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Scope of Appointment Form (cont’d)
 For walk-ins to a plan or a sales agent’s office or other
beneficiary-initiated contact, the sales agent must complete
a scope of appointment form and secure beneficiary
signature prior to discussing plans:
o Plans and sales agents should note on the scope of appointment
form that the beneficiary was a “walk-in”
 Plan sponsors and their contractors should note that the
beneficiary’s decision to visit must be unprompted.
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
CMS Marketing Surveillance
Surveillance will include
– Tripling the number of “secret shopper”
activities
– Reviewing plans’ local print and broadcast
advertisements
– Reviewing recordings of enrollment calls to
ensure compliance with the new regulations
– Ensuring plans detect, report, and respond to
marketing misrepresentation and other issues
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Agent/Broker Compensation


New guidance
MAs and PDPs must limit
agent/broker compensation
– Designed to eliminate inappropriate
beneficiary moves
– Applies to contracted and employed
agents/brokers
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Agent Resources
 Overwhelmed? You are not alone – HealthPlus is here to
help you be successful.
 Medicare publications & websites
o Medicare & You handbook
o Understanding the Choices You Have in How You Get Your Medicare
Health Care Coverage
o www.medicare.gov
 HealthPlus MedicarePlus Contact #’s:
– Agent line – 1-877-562-0907
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Let’s discuss:
 HealthPlus MedicarePlus Products
 CMS Rules for Selling Medicare
Advantage Products
84
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Now there’s a healthy Plus
Now the a
for all Medicare beneficiaries!
Introducing new, affordable Medicare plans from
HealthPlus!
That’s our message!
New, affordable Medicare plans designed to:
 meet everyone’s healthcare needs,
 offer affordable benefit choices, and
 provide convenient access to quality healthcare!
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A Medicare Program for Everyone!
 HealthPlus MedicarePlus AdvantageHMO
– Primary care doctor serves as member’s health advocate –
coordinating all medical care.
 HealthPlus MedicarePlus AdvantagePPO
– Member has freedom of choice to see any doctor in or out of
HealthPlus’ preferred provider network.
 HealthPlus MedicarePlus SupplementalHMO
– Additional coverage to help fill some gaps in Original Medicare
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A few more facts about us..
 Dedicated to improving health in the community for over 30 years.
 Headquarters in Flint; regional offices in Saginaw and Troy.
 HealthPlus MedicarePlus AdvantageHMO plans earn “Excellent”
Accreditation from NCQA.
 Ranked as one of “America’s Best Health Plans 2008-09” in the U.S.
News & World Report/NCQA yearly listing.
 Vast network of contracted physicians, hospitals, pharmacies, and
medical professionals.
 Members have access to tools and programs to feel great, boost
energy, and learn about their health.
 Superior customer service!
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How do the plans work?
MedicarePlus AdvantageHMO
 Counties Served: Arenac, Bay, Genesee, Lapeer, Oakland,
Saginaw, Shiawassee, St. Clair, Tuscola
 When members enroll, they select their Primary Care
Physician (PCP) to coordinate care. When they select their
PCP, a primary hospital goes with their designation.
 Easy to choose a conveniently located PCP by using the
– MedicarePlus AdvantageHMO online Provider Directory at
www.healthplus.org
– Printed HMO Provider Directory
– Toll-free Customer Service # - 1-800-332-9161
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How do the plans work?
MedicarePlus AdvantageHMO
 Comprehensive Benefits
– Referrals – If a member needs specialty care, their PCP will refer them to
another physician or appropriate medical professional. Referrals are not
needed for some services.
– Part D Coverage –
• Open Drug Formulary covers every Part D prescription drug available.
• “Ask for 90 Rx” program allows members to receive a 90-day supply of
medication from a participating pharmacy or by mail.
• “Rx Coverage Gap” available with certain AdvantageHMO plans.
– Emergency Coverage 24/7 available anywhere in the world!
– Personal Assistance available 8:00 a.m. – 6:00 p.m., Monday-Friday
– Health and Wellness Programs
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How do the plans work?
MedicarePlus AdvantagePPO
 Counties Served: Genesee, Saginaw
 In-Network Services from HealthPlus preferred PPO providers.
Members can choose a physician by using:
– MedicarePlus AdvantagePPO online Provider Directory at
www.healthplus.org
– Printed PPO Provider Directory
– Toll-free Customer Service # - 1-800-332-9161
 Out-of-Network Services available at additional cost to members.
Members will pay a greater portion of the cost of care:
– Higher deductibles
– Higher coinsurance and copays
– May have to submit their own claims.
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How do the plans work?
MedicarePlus AdvantagePPO
 Comprehensive Benefits
– In-Network Services
• Preventive services are not subject to deductible or coinsurance.
• Prior Authorization required for certain services and/or supplies.
Information on which services can be found in Certificate of Coverage and
applicable benefit rider(s).
– Out-of-Network Services
• Available at additional cost.
• Care is covered only after total annual deductible.
• Non-preferred provider may bill and charge member for the difference
between their charge and the amount HealthPlus allows for that
particular service.
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How do the plans work?
MedicarePlus AdvantagePPO
 Comprehensive Benefits
– Part D Coverage –
• Open Drug Formulary covers every Part D prescription drug available.
• “Ask for 90 Rx” program allows members to receive a 90-day supply of
medication from a participating pharmacy or by mail.
• “Rx Coverage Gap” available with certain AdvantagePPO plans.
– Emergency Coverage 24/7 available anywhere in the world!
– Personal Assistance available 8:00 a.m. – 6:00 p.m., Monday-Friday
– Health and Wellness Programs
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How do the plans work?
MedicarePlus SupplementalHMO
 Counties Served: Arenac, Bay, Genesee, Lapeer, Oakland,
Saginaw, Shiawassee, St. Clair, Tuscola
 When members enroll, they select their Primary Care
Physician (PCP) to coordinate care. When they select their
PCP, a primary hospital goes with their designation.
 Easy to choose a conveniently located PCP by using the
– Commercial online Provider Directory at
www.healthplus.org
– Printed Commercial Provider Directory
– Toll-free Customer Service # - 1-800-332-9161
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How do the plans work?
MedicarePlus SupplementalHMO
 Comprehensive Benefits
– Referrals – If a member needs specialty care, their PCP will refer them to
another physician or appropriate medical professional. Referrals are not
needed for some services.
– Part D Coverage – There is no Part D coverage. Member must select a standalone Medicare-approved Part D plan from available plans in the area they
reside. Available plan options can be found at www.medicare.gov
– Emergency Coverage 24/7 available anywhere in the world!
– Personal Assistance available 8:00 a.m. – 6:00 p.m., Monday-Friday
– Health and Wellness Programs
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Summary of Benefits
The HealthPlus MedicarePlus Summary of
Benefits provides all the detail you need to make
sure your client makes the right health care
coverage decision.
(Refer to Summary of Benefits document.)
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Benefit
Service Area
Premium
(You must continue to
pay your Part B
Medicare Premium to
qualify for this plan)
Doctor Office Visits
(Copay Per Visit)
Routine Physical
Exams (1 per year)
AdvantageHMO Option 1
AdvantageHMO Option 2
AdvantagePPO Basic
Arenac, Bay, Saginaw,
Arenac, Bay, Saginaw,
Genesee and Saginaw Counties
Tuscola, Genesee, Lapeer, Tuscola, Genesee, Lapeer,
Shiawassee, St. Clair and Shiawassee, St. Clair and
Oakland Counties
Oakland Counties
$72 Monthly Premium
$102 Monthly Premium
$72 Monthly Premium
AdvantagePPO Enhanced
Genesee and Saginaw Counties
$107 Monthly Premium
Out-of-network: $500 yearly
deductible
$15 for primary care doctor
$35 for specialist
$15 copay
$10 for primary care doctor; In-network:
$25 for specialist
$15 for primary care doctor;
$35 for specialist
$10 copay
In-network:
$10 for primary care doctor;
$25 for specialist
Out-of-network: 30% coinsurance
Out-of-network: 20% coinsurance
In-network: $15 copay
In-network: $10 copay
Out-of-network: 30% coinsurance
Out-of-Network: 20% coinsurance
Prescription Drugs
Generic:
34-day/90-day supply
$7/$14 copay
$6/$12 copay
$8/$16 copay
$6/$12 copay
Preferred Brand:
34-day/90-day supply
$39/$78 copay
$35/$70 copay
$37/$74 copay
$35/$70 copay
Non-Preferred Brand:
34-day/90-day supply
$74/$148 copay
$70/$140 copay
$74/$148 copay
$70/$140 copay
Lesser of $125 copay or
25% coinsurance
Lesser of $125 copay or
25% coinsurance
Lesser of $125 copay or 25%
coinsurance
Lesser of $125 copay or 25%
coinsurance
Generic only:
$6 for 30-day supply
Not covered
Generic only:
$6 copay for 30-day supply
Specialty:
Rx Coverage Gap
Not covered
(costs from $2,830 until
TrOOP costs reach
$4,550)
$12 for 90-day supply
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$12 copay for 90-day supply
96
2010 Medicare
Advantage
Benefits96
Benefit
AdvantageHMO Option 1
AdvantageHMO Option 2
AdvantagePPO Basic
AdvantagePPO Enhanced
Urgent Care
$35 copay
$25 copay
$35 copay
$25 copay
Emergency Care
$50 copay worldwide
$50 copay worldwide
$50 copay worldwide
$50 copay worldwide
$0 if admitted to hospital
$0 if admitted to hospital
$0 if admitted to hospital
$0 if admitted to hospital
$300 copay
In-network: $400 copay
In-network: $300 copay
Out-of-network: $600 copay
Out-of-network: $500 copay
Inpatient Hospital Care $400 copay
(Copay per stay)
Outpatient
Services/Surgery
$100 copay at an ambulatory $50 copay at an ambulatory In-network: $100 copay at an
surgery center;
surgery center;
ambulatory surgery center;
In-network: $50 copay at an
ambulatory surgery center;
(In-Network = Copay per $200 copay in an outpatient $100 copay in an outpatient $200 copay in an outpatient hospital $100 copay in an outpatient hospital
surgery)
hospital setting
hospital setting
setting
setting
Diagnostic Tests, XRays, Lab Services
$0 copay
Skilled Nursing Facility Days 1-20: $0 copay
Days 21-100: $100 copay
per day
Routine Vision
Services
$35 copay for annual
routine eye exam
Out-of-network: 30% coinsurance
Out-of-network: 20% coinsurance
$0 copay
In-network: $0 copay
Out-of network: 30% coinsurance
In-network: $0 copay
Out-of-network: 20% of the cost
Days 1-20: $0 copay
In-network:
Days 1-20: $0 copay
In-network:
Days 1-20: $0 copay
Days 21-100: $50 copay per
day
Days 21-100: $100 copay per day
Days 21-100: $50 copay per day
Out-of-network:
Days 1-20: $100 copay per day
Out-of-network:
Days 1-20: $100 copay per day
Days 21-100: $139 copay per day
Days 21-100: $139 copay per day
$25 copay for annual routine In-network: $35 copay for annual
eye exam
routine eye exam
In-network: $25 copay for annual
routine eye exam;
$100 limit for eye wear every Out-of-network: 30% of the cost for $100 limit for eye wear every 2 years
two years
Medicare-covered exams
Out-of-network: 20% of the cost for
Medicare-covered exams
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2010 Medicare
Advantage
Benefits97
Benefit
AdvantageHMO Option 1
AdvantageHMO Option 2
AdvantagePPO Basic
AdvantagePPO Enhanced
Hearing Services
$35 copay for yearly routine $25 copay for one yearly
hearing test; hearing aids not routine hearing test; hearing
covered
aids not covered
$35 copay for yearly routine hearing
test; hearing aids not covered
$25 copay for one yearly routine
hearing test; hearing aids not covered
Preventive Dental
Services
Preventive dental services
(e.g., cleaning) not covered
Preventive dental services (e.g.,
cleaning) not covered
$0 copay for one oral exam and one
cleaning every six months; one dental
x-ray every two years
$0 copay for one oral exam
and one cleaning every six
months; one dental x-ray
every two years
12009
amounts (2010 amounts have not yet been announced and may increase)
Benefit Period starts the day you enter a hospital or skilled nursing facility and ends when
you go for 60 days in a row without hospital or skilled nursing care.
2A
This is an abridged summary of benefits; please refer to the AdvantageHMO Subscriber
Contract and respective Benefit Riders, and the AdvantagePPO Certificate of Coverage and
respective Benefit Riders for exact descriptions of benefits.
HealthPlus MedicarePlus Advantage plans are contracted with Medicare and plan contracts
are renewed annually.
For more complete information on the HealthPlus MedicarePlus AdvantageHMO or
AdvantagePPO, please call the HealthPlus Customer Service Department at 1-800-332-9161;
for TTD/TTY users, please call 1-800-992-5070. A Customer Service Representative is available
Monday through Friday from 8 a.m. to 6 p.m. or visit www.healthplus.org.
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2010 HealthPlus
Supplemental HMO Benefits
• No Change in Benefits from 2009
• Part D Prescription Drug Benefit Must Be Purchased
Separately
• 2010 Monthly Premiums:
W7
W8
W9
WA
$80.00
$94.00
$123.75
$147.75
*Monthly Premium Does Not Include the Cost of a Stand-Alone Prescription Drug
Plan.
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Enrolling Medicare Beneficiaries
Enrolling with HealthPlus MedicarePlus is easy & convenient.
 The Annual Enrollment Period begins November 15 and ends December 31
 Many Ways Beneficiaries can enroll:
 Submit Paper Application to HealthPlus
 Enroll through a select HealthPlus Insurance Agent
 Enrollment On-Line at HealthPlus’ website at:
www.healthplus.org/medicare.aspx
 Call HealthPlus MedicarePlus direct at 1-800-332-9161
Hearing Impaired: TDD 1-800-992-5070
 Direct with Medicare on-line at: www.medicare.gov
 Call Medicare anytime at 1-800-MEDICARE (1-800-633-4227)
Hearing Impaired: 1-877-486-2048
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Agent Compensation
MedicarePlus AdvantageHMO & AdvantagePPO
• $300 upon initial enrollment
• $150 upon each renewal for 5 years
MedicarePlus SupplementalHMO
• 15% of paid premium
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Ready, Set, Go – Let’s take the Test!
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