caremore’s southern california 2013 product...

CareMore’s Southern California

2013 Product Overview

“Internal Use Only”

AGENDA •Compliance Reminders & Updates

•Agent Certification/ Re-Certification

•CareMore Care Model

•CareMore Care Centers (CCC)

•CareMore’s 2013 Benefits

•Website

•Enrollment Application and Forms

•Contact Information

• Tips to avoid allegations: Ensure member understands the plan completely

Always collect a Scope of Appointment

Try to have a family member present

Never modify any approved marketing material

Avoid non-solicited contacts (phone, email, etc.)

Follow the 48 hour “cooling off” period

When in doubt, please Ask

COMPLIANCE MARKETING AND SALES


• Do’s: Review the summary of benefits with each beneficiary

Explain the MA Plan is not a Medicare Supplement

Disclose enrollment periods and limitations

Leave a Summary of Benefits, Copy of Enrollment Form

Review Provider Network and limitations

• Do Not’s: Introduce yourself as a Medicare Representative

Tell the beneficiary the plan is endorsed by CMS

Modify or edit the marketing materials

COMPLIANCE MARKETING AND SALES


FRAUD, WASTE & ABUSE


• Fraud: An intentional act of deception, misrepresentation, or concealment in order to gain something of value.

• Waste: Over-utilization of services (not caused by criminally negligent actions) and the misuse of resources.

• Abuse: Excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss.

Examples include: • Charging in excess for services or supplies. • Providing medically unnecessary services. • Billing for items or services that should not be paid for by Medicare. • Billing for services that were never rendered. • Billing for services at a higher rate than is actually justified. • Misrepresenting services resulting in unnecessary cost to the Medicare

program, improper payments to providers, or overpayments.


FRAUD, WASTE & ABUSE


You are responsible for reporting potential Fraud, Waste, and Abuse issues or concerns to:

• CareMore’s confidential Helpline 562-741-4303

• CareMore’s Sales Compliance Department Stephanie Smith, [email protected] 562-677-2462

• Medicare 800-MEDICARE (800-633-4227)

Remember: You may report anonymously and retaliation is prohibited when you report a concern in good faith.

NEW AGENT CONTRACTING & CERTIFICATION

• 2013 CareMore Product Training & Exam

• Contracting Paperwork: Contract signature pages Copy of current state insurance license (Life and Health) Copy of 2013 AHIP Sales Allegation Attestation Form W9 – Direct Agents Only

• Once your contracting and certification is complete you will receive a welcome

letter, via email, that will include important information as well as your broker ID number. This process can take up to 2 weeks to complete. Please DO NOT sell until you have received your welcome letter.

• Email contract information to [email protected] or Fax to 562-741-4408

All agents must remain in good standing to sell and/ or market CareMore Medicare Advantage Plans.


AGENT RE-CERTIFICATION

How to re-certify for 2013

Review or attend CareMore Certification presentation. Complete certification test. Scan & email certification test and 2013 AHIP to

[email protected] or Fax to 562-741-4408

America’s Health Insurance Plans (AHIP) 2013 exam now available at:

http://www.ahipmedicaretraining.com/clients/caremore

All agents must remain in good standing to sell and/ or market CareMore Medicare Advantage Plans.


WHAT’S NEW FOR CAREMORE IN 2013

Commission Update

• Effective January 1, 2013 CareMore raised commission payments to maximum.

STATE YEAR 1 YEARS 2-6

California $517.00 $258.50 Arizona $413.00 $206.50 Nevada $413.00 $206.50




Expanding into 3 new areas:

• Northern CA - Alameda County, servicing the Tri-County area (Pleasanton, Livermore & Dublin)

• Southern CA – Corona, Riverside County • Southern CA – Upland, San Bernardino County

Covering ALL zip codes in Upland, Rancho Cucamonga, Ontario, Fontana & Chino Hills.

The Upland Care Center will be servicing LA County’s Pomona and Chino zip codes.

Opening 6 new Care Centers in California: • Pleasanton, CA • Corona, CA • Upland, CA

• Montebello, CA • Los Angeles, CA • Lawndale, CA


Now offering:

• CareMore Breathe in Riverside County, CA • CareMore StartSmart in Pima County, AZ

Increased StartSmart Part B Premium Reduction:

• San Bernardino County, CA $72 • Riverside County, CA $72 • Maricopa County, AZ $47 • Clark County, NV $57


CareMore Care Model


WHO IS CAREMORE?

• CareMore started in 1993 as a Medical Group, founded by Physicians.

• Began in Downey, California Expanded to Arizona, Nevada & Northern CA Acquired by WellPoint in 2011

• Unique Model of Care Care designed by physicians to meet the needs of

Medicare beneficiaries. Care for our frail & chronically ill members is monitored &

managed at the CareMore Care Centers.

CareMore Care Centers (CCC)

Medicare Advantage HMO Plan

• Select a PCP from the network

• Get referrals to see specialists • Go to in-network urgent care

facilities

CareMore Health Plan Competitor A Competitor B Competitor C

CareMore Health Plan Competitor A Competitor B Competitor C

CAREMORE CARE CENTERS

• Purpose Provide comprehensive, coordinated care for CareMore members

• Goals Healthy Start Appointment Identify and manage care for members that are frail and/or have a

chronic condition Coordinate use of all available programs to provide comprehensive care Communication and coordination of care with primary care physician

o Within 48 hours, communication is sent to the PCP detailing the visit and medication changes, if any.

Please note: CareMore Care Centers are not an Emergency Room, Urgent Care or Walk in Clinic. Services provided at the Care Center are through scheduled appointments.


CAREMORE CARE CENTERS

Care Centers

• Safe and comfortable clean environment

• Low glare surfaces • Modern clinical exam

and consultation rooms with chairs

Staff

• Nurse Practitioners • Extensivists • Office Manager • Medical Assistants • Case Management • Specialists

(specialists vary per location)

• Healthy Start Appointment

Comprehensive Medical Assessment Identify healthcare needs and history Head to Toe examination (45 minutes to 1 hour) Review medications On-site lab results (Less than 20 minutes) Personalized care plan Referrals for other CareMore plans and services

95% of new members accept Healthy Start Appointment, 97.3% leave very satisfied.

HEALTHY START PROGRAM


• Brokers are encouraged to facilitate the Healthy Start appointment for their clients: 1-888-291-1387

Observation: Many conditions go undiagnosed and untreated, leading to a variety of health problems and costs. CareMore: Established Healthy Start program and exam, resulting in identifying undiagnosed conditions.


• Electronic Blood Pressure Monitoring

• Electronic Weight Scale (CHF patients)

Electronically monitored through member home telephone line. Information is sent to a centralized location monitored by a Nurse Practitioner. If a member has a sudden weight gain or high blood pressure, the Nurse Practitioner can adjust member’s medication, via phone call, or request member come to Care Center.

ELECTRONIC MONITORING PROGRAM

Observation: Physicians have limited ability to obtain correct readings between patient visits. CareMore :Equips patients with electronic blood pressure monitors and wireless cuffs. Patients have shown a reduction in systolic blood pressure, reducing chances for a stroke.

Observation: CHF is the leading cause of hospital

admissions and readmissions. CareMore: Equip each patient with weight scale. Same day call or visit with clinician,

resulting in 50% reduction in hospital admission rate in 3 months.

• CareMore Diabetes Care Management Program Individual Attention and Personalized Care Plan

o Primary Care Physician o Nurse Practitioner o Diabetic Supplies o Registered Dietician & Exercise Coach

DiabeatIT o HbA1c levels checked every 3 months o Education and Information for controlling blood sugar o Nutritional Education & Access to Support Groups o Toll-Free Nurse Practitioners Help Line 1-800-589-3148

DIABETES CARE PROGRAM

Observation: Improper dosing and insufficient support (areas of nutrition and exercise). CareMore: Targets patients with HbA1c > 8 and provides them intensive diabetic management, resulting in lower HbA1c levels.


ROUTINE PODIATRY & WOUND CARE

• Routine Foot Care Light Callus Removal Toe Nail Trimming Check Feet for Ulcers & Wounds

Medical podiatry requires authorization

• Wound Care Evaluate wounds to better understand if there are other

health factors that may be affecting the wound healing process

Develop an individualized care plan to assure that members get the appropriate wound care treatment

Review nutritional status and develop an individualized dietary plan to assure that patient’s diet promotes healing

Receive education on how to care for wounds at home. We also provide take home wound care supplies

On average, CareMore has 105

appointments each day for routine Podiatry services at the Care

Centers.

Observation: Routine wound care is being primarily delivered by vascular and orthopedic surgeons who are not inclined to supply highly-repetitive and low-intensity care for wounds. CareMore: During routine foot care, MA’s, certified in wound care look for, monitor & treat any open sores. With early detection & treatment, our amputation rate is 78% less than the national average.

FALL PREVENTION PROGRAM

• Fall Prevention Clinic Assessment Medication Review Vision & Hearing Acuity Check Physical Mobility & Balance Assessment Muscle Weakness (NAF) Bone Density Home Safety Evaluation

(if a fall has already occurred)

Observation: 1 out of 3 seniors fall each year; chance of falling again increases by 400%. 1 out of 10 falls result in serious injury such as fracture, head injury, serious soft tissue injury.

CareMore: Established a Fall Prevention Program,

individualized evaluation. Members are referred to our Exercise & Strength Training Program, with

a focus on balance, resulting in decreased falls & fractures in frail senior members.


EXERCISE & STRENGTH TRAINING PROGRAM

• Exercise & Strength Training at Nifty after Fifty Conveniently located within the CCC, or close by, that offers strength training,

physical fitness, and social interaction.

Covered Benefit (Authorization Required)

One-on-on training with a certified kinesiologist

Programs specifically designed with a wide variety of orthopedic and neurological conditions to proactively reverse reduced muscle strength and mass that is common in mature adults

State-of-the-Art workout equipment with senior-minded technology

o Air-compressed machines

o Convenient adjustable settings to provide comfort

o Easy to read digital boards to help monitor current workout with built-in tracking mechanism for future progress.

HOSPITALIST EXTENSIVIST PROGRAM

• Internal Medicine Physician Visits member at Skilled Nursing Facilities and Hospitals upon admission Follows patient care after being discharged from Hospital or Skilled Nursing

Facility Refers members to Specialists or other needed services Patients seen as long as necessary (possibly for the rest of patient's life) Case Management Reviews Cases on patients admitted to hospitals Facilitates and Coordinates discharge needs

CareMore: Monitors all hospital discharges by making Care Center appointment or home visit. Includes verification of correct medication, dosing, and home support. Extensivist follows up to verify recuperation, resulting in 4% less re-admission rate.

Observation: 1 in 5 Medicare beneficiaries will return to the hospital within 1 month of discharge because of poor post-discharge follow-up or lack of continuity of care.


Los Angeles County

• East LA 3513 E 1st St., Los Angeles, CA • Downey 10000 Lakewood Blvd, Downey, CA • Glendale 908 S Central Ave., Glendale, CA • La Mirada 15034 Imperial Hwy, La Mirada, CA • Long Beach 4540 E 7th St., Long Beach, CA • Montebello 433 N 4th St. #208, Montebello, CA • Torrance 4201 Torrance #260, Torrance, CA • West Covina 301 North Azusa Ave., West Covina, CA • Whittier 14350 E. Whittier Blvd. #100, Whittier, CA

• Montebello 2444 W. Beverly Blvd., Montebello, CA • Los Angeles 303 S. Union Ave, Los Angeles, CA • Lawndale 15202 Hawthorne Blvd., Lawndale, CA

Los Angeles “NEW” for 2013

CARE CENTER LOCATIONS SOUTHERN CALIFORNIA

Orange County

• Anaheim 1182 N Euclid St., Anaheim, CA • Brea 340 W Central Ave. #110, Brea, CA • Placentia 1325 N Rose Dr. #102, Placentia, CA • Santa Ana 1945 E. 17th St., Santa Ana, CA

San Bernardino County

• Apple Valley 19059 Bear Valley Rd., Apple Valley, CA • Hesperia 1708 Main St., Hesperia, CA • Upland 141 W. Foothill Blvd., Upland, CA

Riverside County

• Riverside 2190 Market St., Riverside, CA • Corona 203 W 6th St Ave., Corona, CA

Upland, CA “NEW” for 2013

Corona, CA “NEW” for 2013

CARE CENTER LOCATIONS SOUTHERN CALIFORNIA


CARE CENTER LOCATIONS NORTHERN CALIFORNIA

Santa Clara County

• San Jose 255 N White Rd. #200, San Jose, CA • Atherton 4885 Atherton Ave., San Jose, CA

Stanislaus County

• Modesto 1234 McHenry Ave., Modesto, CA • Turlock 1000 Delbon, Turlock, CA

Alameda County

• Pleasanton 4270 Rosewood Dr., Pleasanton, CA

“NEW” Opening for 2013

“THE CAREMORE MODEL”

“Internal Use Only” “Internal Use Only”

2013 Southern California Product Overview


SOUTHERN CALIFORNIA

• Medicare Advantage Plan (HMO) CareMore Value Plus (CVP) CareMore StartSmart

• Special Needs Plans (HMO)

CareMore Reliance/ Diabetes CareMore Breathe CareMore Heart* CareMore ESRD* CareMore Connect (Dual SNP)**

*Heart & ESRD Plans are not available in Riverside County. **Available in Los Angeles only.

CareMore’s Value Plus (CVP) Plan MA-PD plan suitable for the General Medicare Population

• Members must: Have Medicare Parts A & B Live in the Service Area NOT have End Stage Renal Disease (ESRD)

• Must join during an Annual Election Period (AEP), unless Special Enrollment Period eligible.

Age-In Limited Income/Resource Assist. Medi-Medi Relocated/Life Change Loss of Retirement or Commercial Insurance


CVP PRODUCT OVERVIEW Eligibility Requirements


CAREMORE VALUE PLUS PRODUCT OVERVIEW

When a benefit is listed as $0-$XX, the $0 copay applies for Specialist services provided at the CCC.

BENEFITLOS ANGELES &

ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO

COUNTY

Monthly Premium $0 Copay $0 Copay $0 Copay

Maximum Out-0f-Pocket (MOOP) Limit $3,400 $3,400 $3,400

INPATIENT SERVICES

Inpatient Hospital Acute Day Day 1-90: $0 Copay Day 1-90: $0 Copay Day 1-90: $0 Copay

Additional Days $0 Copay $0 Copay $0 Copay

InPatient Psychiatric Day Day 1-90: $0 Copay Day 1-90: $0 Copay Day 1-90: $0 Copay


Skilled Nursing Facility (SNF) Day 1 - 20: $0 Copay Day 1 - 20: $0 Copay Day 1 - 20: $0 Copay

Day 21 - 100: $25 Copay

Day 21 - 100: $50 Copay

Day 21 - 100: $50 Copay

Home Health Care $0 Copay $0 Copay $0 Copay

OUTPATIENT SERVICES

Emergency Care $65 Copay Waived if Admitted

$65 Copay Waived if Admitted


Urgent Care $0 Copay $0 Copay $0 Copay

Emergency - Urgent Care Worldwide Annual Benefit Limit

$10,000 Limit, ER and UC Combined






COUNTYOUTPATIENT SERVICES, cont.

Primary Care Physician (PCP) $0 Copay $0 Copay $0 Copay

Physician Specialist Visits Including Nephrologist $0 Copay $0 Copay $0 Copay

Medical Podiatry $0 Copay $10 Copay $10 Copay

Podiatry/Routine Foot Care $0 Copay; 12 visits/Year $0 - $10 Copay; 4 visits/Year

$0 - $10 Copay; 4 visits/Year

Psychiatric Services $0 Copay $0 Copay $0 - $10 Copay

Physical Therapy $0 Copay $0 - $10 Copay $0 - $10 Copay

Speech Therapy $0 Copay $10 Copay $10 Copay

Chiropractic Services $0 Copay $0 Copay $0 Copay

Routine Chiropractic Not Covered Not Covered Not Covered

Occupational Therapy $0 Copay $10 Copay $10 Copay

Outpatient Mental Health $0 Copay $0 - $10 Copay $0 - $10 Copay

X-Rays $0 Copay $0 Copay $0 Copay

Outpatient CT / MRI / PET $75 Copay $100 Copay $100 Copay




COUNTYOUTPATIENT SERVICES, cont.

Outpatient Hospital $0 Copay $0 Copay $0 Copay

Ambulatory Surgical Center (ASC) $0 Copay $0 Copay $0 Copay

Outpatient Substance Abuse $15 Copay $30 Copay $30 Copay

MEDICAL SERVICES & SUPPLIES

Outpatient Diagnostic Radiology $0 Copay $0 Copay $0 Copay

Outpatient Therapeutic Radiology $60 Copay 20% Coinsurance 20% Coinsurance

Ambulance $100 Copay $100 Copay $100 Copay

Transportation 24 One Way Trips to PAL Limited Clinical Benefit Limited Clinical Benefit

DME and Prosthetics Line item, lease or purchase

0% Coinsurance, $0-$499



20% Coinsurance, $500 +



Dialysis $25 Copay 20% Coinsurance 20% Coinsurance

Therapeutic Shoes $50 Copay $50 Copay $50 Copay

Diabetes Supplies 20% Coinsurance 20% Coinsurance 20% Coinsurance




COUNTYADDITIONAL SERVICES

Over-the-Counter (OTC) Program $20 allowance per month Not Covered $15 allowance per month

Nutritional Consultation $0 Copay; 2 visit(s) / Year

$0 Copay; 1 visit(s) / Year


Exercise and Strength Training $0 Copay $0 Copay $0 Copay

Vision Exam - Medical $0 Copay $10 Copay $10 Copay

Vision Exams - Routine $0 Copay $0 Copay $0 Copay

Eye Ware UniView Vision; Eye-Med Network

Glass Lenses Copay - $20

Contacts, Frames, Lenses/Frames Copay -

$0$100 Benefit Limit per 2

years




years




years

Hearing - Exams $0 Copay $0 Copay $0 Copay

Hearing Aids $250 Allowance Every 1 year

$250 Allowance Every 1 year


Liberty Dental Plan Basic Dental Coverage Basic Dental Coverage Basic Dental Coverage

Liberty Dental Plan Optional Supplemental Buy Up

$8.00 Premium for : Optional Dental



OVER THE COUNTER (OTC) BENEFIT

CareMore offers an over-the-counter monthly benefit allowance!

Visit a network pharmacy Choose approved OTC products Take items to pharmacy, show CareMore member ID Card

Member is responsible for all costs above and beyond the monthly allowance.

Any balance on the allowance that is not used will be lost at the beginning of the following month.

TODAY

I am supplementing my good health.

COUNTY

CVP

START SMART

SNP

ESRD

CONNECT

LA/OC $20 $15 $25 $25 $30

San Bernardino

$15

$15

$15

Not Covered

N/A

Riverside

Not Covered

$15

$15

N/A

N/A


OVER THE COUNTER (OTC) BENEFIT

Product (Dose) Qty Product (Dose) QtyAcetaminophen Tablets, 325mg 100 Hydrocortisone Cream, 1% 30 gAntacid Anti-Gas Reg. Strength 355 ml Loratadine, 10 mg 30Antacid Tabs, Reg. Strength 150 Magnesium Tablets, 250 mg 100Asprine, 81mg 150 One Daily Vitamins 100Bacitracin Ointment 30 g Opti-Vitamins 100Calclum 600+D 60 Pain Releving Cream 90 gCentruy Senior Tablets 100 Rena-Vite Tablets 100Chewable Vitamin C, 500 mg 100 Saline Nasal Spray 45 mgDenture Adhesive Cream 72 g Stool Softner, 100 mg 100Ear Wax Removal Kit 15 ml Tolnaflate Cream 1% 30 gEye Allergy Drops 15 ml Tussin/ Tussin DM 120 mlFerrous Sulfate, 325 mg 100 Vitamin B6 Tablets, 100 mg 100Fiber Laxative Tablets, 625 mg 90 Vitamin D3 Tablets, 400IU 100Glucosamine/Chandroitin 500mg/ 4 50 Vitamin E Tablets, 400 IU 100Hemorrhoid Ointment 60 g Zinc Gluconate, 50 mg 100Hemorrhoid Wipes 100 ZincOxide Ointment 57 g

Quantity may vary depending on the pharmacy.

TRANSPORTATION HIGHLIGHTS

Transportation Benefit County CVP StartSmart Heart, Breathe

& Diabetes ESRD Connect

LA/OC

24 one way trips to PAL

Not Covered




Riverside

Limited Clinical Benefit

Not Covered


Unlimited CCC

N/A

N/A

San Bernardino


Not Covered




• PAL = Plan Approved Location: PCP, Specialist, Care Center or Surgery Center • Limited Clinical Benefit: Healthy Start Appointment or Care Center for pre &

post operation • Unlimited CCC: Unlimited transportation to the CareMore Care Center Transportation must be scheduled in advance. Transportation includes the member plus one.


TESTING HIGHLIGHTS

All County’s Copay

Immunizations $0

Bone Mass Measurement $0

Pap Smears/ Pelvic Exams $0

Prostate Cancer Screens $0

Mammograms $0

Cardiovascular Screening $0

Abdominal Aortic Aneurysm Screening

$0

Colorectal Cancer Screening $0

County CVP StartSmart Heart, Breathe & Diabetes ESRD Connect

LA/OC $60 20% Coinsurance $60 $60 $0

Riverside 20% Coinsurance

20% Coinsurance

20% Coinsurance N/A N/A

San Bernardino

20% Coinsurance

20% Coinsurance

20% Coinsurance

20% Coinsurance N/A

Screenings/ Lab Therapeutic Radiology

CT/ MRI/ PET

County CVP StartSmart Heart, Breathe & Diabetes ESRD Connect

LA/OC $75 $75 $75 $75 $0

Riverside $100 $75 $100 N/A N/A

San Bernardino $100 $75 $100 $100 N/A

CVP PRODUCT OVERVIEW

Rx Benefits

Medicare Part D Benefit Parameters 2013 “National” Catastrophic Level Is $4,750



COUNTY

Rx Gap Coverage Full coverage through the gap Tiers 1 & 2 Tiers 1 & 2

Rx ICL $2,970 $2,970 $2,970

Tier 1 Preferred Generic Drugs $0 Copay/ 30 Day Supply

$0 Copay/ 30 Day Supply


Tier 2 Non-Preferred Generic Drugs $5 Copay/ 30 Day Supply



Tier 3 Preferred Brand Drugs $25 Copay/ 30 Day Supply



Tier 4 Non-Preferred Brand Drugs $85 Copay/ 30 Day Supply



Tier 5 Specialty Tier Drugs 33% Coinsurance 33% Coinsurance 33% Coinsurance

Tier 6 Select Care Drugs $0 Copay/ 30 Day Supply



Part B Rx - Chemo/ Other$0 copay, up to $50,

20% coinsurance; $51 and up

20% coinsurance 20% coinsurance

Mail Order Available through Walgreens for 2 ½ times the monthly copay for a 90 day supply

Diabetic Insulin falls under Tier 6 benefits.

CareMore’s Heart Plan A Special Needs Plan for those suffering from chronic conditions

• Members must: Have Medicare Parts A & B Live in the Service Area

• Must have ONE of the following Chronic Heart Conditions: Congestive Heart Failure (CHF) Cardiovascular Disorders Coronary Artery Disease (CAD) Cardiac Arrhythmias Peripheral Vascular Disease Chronic Venous Thromboembolic Disorder

Once chronic diagnosis is identified and documented by a doctor, one Special Enrollment Period (SEP) is awarded by beneficiary (can be used during Lock-In)


HEART PRODUCT OVERVIEW Eligibility Requirements


CareMore’s Breathe Plan A Special Needs Plan for those suffering from chronic conditions


• Must have ONE of the following Chronic Lung Conditions: Chronic Bronchitis Emphysema Asthma Pulmonary Fibrosis Pulmonary Hypertension



BREATHE PRODUCT OVERVIEW Eligibility Requirements

CareMore’s Reliance/ Diabetes Plan A Special Needs Plan for those suffering from diabetes


• Must be ONE of the following:

Insulin-dependent diabetic Oral Hypoglycemic-dependent diabetic



RELIANCE/DIABETES PRODUCT OVERVIEW Eligibility Requirements


HEART, BREATHE & DIABETES PRODUCT OVERVIEW




COUNTY

CareMore Plan Reliance (Diabetes), Breathe & Heart

Diabetes & Breathe* *New for 2013

Diabetes, Breathe & Heart

Monthly Premium $0 $0 $0

Maximum Out-0f-Pocket (MOOP) Limit $3400 $3400 $3400

INPATIENT SERVICES

Inpatient Hospital Acute Day Day 1 - 90: $0 Copay Day 1 - 90: $0 Copay Day 1 - 90: $0 Copay


InPatient Psychiatric Day Day 1 - 90: $0 Copay Day 1 - 90: $0 Copay Day 1 - 90: $0 Copay



Day 32 - 100: $25 Copay

Day 32 - 100: $50 Copay

Day 32 - 100: $50 Copay


OUTPATIENT SERVICES

Emergency Care $65 Copay $65 Copay $65 Copay









COUNTY

OUTPATIENT SERVICES, cont.


Physician Specialist VisitsIncluding Nephrologist $0 Copay $0 Copay $0 Copay

Medical Podiatry $0 Copay $0 Copay $0 Copay

Podiatry/Routine Foot Care $0 Copay; 12 visits/Year $0 Copay; 12 visits/Year $0 Copay; 12 visits/Year

Psychiatric Services $0 Copay $0 Copay $0 Copay

Physical Therapy $0 Copay $0 Copay $0 Copay



Routine Chiropractic Not Covered Not Covered Not Covered


Outpatient Mental Health $0 Copay $0 Copay $0 Copay






COUNTY







Outpatient Therapeutic Radiology $60 Copay 20% Coinsurance 20% Coinsurance


Transportation44 One Way Trips to

PAL 10 One Way Trips to

PAL Unlimited Trips to CCC

10 One Way Trips to PAL








Dialysis $0 Copay $0 Copay $0 Copay

Therapeutic Shoes $0 Copay $0 Copay $0 Copay

Diabetes Supplies $0 Copay $0 Copay $0 Copay




COUNTY

ADDITIONAL SERVICES

Over-the-Counter (OTC) Program $25 allowance per month $15 allowance per month $15 allowance per month





Vision Exam - Medical $0 Copay $0 Copay $0 Copay






years




years




years





Liberty Dental Plan Basic Dental Coverage Basic Dental Coverage Basic Dental Coverage






Rx Benefits




COUNTY

Rx Gap Coverage Full coverage through the gap Tiers 1, 2 & 6 Tiers 1, 2 & 6

Rx ICL $2,970 $2,970 $2,970

















Part B Rx - Chemo$0 copay, up to $50,

20% coinsurance; $51 and up

20% coinsurance 20% coinsurance


Diabetic Insulin falls under Tier 6 benefits. Needles, Test Strips, Glucometer & Insulin = $0 copay. Tier 6 is covered in the gap.

CareMore’s ESRD Plan A Special Needs Plan for those suffering from chronic conditions


• Must have End Stage Renal Disease:

requiring dialysis



ESRD PRODUCT OVERVIEW Eligibility Requirements


ESRD PRODUCT OVERVIEW



ORANGE COUNTY SAN BERNARDINO

Monthly Premium $0 $0

Maximum Out-0f-Pocket (MOOP) Limit $6700 $6700

INPATIENT SERVICES

Inpatient Hospital Acute Day Day 1 - 5: $75 Copay Day 1 - 4: $100 Copay

Day 6 - 90: $0 Copay Day 5 - 90: $0 Copay

Additional Days $0 Copay $0 Copay

InPatient Psychiatric Day Day 1 - 5: $75 Copay Day 1 - 4: $100 Copay


Additional Days $0 Copay $0 Copay

Skilled Nursing Facility (SNF) Day 1 - 31: $0 Copay Day 1 - 31: $0 Copay


Home Health Care $0 Copay $0 Copay

OUTPATIENT SERVICES



Urgent Care $0 Copay $0 Copay








Primary Care Physician (PCP) $0 Copay $0 Copay

Physician Specialist Visits $0 Copay $0 Copay

Nephrologist Visits $0 Copay $0 Copay

Medical Podiatry $0 Copay $0 Copay

Podiatry/Routine Foot Care $0 Copay; 12 visits/Year $0 Copay; 12 visits/Year

Psychiatric Services $0 Copay $0 Copay

Physical Therapy $0 Copay $0 Copay

Speech Therapy $0 Copay $0 Copay

Chiropractic Services $0 Copay $0 Copay

Routine Chiropractic Not Covered Not Covered

Occupational Therapy $0 Copay $0 Copay

Outpatient Mental Health $0 Copay $0 Copay

X-Rays $0 Copay $0 Copay

Outpatient CT / MRI / PET $75 Copay $100 Copay





Outpatient Hospital $0 Copay $50 Copay

Ambulatory Surgical Center (ASC) $0 Copay $0 Copay

Outpatient Substance Abuse $15 Copay $30 Copay


Outpatient Diagnostic Radiology $0 Copay $0 Copay

Outpatient Therapeutic Radiology $60 Copay 20% Coinsurance

Ambulance $100 Copay; Waived if Admitted

$100 Copay; Waived if Admitted

Transportation 150 One Way Trips to PAL Limited Clinical Benefit






Dialysis $0 Copay $0 Copay

Therapeutic Shoes $0 Copay $0 Copay

Diabetes Supplies $0 Copay $0 Copay




ADDITIONAL SERVICES

Over-the-Counter (OTC) Program $25 allowance per month Not Covered



Exercise and Strength Training $0 Copay $0 Copay

Vision Exam - Medical $0 Copay $0 Copay

Vision Exams - Routine $0 Copay $0 Copay





years




years

Hearing - Exams $0 Copay $0 Copay



Liberty Dental Plan Basic Dental Coverage Basic Dental Coverage





Rx Benefits


BENEFITLOS ANGELES & ORANGE

COUNTY SAN BERNARDINO

Rx Gap Coverage Full coverage through the gap Tiers 1 & 2

Rx ICL $2,970 $2,970

Tier 1 Preferred Generic Drugs $0 Copay/ 30 Day Supply $0 Copay/ 30 Day Supply

Tier 2 Non-Preferred Generic Drugs $5 Copay/ 30 Day Supply $5 Copay/ 30 Day Supply

Tier 3 Preferred Brand Drugs $25 Copay/ 30 Day Supply $35 Copay/ 30 Day Supply

Tier 4 Non-Preferred Brand Drugs $85 Copay/ 30 Day Supply $85 Copay/ 30 Day Supply

Tier 5 Specialty Tier Drugs 33% Coinsurance 33% Coinsurance

Tier 6 Select Care Drugs $0 Copay/ 30 Day Supply $0 Copay/ 30 Day Supply

Part B Rx - Chemo $0 copay, up to $50, 20% coinsurance; $51 and up 20% coinsurance



CareMore’s StartSmart Plan MA-PD plan suitable for the Healthy Medicare Population

• Members must: Have Medicare Parts A & B Live in the Service Area NOT have End Stage Renal Disease (ESRD)

• Must join during an Annual Election Period (AEP), unless Special Enrollment Period eligible.

Age-In Limited Income/Resource Assist. Medi-Medi Relocated/Life Change Loss of Retirement or Commercial Insurance


STARTSMART PRODUCT OVERVIEW Eligibility Requirements


STARTSMART PRODUCT OVERVIEW




COUNTY

Part B Premium Reduction $72.00 $72.00 $72.00

Maximum Out-0f-Pocket (MOOP) Limit $6700 $6700 $6700

INPATIENT SERVICES

Inpatient Hospital Day Day 1 - 5: $100 Copay Day 1 - 5: $100 Copay Day 1 - 5: $100 Copay

Day 6 - 90: $0 Copay Day 6 - 90: $0 Copay Day 6 - 90: $0 Copay

InPatient Psychiatric Day Day 1 - 5: $100 Copay Day 1 - 5: $100 Copay Day 1 - 5: $100 Copay

Day 6 - 90: $0 Copay Day 6 - 90: $0 Copay Day 6 - 90: $0 Copay


Day 21 - 100: $50 Copay

Day 21 - 100: $50 Copay

Day 21 - 100: $50 Copay


OUTPATIENT SERVICES












COUNTY



Physician Specialist VisitsIncluding Nephrologist $0 - $20 Copay $0 - $20 Copay $0 - $20 Copay

Medical Podiatry $0 - $20 Copay $0 - $20 Copay $0 - $20 Copay

Podiatry/Routine Foot Care Not Covered Not Covered Not Covered

Psychiatric Services $0 - $20 Copay $0 - $20 Copay $0 - $20 Copay

Physical Therapy $0 - $20 Copay $0 - $20 Copay $0 - $20 Copay



Routine Chiropractic $20 Copay; 12 visits/Year

$20 Copay; 12 visits/Year

$20 Copay; 12 visits/Year


Outpatient Mental Health $0 - $20 Copay $0 - $20 Copay $0 - $20 Copay






COUNTY







Outpatient Therapeutic Radiology 20% Coinsurance 20% Coinsurance 20% Coinsurance


Transportation Not Covered Not Covered Not Covered








Dialysis 20% Coinsurance 20% Coinsurance 20% Coinsurance

Therapeutic Shoes 20% Coinsurance 20% Coinsurance 20% Coinsurance

Diabetes Supplies 20% Coinsurance 20% Coinsurance 20% Coinsurance




COUNTY

ADDITIONAL SERVICES

Over-the-Counter (OTC) Program $15 allowance per month

$15 allowance per month

$15 allowance per month





Vision Exams - Medical $5 - $20 Copay $5 - $20 Copay $5 - $20 Copay






years




years




years


Hearing Aids Not Covered Not Covered Not Covered

Liberty Dental Plan Basic Dental Coverage Optional Supplemental only

Optional Supplemental only






Rx Benefits




COUNTY

Rx Gap Coverage None None None

Rx ICL $2,970 $2,970 $2,970

















Part B Rx - Chemo 20% coinsurance 20% coinsurance 20% coinsurance


Diabetic Insulin falls under Tier 6 benefits.

CareMore’s Connect Plan A Special Needs Plan for those with dual eligibility (medi-medi)

• Members must: Have Medicare Parts A & B (No SEP for Part D) Live in the Service Area NOT have End Stage Renal Disease (ESRD)

• Continuous Special Election Period

• Reasons to join: World Wide Emergency Coverage up to $10,000 Basic Dental Coverage Included Transportation Benefit – 50 one-way trips to plan-approved locations OTC Benefit - $30 monthly $0 Generic Drugs (all other LIS- co-pays apply) CareMore Care Model Dual Demonstration Project – Dual-eligibles will be auto-assigned to managed

care (HMO) beginning June 2013.


CONNECT PRODUCT OVERVIEW Eligibility Requirements


CONNECT PRODUCT OVERVIEW BENEFITS

Monthly Premium $0 Maximum Out-0f-Pocket (MOOP) Limit $0

Inpatient Hospital Acute Day Day 1 - 90: $0 Copay Skilled Nursing Facility (SNF) Day 1 - 100: $0 Copay

Additional Days $0 Copay Home Health Care $0 Copay

Inpatient Psychiatric Day Day 1 - 90: $0 Copay

Additional Days $0 Copay

Emergency Care $0 Copay Chiropractic Services $0 Copay

Urgent Care $0 Copay Routine Chiropractic Not Covered



Occupational Therapy $0 Copay

Primary Care Physician (PCP) $0 Copay Outpatient Mental Health $0 Copay

Physician Specialist VisitsIncluding Nephrologist $0 Copay X-Rays $0 Copay

Medical Podiatry $0 Copay Outpatient CT / MRI / PET $0 Copay

Podiatry/Routine Foot Care $0 Copay; 12 visits/Year

Outpatient Hospital $0 Copay

LOS ANGELES COUNTY ONLY

INPATIENT SERVICES

OUTPATIENT SERVICES

CONNECT PRODUCT OVERVIEW BENEFITS

Psychiatric Services $0 Copay Ambulatory Surgical Center (ASC) $0 Copay

Physical Therapy $0 Copay Outpatient Substance Abuse $0 Copay

Speech Therapy $0 Copay

Outpatient Diagnostic Radiology $0 Copay Ambulance $0 Copay

Outpatient Therapeutic Radiology $0 Copay Transportation 50 One Way Trips to PAL

DME and Prosthetics $0 Copay Therapeutic Shoes $0 Copay

Dialysis $0 Copay Diabetes Supplies $0 Copay

Over-the-Counter (OTC) Program $30 allowance per month

Hearing - Exams $0 Copay


Hearing Aids $1,500 allowance every 2 years

Enhanced Nutritional Training $0 Dental Basic Dental Coverage

Exercise and Strength Training $0 Copay Vision Exam - Routine & Medical $0 Copay


LOS ANGELES COUNTY ONLY

Glass Lenses Copay - $20Contacts, Frames, Lenses/Frames Copay - $0$100 Benefit Limit per 2 years



ADDITIONAL SERVICES

CONNECT PRODUCT OVERVIEW

Rx Benefits Member LIS Co-pays Valid for Tiers 3 - 5

BENEFIT LOS ANGELES COUNTY ONLYRx Gap Coverage Tiers 1, 2 & 6

Rx ICL $2,970

Rx Deductible 325

Tier 1 Preferred Generic Drugs $0 Copay

Tier 2 Non-Preferred Generic Drugs $0 Copay

Tier 3 Preferred Brand Drugs 25% Coinsurance

Tier 4 Non-Preferred Brand Drugs 25% Coinsurance

Tier 5 Specialty Tier Drugs 25% Coinsurance

Tier 6 Select Care Drugs $0 Copay

Part B Rx - Chemo $0 Copay


CareMore’s Website www.caremore.com


www.caremore.com

Update-to-date information at the touch of a finger: www.caremore.com

Agents can use this section to look up and find:

2013 Drug Formulary, Pharmacy Search, Summary of Benefits & Evidence of Coverage

• Click on , mid-way down the page “Find your CareMore plan”, click on .

• Go to question 3 and from the drop down menu, choose client’s county. The plans available will automatically populate.

• To the right of each plan, you can click on formulary, pharmacy search, SOB or EOC to view and/or search.

www.caremore.com

• Coverage Service Areas • Covered Doctors • Covered Hospitals • Covered Urgent Care Centers

• Locate CareMore Care Center • Covered Laboratories • Covered Skilled Nursing Facility • Locate Nifty after Fifty

www.caremore.com


To view Arizona or Nevada, click here to change.

View and learn more about: • CareMore Health Plans • Specialized Care Treatments • Over the Counter Benefits • Exercise and Strength Training • Value Added Items & Services (VAIS)

Look up: • Care Center Locations • Member Materials • Drug Formulary and Pharmacy Search • Health News and Education • Newsletter

Learn more about programs that can help with: • Diabetes • Hypertension • Chronic Kidney Disease • Congestive Heart Failure • Chronic Obstructive Pulmonary Disease

Completing Applications & Forms


• Complete the entire application for the MAPD plan you are enrolling the beneficiary in:

CVP/ StartSmart Special Needs Plans (SNP)/ Please check plan box Connect

• Include the Personal Physician Choice/ Name and ID

Number

• Ensure the application is signed and dated by the beneficiary

• Complete the “Office Use Only” section: Name of staff member/agent/broker/broker ID # Date Received by Plan (this is the date you received the

application, if later than beneficiary signature date) Effective Date of Coverage Check ICEP/IEP, AEP or SEP (type)

COMPLETING APPLICATIONS

APPLICATION OVERVIEW Required Forms • Continuity of Care

CVP/ StartSmart Connect

• Pre-Qualification and COC

Special Needs Plans Questions 6, 7 & 8 of SNP

Application

• Authorization Form Special Needs Plans

• Scope of Appointment

All Applications


CONTINUITY OF CARE FORM

• To be submitted with: CVP/ StartSmart Connect

• Complete as much

information as possible

• Required Information Member Information CareMore Provider

Information DME Information (if

applicable)

PRE–QUALIFICATION AND COC FORM

Page 1

• To be submitted with: SNP Applications ONLY

• Required Information

Member Information PCP Currently Treating Name

& Phone number New CareMore PCP & Provider

ID New CareMore Nephrologists

(ESRD ONLY) DME Information (if applicable)


PRE–QUALIFICATION AND COC FORM

Page 2

• Required Information Clinical Qualifying Questions

(to be used in conjunction with questions 6, 7 & 8 of SNP Application)

Current Medications

• You may want to include the pharmacy name and phone number

• Enrollee Signature & Date

• Agent/ Broker Signature & Date

• Schedule Healthy Start Appointment


AUTHORIZATION FORM

Leave Blank

Page 1

• To be submitted with:

All SNP

• Leave 1st line blank

• Check top box

*Doctor will complete another authorization form if psychotherapy notes are required

AUTHORIZATION FORM

Page 2

• Beneficiary’s Signature & Date

• Witness Signature: Guardian Beneficiary Conservator


SCOPE OF APPOINTMENT

CareMore Sales Appointment Confirmation Form To be completed by person with Medicare. Please initial below in the box beside the plan type that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty. (Please note that an agent may also discuss a Medicare Supplement policy with you.)

Medicare Advantage (Part C), Medicare Advantage Prescription Drug Plans, and other Medicare Plans

Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMOs, you can only go to doctors, specialists, or hospitals in the plan’s network except in an emergency.

Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.

By signing this you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing plan options with you is either employed or contracted by a Medicare health plan or prescription drug plan that is not the Federal government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan. Beneficiary Signature: _______________________________________________ If you are the authorized representative, you must sign above and provide the following information: Name: ___________________________________________ Address: ______________________________ Phone number: ________________ Relationship to Beneficiary: ____________________________________________ To be completed by Agent:

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone:

Beneficiary Address:

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.) Agent’s Signature:

[Plan Use Only:]

Y0017_031115A CHP CMS Approved (03282011)

• To be submitted with:

CVP/ StartSmart Special Need Plans (SNP) Connect

• Required Information

Beneficiary’s Initials (Red Arrows)

Beneficiary’s Signature Agent Section

You may use any CMS approved Scope of Appointment

SUBMITTING APPLICATIONS

• Applications and forms must be submitted within 2 days of beneficiary’s signature date or by the date you received the application

• Applications can be faxed to:

(562) 207-3660

• Applications can be mailed or hand delivered to:

CareMore Health Plan 12900 Park Plaza Dr., #150 Cerritos, CA 90703 Attention: Enrollment

• Telephonic Enrollment



TELEPHONIC ENROLLMENT

Benefits

• 20 minutes or less

• No paperwork required • Agent receives confirmation and full credit

• ID Cards are expedited

• Call is entirely recorded to protect You

Avoid allegations such as: Agent didn’t leave materials Agent didn’t explain correctly Agent signed me up without my knowledge

• Requirements

Agent CANNOT be in the room while member enrolls

• CMS Guideline

Agent must still retain Scope of Appointment • 10 years

Enrollee notifies call-taker:

• “I’m working with my Agent, John Doe”.


TELEPHONIC ENROLLMENT


Broker Contact Information


John Ingle [email protected] Head of Broker Sales & Operations 562-207-3705 Cynthia Jett [email protected] Broker Sales & Operations 562-622-2920 Leticia Uribe [email protected] Broker Sales Support & Contracting 562-741-4398 David Luna [email protected] Broker Manager, AZ & NV 602-206-9517 Alexander Rubio [email protected] Broker Sales Support, AZ & NV 480-257-0605 Broker Support Line 866-660-7037

• Plan, benefit & formulary questions • Parts A & B verification

BROKER CONTACT INFORMATION



Application Fax Line 562-207-3660 Telephonic Enrollments 866-660-7037 Supply Requests [email protected] Member Services 800-499-2793 Healthy Start Appointment Scheduling 888-291-1387 Case Management 562-622-2960 Website www.caremore.com Locate Care Centers, find doctors, covered zip codes, plan & benefit information

Low Income Subsidy

• Medicare 800-633-4227 • Social Security Administration 800-772-1213

BROKER CONTACT INFORMATION


Thank You for Choosing CareMore


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