HealthTeam Advantage Overview

Plan Offerings

Providers

Healthcare Concierge

Agent Concierge

Eligibility

Enrollment Process / Application Submission

Cancellation vs. Disenrollment

CMS Marketing Rules

Agent Oversight

Agent Compensation

New for 2017

Important Information

Wrap Up

Certification Overview

Hello and welcome to the 2017 HealthTeam Advantage Agent Certification module. My name is Tana Kersten, Sales Operations Manager.

This training module will help you learn about HealthTeam Advantage and what sets us apart from other Medicare Advantage companies.

With your help, we anticipate 2017 being a banner year and are

looking forward to a mutually rewarding relationship.

Introduction

HealthTeam Advantage (HTA) is a doctor-directed, local Medicare Advantage option for residents in the Piedmont Triad area. This is a partnership between Cone Health and Care N’ Care Insurance Company, Inc. of North Carolina.

Offers Two PPO Plans:

Innovative Member Service Program designed to give members a “concierge” experience.

Available in Four counties:• Alamance• Guilford• Randolph• Rockingham

HealthTeam Advantage

2 PPO Options:

• Predictable copayments and low annual out-of-pocket maximums

• A $0 premium option is available

• Optional dental or combination rider that covers preventive vision, dental, and hearing benefits for additional monthly premium

• Health club membership through Silver&FitFitness Program

• Service Area in the following counties:

• Alamance

• Guilford

• Randolph

• Rockingham

HealthTeam Advantage is an affordable alternative to Medicare Supplement insurance and other types of Medicare health plans. To assist its members in living healthier and happier lives, HealthTeam Advantage offers the following benefits to eligible Medicare beneficiaries in their service area:

Our Plans

Staying healthy and active is important to our member’s overall health. When they join a HealthTeam Advantage PPO plan, they will receive a membership to Silver&Fit Exercise and Healthy Aging program to no additional cost. This program is a unique opportunity to help them stay active whether they are at home or on the road.

Silver&Fit gives members the ability to enjoy:

• Access to fitness club or exercise center

• Group classes made for older adults, where offered.

• The option to work out at home using up to 2 Home Fitness Kits per year

• Healthy aging material (online or DVD)

• A newsletter 4 times a year

• The Silver & Fit Connected program, a fun an easy way to track exercise at a facility or through a wearable fitness device

Silver&Fit

Optional Riders for PPO & HMO Plans

• At HealthTeam Advantage, we believe the member’s dental health can have a direct impact on their overall health and well-being, and may have an influence on the development of certain conditions, such as diabetes and heart disease.

• HealthTeam Advantage’s Dental Rider, covers services most often used, without the need for a referral or preauthorization. You can choose from more than 200 in-network dentists.

Plan Highlights (Refer to benefits for complete details)

Dental Rider (cont.)

Plan Highlights (Refer to benefits for complete details)

Combination Rider: (Dental, Hearing, and Vision)

Sometimes, we need a little something extra to care for our eyes, ears, and teeth. HealthTeamAdvantage offers a supplemental combination rider to fill the gap.

• Preventive and Comprehensive Dental Services

• Hearing Services

• Vision Services

Plan Highlights (Refer to benefits for complete details)

Combination Rider: (cont.)

Plan Highlights (Refer to benefits for complete details)

• Lower copayments and out of pocket costs for members.

• Ensure that plan benefits are properly coordinated, to provide a seamless continuation of care.

• Ensure that plan providers follow plan processes to minimize billing errors.

• Members properly and effectively manage challenging and costly chronic health conditions.

Choosing the right physician can greatly influence many factors in our lives. At HealthTeamAdvantage, quality of care is an important focus. Choosing In-Network providers can help:

Benefits of Selecting In-Network Providers

Find a Provider at:www.healthteamadvantage.com

• Click Find a Provider -“Search Now” on our homepage

• Select from the following options:

• Primary Care Physician• Specialist • Vision• Hearing • Dental • Pharmacy • Facility

Finding Providers On HealthTeam Advantage’s Website

Choosing one additional filter – Select Specialty, and then click Search

Choosing two additional filters – Select Specialty, type the Dr. Last name, then click Search

Choosing all five additional filters – Select Select Specialty, type the Dr. Last name, City, and the Zip Code, then click Search

When conducting a search be aware it works best when it is a “general” search rather than a specific search, such as entering all additional filters.

Finding Providers On HealthTeam Advantage’s Website (cont.)

Excellence in Customer Service

At HealthTeam Advantage, we work hard to provide our members excellent customer service. Whenever they have a question, we are always just a phone call or email away.

When a beneficiary enrolls in a HealthTeam Advantage PPO plan, they will have a personal Healthcare Concierge (HCC) who will work closely with them each time they need assistance, as well as follow up with them when needed.

At HealthTeam Advantage, the Healthcare Concierge can help:

• Explain health plan benefits.

• Coordinate healthcare services with an In-Network doctor.

• Verify health plan coverage with a participating provider.

• Find a healthcare facility near the member.

And much more!

As part of its quality assurance process, HealthTeam Advantage completes a welcome call with each new enrollee.

The purpose is to confirm the accuracy of the information on the enrollment form andto ensure that the enrollee understands and wants to enroll in the HealthTeamAdvantage Medicare Advantage Plan.

The recorded call provides a record of the transaction and protection for both the enrollee and the Sales Agent.

The agent should cover the purpose of the welcome call during enrollment process.

Welcome Call

During the member’s initial Welcome Call, the Healthcare Concierge will cover the following:

• Verification of plan selection as well as any riders if applicable

• Verification of Primary Care Physician (PCP) selection and if they selected an Out-Of-Network provider, the Healthcare Concierge will cover the benefits of utilizing an IN-Network provider

• Reminder of the Welcome to Medicare Preventive Visit or Annual Wellness Visit

• Payment method for enrollment in plans with premiums

• Emergency contact information and who member would like as their HIPAA contact

• Ask about current medications to see if the member might be eligible for the Medication Therapy Management Program and explains the benefit of being part of the program

• Current Medications

• If member had previously hit the coverage gap

• If member required any prior authorizations for any medications before

• Any medications member is concerned about

• Any diagnosis of chronic illnesses like diabetes, COPD, arthritis, cancer, etc.

• Ask about any current Durable Medical Equipment (DME) member is using. Verify if that current DME provider is In-Network and if they are Out-Of-Network, they will offer to assist member in locating an In-Network DME provider

• Does member have any upcoming scheduled procedures that they need assistance with as far as authorization or possible follow up care or coordination with facility

Welcome Call (cont.)

The Healthcare Concierge is the member’s resource for all items if they require assistance. The member will receive a Welcome Kit after enrolling that will have their personal Healthcare Concierge’s business card and magnet. Healthcare Concierges are available from October 1st to February 14th, from 8 AM to 8 PM, 7 days a week or February 15th to September 30th, from 8 AM to 8 PM Monday through Friday. TTY users should call 711.

The Healthcare Concierge will provide assistance with the following:

• Plan benefit questions

• Coordination of healthcare services

• Billing questions

• Claims questions / reimbursements

• Assistance with locating a provider

• Any other items that require assistance

** In the welcome packet, the member will also get a form to fill out and return if they wish to receive emails in the future regarding items such as healthy tips, newsletters, upcoming events, etc.

Welcome Call (cont.)

Excellence in Agent Support

• Application Issues & Status

• Benefit Questions/ Rider Questions

• Billing

• Certification

• Claims

• Commissions

• Eligibility

• Enrollment Status

• ID Cards

• Member Issues

• Pharmacy

• Provider

Please Contact for Assistance: By Phone, Call : (855) 547-0344

or email: agentsupport@healthteamadvantage.com & appstatus@healthteamadvantage.com

The Agent Concierge department is dedicated to assist contracted HealthTeam Advantage

agents throughout the sales and enrollment process and continues as long as that member

is enrolled in HTA.

The Agent Concierge team is available from 8 to 5, Monday through Friday.

For assistance in the following areas/topic’s :

1. Entitled to Medicare Part A and enrolled in Medicare Part B

2. Must reside in the Plan’s approved service area

3. Do not have End Stage Renal Disease (ESRD)

4. Beneficiary is a US Citizen or lawfully present

Medicare beneficiaries are eligible to join a HealthTeam Advantage Medicare Advantage Plan if they meet the following conditions:

Eligibility

Beneficiaries with ESRD who meet the following conditions:

• If the beneficiary has recovered normal kidney function and no longer requires a regular course of dialysis to maintain life

• If the beneficiary has had a successful kidney transplant

Please note: If the beneficiary has been diagnosed with ESRD, they will be asked to send a note or records from their doctor showing they have had a successful kidney transplant and/or they don’t need dialysis. They can either fax it to 817-810-5214 or mail it to 1701 River Run Ste. 402, Fort Worth, TX 76107. Information should be sent to Attn: Enrollment Department. In order for the enrollment to be valid, receipt of documentation request needs to be received by HealthTeamAdvantage within the next 7 calendar days.

End Stage Renal Disease (ESRD) Exception

October 1 – October 14, 2016

Plans can begin marketing 2017 benefits, but agents cannot accept applications until OEP begins.

October 15 – December 7, 2016

Medicare Open Enrollment Period (OEP)

This is the time where you may to choose to switch, drop or join a Medicare Advantage plan. Changes take effect January 1, 2017.

January 1 – February 14, 2017

Medicare Annual Disenrollment Period (MADP)

For Medicare Advantage plans, you can leave your plan and switch to Original Medicare. If you switch to

Original Medicare, you have until February 14, 2017, to sign up for a prescription drug plan. During this period,

you cannot:

• Switch from Original Medicare to a Medicare Advantage plan

• Switch from one Medicare Advantage plan to another

• Join, switch, or drop a Medicare Medical Savings Account (MSA) plan

February 15 – October 14

Lock-In Period – Enrollments/Dis-enrollments during this time require a Special Election Period (SEP)

Important Enrollment/ Eligibility Dates

If you answer yes to any of the following questions, you may be eligible for a SEP.

If you think you qualify, talk to your local sales agent.

• Recently moved

• Currently receiving Extra Help with health care costs

• No longer qualify for Extra Help with health care costs

• Recently left a PACE program (Program of All-inclusive Care for the Elderly)

• Live in a long-term care facility

• Recently retired and lost employer or union coverage

• Moving into a long-term care facility

• Recently moved out of a long-term care facility

• Currently receiving Medicaid

• Recently stopped receiving Medicaid

• Loss of credible drug coverage

• Release from jail

• Enrolled in a State Pharmaceutical Assistance Program (SPAP)

• Granted lawful presence in the US (became a citizen)

Special Election Period: Year-Round

“Split Dates”

• Three months prior to the Part B entitlement date to enroll

• Three months after only applies when A & B dates are the same

• When signing up for Part B during the “Part B General Enrollment Period”

(January 1 – March 31 each year) Coverage will start July 1. – May enroll in

MA Plan in the three months prior (April 1 – June 30)

Entitlement to Medicare Part A & B

The best way to remember this is if your enrollee has split A and B dates they can

not be effective to join HTA AFTER the Part B goes into effect UNLESS they have

another SEP available. CMS will deny these applications as no valid election period.

*** Please see example on next slide

“Split Dates” (cont.)

v

Medicare Coverage

1. Determine eligibility

2. Identify the election period. Make sure you submit the attestation form along with the application as proof of the eligibility

3. Select a plan

4. Explain the MA‐PD monthly premium amount and supplemental coverage

5. Select a payment option

6. Explain disenrollment procedures

7. Explain the Welcome Call

8. Submit the enrollment form along with Scope Of Sales, Attestation Form, and the Application Checklist

9. Discuss the Medication Therapy Management (MTM) program

Enrollment Process

• Plan selection

• Beneficiary full name(including middle initial), birth date, sex and contact information such as home phone number, and/or cell phone number

• Permanent residence street address (PO Box can only be used for mailing address). Include mailing address if different than permanent address.

• Include an Emergency Contact with contact phone number

• In addition to contact information enter E-mail Address if provided, indicate if none

• Enter Medicare Claim number and Part A and B Effective dates

• Double check spelling and other pertinent information as noted on the beneficiary’s Medicare card

• Write legibly with a black ball point pen

HTA Application – Page 1

• Monthly Invoice

• Electronic funds transfer (EFT) from bank account each month

• Automatic deduction from monthly Social Security/Railroad Retirement Board (RRB) benefit check

• If you select this option: The Social Security/Railroad Retirement Board deduction may take two or more months to begin after Social Security/RRB approves the deduction. In most cases, if Social Security or RRB accepts the request for automatic deduction, the first deduction from the Social Security or RRB benefit check will include all premiums due from the enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve the request for automatic deduction, we will send a paper bill for the monthly premiums.

Payment Options – Page 2

Note: if member does not wish to select a payment option for any reason HealthTeam Advantage will automatically send a monthly invoice. To change this payment option, beneficiary can call the Health Care Concierge.

• Make sure to answer questions 1-5

• Enter the beneficiaries chosen PCP

• Select the option for other than English language format

• Read the important information

PCP Selection – Page 3

• Signatures and dates from either the beneficiary or an authorized representative

• To ensure proper commission credit, the Agent/Broker assisting must provide their name, plan selected, effective date of coverage, election period, and the NPN number.

Broker Information - Page 4

To ensure timely enrollment processing,

agents must complete and submit an

Application Checklist with all enrollment

applications.

• All items need initialed by beneficiary

as well as document signed and date.

• All applicable items need filled out in

its entirety

Application Checklist

New additions for 2017:

• Do you currently use any durable medical equipment (i.e. oxygen, wheelchair, etc.)?

• Are you scheduled for any upcoming surgical events?

• I understand that my Primary Care Physician is ___________________.

• The payment method I have selected is…………………………………

NOTE: The reason for the DME and upcoming procedure question is based on trying to identify members that may need immediate assistance once they enroll.

The PCP and payment method is based on complaints against agents that the method selection on the application is truly not what they wanted. This will cover you as the agent since they are filling in their PCP selection and initialing.

Application Checklist (cont.)

To ensure timely enrollment processing, agents must complete and submit an Attestation Form with all enrollment applications.

Application Attestation

New for 2017

• A beneficiary or existing Member must agree on the SOA prior to the agent scheduling in-person presentation, other than a community sales meeting.

• Agents must have a signed CMS-approved SOA form prior to any in-person meeting. SOA is required for all such meetings with current or new clients to discuss Medicare Advantage or PDP products.

• Agent must disclose all product types to be discussed (i.e. MA, MAPD, PDP) during the appointment by securing a SOA priorto the meeting.

Scope of Appointment (SOA)

Exception Policy: if it is not feasible to obtain the SOA

Form prior to the appointment, the agent may have the

beneficiary sign the form at the beginning of the

appointment.

• Agent must record in writing and maintain

documentation on why it was not feasible to

obtain the SOA prior to the appointment. CMS

expects HealthTeam Advantage to record and

maintain this documentation, and upon

request, must be able to produce it.

A new SOA form is required if the beneficiary has

requested to discuss another MA or PDP product type

during an appointment. However, a new appointment is

not required. The additional product can be discussed as

soon as the beneficiary request is documented.

NOTE: CMS requires SOA to be retained for 10 years.

Scope of Appointment (SOA) (cont.)

Completed applications along with the Attestation, Application Checklist, and Scope of Sales must be received by HealthTeam Advantage within two (2) calendar days of signature and may be sent via fax, overnight mail or personal delivery.

HealthTeam Advantage Fax Number

(844) 644-5376 – Attn: Sales Department

HealthTeam Advantage Mailing Address

Attn: Sales Department

1150 Revolution Mill Dr Studio # 6

Greensboro, NC 27405

Application Submission

A “cancellation” occurs prior to the beneficiary’s effective date.

• Beneficiaries can cancel via a verbal request over the phone, by calling their Healthcare Concierge at (888) 965-1965 but the request MUST come from the beneficiary (i.e., agents cannot cancel, or a husband cannot cancel for his spouse), or the request can be submitted in writing.

A “disenrollment” occurs after a beneficiary is a Plan member.

• The disenrollment request must be made by written notice from the beneficiary or authorized representative, or by calling 1-800-MEDICARE.

• Disenrollments are subject to strict CMS guidelines.

Per CMS guidelines, beneficiaries may disenroll from an MA or MAPD plan only during certain times of the year by:

• Mailing/faxing a signed, dated, written notice to HealthTeam Advantage.

• Calling 1-800-MEDICARE.

HealthTeam Advantage cannot accept verbal requests; requests must be in writing, signed and dated.

Cancellation vs. Disenrollment

• Beneficiaries cannot choose the effective date of disenrollment. HealthTeamAdvantage will assign the effective date of disenrollment based on the enrollment period.

Per CMS guidelines, HealthTeam Advantage is required to recover compensation payments from agents under two circumstances:

• When a beneficiary voluntarily disenrolls from HealthTeam Advantage within the first three months of enrollment (rapid disenrollment)

• Any other time a beneficiary is not enrolled in a plan

Voluntary Disenrollment Procedures (cont.)

HealthTeam Advantage is required to involuntarily disenroll an individual in the following situations:

• change in address that is outside the service area;

• the member loses entitlement to Medicare;

• death;

• the plan contract is terminated.

HealthTeam Advantage may disenroll a member if:

• premiums are not paid on a timely basis;

• member engages in disruptive behavior

• (requires CMS approval)

• beneficiary provides fraudulent information on the application or permits abuse of an enrollment card.

Disenrollments

HealthTeam Advantage Health Plan requires all agents/brokers be well versed in and adhere to the CMS Marketing Rules, particularly as they pertain to how agents present our plan. The rules can be found in Chapter 3, Medicare Marketing Guidelines of the 2017 Medicare Managed Care Manual.

The full text is available for download at http://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPartCMarketingGuidelines.html

Agents Must:

• Use only CMS-approved HealthTeam Advantage marketing materials, scripts, electronic Sales Presentations and documents.

• Advise consumers that they do not lose Medicare Parts A and B but they get Medicare Part C where claims are paid by HealthTeam Advantage instead of Medicare.

• Ensure the consumer understands that an MA Plan is not a Medicare Supplement Insurance policy and that they may not utilize a Medicare Supplement Insurance policy to pay any expenses incurred under the MA plan.

CMS Marketing Rules

Agents Must:

• Inform consumers that they will not stop paying their Medicare Part B premium once they join an MA Plan.

• Explain that many, but not all, MA Plans have integrated Medicare Prescription Drug coverage (Part D).

• Obtain a signed Scope of Appointment (SOA) form prior to any in-person sales presentation.

• Ensure that they have reviewed Medicare Basics information about Enrollment Periods, Marketing Guidelines and Application Processes. All of these requirements apply to Medicare Advantage Plans.

• Explain that if the consumer joins an MA-only Plan (i.e., no integrated Medicare Part D coverage), the consumer is prohibited from enrolling in a separate, stand-alone Prescription Drug Plan (PDP) unless the MA-only Plan is a PFFS.

• Explain the plans very carefully. Consumers need to understand the type of product you are presenting and all aspects of cost sharing.

• Advise that the consumer will be automatically disenrolled from their HealthTeam Advantage coverage if they join another MA Plan.

• Review the Outbound Enrollment and Welcome Call with consumers.

CMS Marketing Rules (cont.)

Agents Must:

• Review the “Summary of Benefits” and “Statement of Understanding” at every

sales presentation.

• Walk the consumer through the Enrollment Application. Ensure the form is

complete, dated properly and signed.

• Provide each consumer you meet with a Pre-Enrollment Sales Kit (that includes all

required documentation and disclaimers including the Summary of Benefits and

Appeals and Grievance Process), your contact information and the HealthTeam

Advantage Member Service number.

CMS Marketing Rules (cont.)

Agents Must NOT:

• Refer to HealthTeam Advantage Medicare Advantage plans as “supplement,”

“replacement,” “supplement replacement,” “no cost,” “free plan,” or “zero cost”

plans.

• Market non-health related products when presenting a Medicare Advantage

or Prescription Drug Plan to a consumer.

• Use statements that would lead consumers to believe either the agent or

HealthTeam Advantage are endorsed by the federal government or Medicare.

• Make any superlative statements about HealthTeam Advantage, such as the plan

is “the best,” “the highest-rated,” or “provided much more than any other plan.”

• Enter another agent’s writing number on the Enrollment Application.

• Market to beneficiaries through door-to-door solicitation, including leaving

unrequested information such as a leaflet or flyer at a residence or on cars in

parking areas.

• Market to beneficiaries through unsolicited telephonic or electronic solicitation

(e.g., cold-calls, blast-fax and spam-email) unless an individual has agreed to

receive such communication in writing.

CMS Marketing Rules (cont.)

Oversight of Agent/Broker Sales & Marketing

To maintain Compliance oversight and monitoring of agent/broker sales activities:

• HealthTeam Advantage will monitor & track all agent/broker sales and marketing

activities and respond to all issues or complaints related to member dissatisfaction

or misrepresentation, including those requested by the North Carolina Department

of Insurance (NCDOI) and CMS.

• Activities that are monitored may include, but are not limited to:

• Enrollments, cancellations, and disenrollments, including rapid disenrollment

• Sales and surveillance activities, including presentations and SOA’s

• Complaints against an agent and/or inappropriate identified behaviors (e.g.,

suspicious application signatures, etc.)

• Training and testing

• Data submission/reporting of agent complaints to CMS annually

• State licensing and appointment requirements, including reporting

terminations

• Compensation structures

Agent/Broker Complaints Tracking

• The Sales Operations Manager will track complaints from beneficiaries or their representatives regarding the agent/broker on an ongoing basis. Complaints may come in from, but are not limited to, the following sources:

• The CMS Complaints Tracking Module (CTM) in HPMS

• The CMS Regional Office

• The Member Service call center

• When a complaint is received by HealthTeam Advantage involving an agent/broker, The Compliance Department will contact the Sales Operations Manager who will then contact the agent/broker and request statements of account for the complaint.

• Agent compliance will be tracked using a scoring system that assigns points to complaints based on the severity of the complaint. Agents crossing the threshold will be referred to the Agent Oversight Committee.

Agent/Broker Complaints Tracking (cont.)

• The agent/broker’s cooperation with HealthTeam Advantage is required by HealthTeam Advantage during the investigation of the complaint, as well as during the implementation of any Corrective Action Plan (CAP) developed in response to such complaint

• Corrective Action(s) may include the following:

• Focus training; monitoring sessions

• Full re-training and re-testing

• Termination and prohibition from selling HealthTeam Advantage plans

• Failure to respond within the required timeframe to any of HealthTeam Advantage’s requests during the investigation or corrective action phase will result in suspension or termination of the agent/broker’s ability to market, sell and receive commissions

HealthTeam Advantage is required by CMS to report the termination of any agent, and

the reasons for the termination, to the state where the agent is appointed and to

CMS, where required. The same applies for all contracted distribution partners. When

HealthTeam Advantage agent is terminated, the agent cannot market our products.

**Code of Ethics for Professionalism:

Brokers are required to maintain the highest levels of professionalism at all times

when interacting with potential beneficiaries, other brokers, FMO (if applicable), and

all plan employees.

Agent of Record

During an enrollment period (OEP/SEP), if we get multiple applications for a

beneficiary, we recognize the AOR as the agent associated with the most recent

application on file.

If a member does a plan to plan change, the existing AOR on the policy will remain.

Agent Termination

An Assignment of Commissions must be completed prior to the change taking effect. Both the current agent and new agent need to sign the form and fax to (844)644-5376 or email to: agentsupport@healthteamadvantage.com

Assignment of Commissions

Hierarchy change guidelines

We accept hierarchy change requests when submitted in accordance with the Transfer Release Form.

The Transfer Release Form needs to be completed by the requesting agent and then sent to the HealthTeam Advantage Sales Operations Manager. The Sales Operations Manager will send to the current upline for approval. The up line has the option to:

A. Release Immediately

B. Require 6 months from date of request before releasing

C. If FMO does not respond, release becomes effective 6 months from date request is received from agent.

A Transfer Release Form can be requested from Agent Support by emailing agentsupport@healthteamadvantage.com . This form is required to be filled out by both parties and returned to HealthTeam Advantage prior to transfer being allowed.

Hierarchy

Transfer Release Form

Agent/Broker Compensation

Compensation Rate Adjustment for CY 2017

As provided in 42 C.F.R. §§422.2274(b)(1) and 423.2274(b), the compensation amount paid to an independent agent or broker for an

enrollment must be at or below the fair market value (FMV) cut-off amounts published yearly by CMS.

The chart below summarizes the CY 2017 FMV cut-off amounts for all organizations

NOTE: The FMV amounts for CY 2017 are rounded to the nearest dollar. The Initial Year amount is the maximum allowable to be

paid for enrollments during compensation cycle-year 1. The 2 renewal amount is the maximum allowable to be paid for enrollments

during compensation cycle-years 2 and beyond.

CMS Email Concerning Like/New Compensation

From: Health Plan Management System (HPMS) Date: October 30, 2015 Subject: Agent/Broker Compensation

The purpose of this email is to update and clarify payment guidance in Section 120.4.2 of the Medicare Marketing Guidelines. There are three scenarios affecting how an organization may pay full or pro-rated initial compensation. 1) For a beneficiary's first year of enrollment in a plan, in which the MARx report lists the prior plan type as "none", organizations may pay full or pro-rated initial compensation. 2) When a beneficiary moves from an employer group to a non-employer group plan, in which the MARx report lists the prior plan type as "none", organizations may pay full or pro-rated initial compensation for a beneficiary's first year of enrollment in a plan. 3) For unlike plan changes (e.g. MA-PD to PDP or PDP to Cost Plan), occurring after January 1 in which the MARx report indicates the beneficiary had prior plan history (regardless of plan type), organizations must pay pro-rated initial compensation according to the number of months in the plan. For example, a change from a PDP to an MA-PD effective May 1 is an unlike plan change resulting in a pro-rated initial compensation of 8/12 (May through December) of the MA-PD initial compensation rate. CMS expects organizations to immediately correct their processes and to provide agents/brokers with notification of payment requirements.

This chart shows how HealthTeam Advantage calculates

commissions under CMS rules:

CMS Email Concerning Like/New Compensation (cont.)

New web application (COMING SOON)

• Ability to receive PDF version of application with beneficiaries signature

• Contains all the documents that need to be submitted with the application

• Ability to see all the applications that you have submitted to HTA

• Ability to track your leads

• Can be used without internet access and ability to upload later when WIFI is available

• Can be used on laptops, iPads, Surface, etc.

Agent Portal (COMING SOON)

• Ability to order supplies and have them shipped directly to you

• Ability to customize marketing supplies for your personal use

Commissions (COMING SOON)

• Ability to see your book of business

Tools & Resources: NEW

It is important as an agent with both your reputation and the company’s reputation on the line

to communicate accurate information beginning with your first interaction/visit with the

beneficiary. This will help eliminate any future complaints/grievances against both you and the

plan in the future.

The following are some helpful items that may help with some of the questions that you will be

faced with during an appointment.

There is also additional information on what you can do as an agent to communicate with the

member on what to expect and some options available to them. The discussions around some

of these items can help with our Overall STARS rating which in the end effects both you and the

member’s experience since the STARS rating can effect the benefits from year to year.

Setting Expectations Early On

• Members may be selected to participate in HTA’s MTM program

• Members must meet three criteria in order to be selected for a medication review

• Fill at least eight medications per month

• Accumulate at least $877 in medication costs in the previous quarter

• Have at least three of the following conditions:

• Diabetes

• High Cholesterol

• Osteoporosis

• High Blood Pressure

• Alzheimer’s Disease

• Heart Failure

• Our PBM, Envision determines who is eligible for the program

• If determined to be eligible, Envision will reach out to the member to complete a

medication review

• Please encourage members to complete the medication review when Envision calls

• MTM is a star measure and is used to calculate the overall star rating for HTA

Medication Therapy Management (MTM):

CMS requires health plans to administer two surveys each year

• Consumer Assessments of Health Plan Satisfaction (CAHPS)• Health Outcomes Survey (HOS)• HTA uses a third party vendor to administer the surveys (SPH Analytics)• If selected, the member will receive a survey from SPH• Though long, the survey results are very important to the overall star rating for HTA• Please encourage members to complete the surveys and return them by the deadline

CAHPS survey• Will ask members about their satisfaction with the health plan and their physicians • Star related measures are:

• Getting Needed Care• Getting appointments and care quickly• Customer Service• Overall Rating of Health Care Quality• Overall Rating of Plan • Care Coordination• Rating of Drug Plan • Getting Needed Prescription Drugs• Getting Information from the Plan about Prescription drug coverage and cost • Annual Flu Vaccine

Surveys

HOS survey• Will ask members about their health status• Star related measures are:

• Improving or maintaining physical health • Improving or maintaining mental health • Monitoring physical activity• Improving bladder control • Reducing the risk of falling

Preventative Screenings, Management of Conditions and Medication Utilization:

• CMS “grades” HTA on how many of our members get screenings, how well they manage their

conditions and how well they fill their medications

• HTA will routinely reach out to members to encourage them to get screenings, manage conditions,

take medications

Encourage members to cooperate with requests for screenings

Screenings include:

• Mammogram

• Colorectal Cancer Screening

• Adult BMI (Ht and Wt)

• Bone Density Screening (It is vital that after a woman has a fracture she gets a bone density screening (has to be done within 6 months of fracture)

Surveys (cont.)

Managing Conditions:

Diabetes:

• Diabetics need to get an eye exam

• Diabetics need to make sure that their hbA1c is in control

• Diabetics need to get a Nephropathy screening

High Blood Pressure:

• Members need to make sure that their BP stays in control

Rheumatoid Arthritis:

• If a member has Rheumatoid Arthritis they need to take an Anti-Rheumatic drug

Medications:

• Members prescribed high blood pressure medication need to fill all scripts written by doctor

• Members prescribes cholesterol medication need to fill all scripts written by doctor

• Members prescribed diabetes medication need to fill all scripts written by doctor

Screenings

New Member ID Cards:

New HealthTeam Advantage members are expected to have their 2017 ID cards prior to

December 15, 2016. Please keep in mind if your member enrolls at the very end of OEP, it

may be closer to the end of December when they receive theirs.

Handling of Out-Of-Network Medical Claims:

Every doctor is different on how they may choose to handle HealthTeam Advantage patients

as Out-Of-Network. It is important that your beneficiary understand that even though we

are a PPO, there may be some Primary Care Physicians who will not accept HealthTeam

Advantage patients. We are willing to work with any Out-Of-Network doctors/facilities to

help facilitate that claims process. In many instances, your beneficiary may be expected to

pay the entire bill up front and would then submit that receipt to their Healthcare Concierge

for the reimbursable amount. That amount is based on the Medicare Allowable MINUS any

applicable Out-Of-Network copay. It is best to have your beneficiary check with the doctor’s

office in advance of appointment to understand what they will be responsible for paying at

the time of visit to avoid any confusion.

Important Information

Our riders are currently being handled through Avesis. Currently, if a member decides to go Out-Of-Network for a procedure, they are expected to pay the entire amount of the bill up front and then will be reimbursed by Avesis at the In-Network fee rate for covered service after applicable copay.

Handling of Out-Of-Network Dental / Combo Rider Claims:

Hi again! Now you know about HealthTeam Advantage Medicare Advantage Plans.

Now that you’ve viewed each slide of the presentation, you may proceed to the 2017 HealthTeam Advantage Medicare Advantage Certification Exam.

You will have three attempts to successfully pass the exam with a minimum score of 85%.

Good luck!

Agent Certification Wrap-Up