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Optima Medicare Plans
2010 Certification Training
Optima Medicare Broker Certification
• Welcome to Optima’s Medicare Advantage and
Part D Broker Certification Training Course
• In this course, you’ll cover the following topics:
– Medicare Basics
– MA-PD and Part D eligibility
– Enrollment and Disenrollment Periods
– Marketing Guidelines (including MIPPA Guidance)
– Marketing and Training Expectations
– Optima Plans and Benefits
– Certification Exam
Broker Certification
• Brokers cannot discuss benefits or sell Optima
plans until they successfully complete the
certification courses/exam.
• Why? CMS requires it.
• Brokers must be re-certified each year for all
Medicare Advantage and Part D requirements.
• Why? In addition to CMS requiring it, the rules
around these plans are continually changing, and
it’s to your advantage to stay current.
Section 1
Medicare
Medicare
• Medicare is a Federal health insurance program
for those age 65 or older or individuals at any age
who have certain disabilities, or who have End
Stage Renal Disease (permanent kidney failure)
• The Centers for Medicare and Medicaid Services
(CMS) is the Federal agency which regulates
Medicare.
• The Social Security Administration performs
administrative functions for the Medicare program,
and provides general information.
Medicare
• Medicare Part A (hospital • Medicare Part B (medical
insurance) mainly covers insurance) covers
impatient care in a hospital, outpatient care, including
skilled nursing facility, physician services,
home health care or diagnostic services,
hospice program. ambulance, certain limited
• Most beneficiaries do not drugs, and durable medical
pay for Part A. equipment.
• Beneficiaries will pay
$96.40 for Part B in 2009.
Upper income beneficiaries
will pay more. (CMS has
not yet announced 2010
amounts)
Medicare
• Medicare Part C (Medicare Advantage) plans cover Part A and B
benefits
• Private plans contract with CMS to administer Part C plans under
contract. So do Part D plan sponsors
• CMS pays private plans to provide these benefits
• Medicare Advantage plans have uniform premium and cost-
sharing amounts, except for limited income subsidy beneficiaries
under Part D
• Medicare Advantage plans may include Part D benefits (MA-PD)
• Part D benefits can be provided through:
– Prescription Drug Plans (PDPs)
– Medicare Advantage plans with Part D (MA-PD), or
– Employer sponsored plans that are deemed creditable
Section 2
Marketing Guidelines (Including
MIPPA Requirements and new
Marketing Guidelines)
Plan Sponsors May Contract with Brokers &
Agents to Market Medicare Health Plans
To reach Medicare beneficiaries across the country,
Medicare health plan sponsors frequently contract with
brokers and agents to:
• Carry out marketing efforts;
• Disseminate information about their plans; and
• Sell Medicare health plan packages.
Responsibility for Marketing the Plans
Plan sponsors are responsible for all of the marketing
activities of third-parties contracted to carry-out Medicare
health plan business including a person who:
• Is directly employed by the organization
• Is under contract with the organization
• Is a downstream (hired by someone else)
marketing contractor.
Plan sponsors must use only a state licensed individual
to perform marketing.
This applies to independent agents and internal sales
staff.
Plan Sponsors Ensure Compliance
• Plan sponsors must establish clear provisions in
the broker/agent contracts stating that the
organization is responsible for ensuring the
contractors comply with:
– Applicable MA and/or Part D laws,
– Federal health care laws, and
– CMS policies and Marketing Guidelines
• Plan sponsors must conduct monitoring activities
to ensure compliance.
Unsolicited Contacts Prohibited
Beginning 9-18-2008, the following activities are
prohibited:
– Outbound marketing calls, unless requested.
– Calls to disenrolled or disenrolling members.
– Calls to beneficiaries to confirm receipt of mail.
– Calls to beneficiaries to confirm appointments made
by third parties or independent agents.
– Approaching beneficiaries in common areas.
– Follow up calls or visits to beneficiaries who attend
an event, without their express permission.
Permitted Contacts
Plans may do the following:
• Conduct outbound calls to existing members for normal
plan business, including calls to members who have been
involuntarily disenrolled to resolve eligibility issues.
• Call former members to conduct disenrollment survey for
quality improvement purposes. Disenrollment surveys may
be done by phone or sent by mail, but neither calls nor
mailings may include sales or marketing information.
• Under limited circumstances and subject to advance
approval from the appropriate CMS Regional Office, call
LIS-eligible members that a plan is prospectively losing due
to reassignment to encourage them to remain enrolled in
their current plan.
Permitted Contacts, Con’t
• Agents/brokers who enrolled a beneficiary in a plan may
call that beneficiary while they are member of that
organization.
• Call beneficiaries who have expressly given permission for
a plan or sales agent to contact them, for example by filling
out a Sales Appointment Confirmation reply card or asking
a Customer Service Representative (CSR) to have an
agent contact them. This permission applies only to the
entity from whom the beneficiary requested contact, for the
duration of that transaction, or as indicated by the
beneficiary.
Cross-Selling Prohibited
• Effective 9-18-2008, marketing non-health care
related products (Annuities or Life Insurance)
during any sales activity is prohibited.
• CMS wants beneficiaries to be able to focus on
Medicare coverage options without confusion.
Scope of Appointments
• Marketing representatives must specifically inform beneficiaries of all products
that will be discussed prior to the in-home appointment.
• Beneficiaries must agree to the scope of the appointment, and this must be
documented in writing or recorded prior to the appointment.
• If it is not feasible for the scope of appointment form to be executed
prior to the appointment, an agent may have the beneficiary sign the
form at the beginning of the marketing appointment.
• Appointments made over the phone must be recorded.
• Appointments made at a sales event must be written with a list of the products
to be discussed and signed by the beneficiary.
• Additional products may not be discussed unless the beneficiary requests the
info.
• Additional lines of business will require a separate appointment.
• Any such appointments must be scheduled at least 48 hours after the initial
appointment unless the request for the appointment is made at a sales
presentation.
Promotional Activities: Drawings,
Prizes, Giveaways
• Brokers/Agents may offer during presentations:
– Cannot offer meals, cash, charitable contributions, gift
certificates/cards.
– Gift must be less than retail amount of $15 & must be
offered to all members. Combined value cannot exceed $15
if more than one item given.
– May offer a prize of over $15 ($1,000 sweepstakes on
website), if offered to general public.
– May not use free gifts or prizes to induce enrollment.
– Gifts are offered to eligible members without discrimination;
– Must include a disclaimer on any statement concerning a
prize or drawing that there is no obligation to enroll in the
plan.
Promotional Activities: Referral
Programs
• An organization can request referrals from active members
including names and addresses, but not phone numbers.
(Information can be used for mail solicitation.)
• Brokers/agents may not use cash promotions as part of a
referral program, but may offer thank you gifts of less than
$15 (retail amount).
• Thank you gifts are limited to one gift per member per year.
• A letter sent from an agent or broker to members soliciting
referrals cannot offer a gift for a lead.
• Gifts for referrals must be available to all members that provide a
referral and cannot be conditioned on actual enrollment of the
person being referred.
Marketing Activities:
Unsolicited E-mail Prohibitions
• Marketing agents may not:
– Send e-mail to a beneficiary, unless the
beneficiary agrees to receive e-mails from the
plan sponsor and provides his/her e-mail
address.
– Rent an e-mail list to distribute plan information.
– Acquire e-mail addresses through any type of
directory.
Health Fairs & Educational Events
• Health Fairs and Educational Events are defined as
social or educational events versus sales events which
are sponsored by the plan or other parties with the
purpose of marketing to potential members and
steering potential members towards a specific plan.
Health Fairs and Educational Events should not
include a sales presentation.
• Response by an organization representative to
questions asked at the event will not be considered a
sales presentation as long as no enrollment form or
other marketing materials are distributed at the event.
Activities During Educational Events
May not:
• Include sales activities, distribute marketing materials, collect applications.
• May not discuss plan-specific premiums and/or benefits.
• Distribute business reply cards, scope of appointment forms, or sign-up sheets.
• Set-up personal sales appointments or get permission for an outbound call.
• Attach business cards or plan/agent contact information to educational
materials
• Asked if participants want information about a specific plan(s).
May:
• Distribute materials provided that meet the CMS definition of education.
• Display a banner with the plan name and/or logo
• Provide promotional items, including those with plan name, logo, and toll-free
customer service number and/or website. Promotional items must be free of
benefit information.
• Give a business card if the beneficiary requests information on how to contact
the agent for additional information, as long as the business card is free of plan
marketing or benefit information.
Prohibition on meals
Acceptable Snacks:
• Plans may not provide
• Fruit
meals (directly or indirectly)
• Raw vegetables
at meetings or events
where plan benefits and • Pastries
materials are available to • Cookies
prospective members. • Small dessert items
• Agents and brokers may • Crackers
provide light snacks, • Muffins
however, snacks cannot be • Cheese
“bundled” to provide a • Chips
meal. • Yogurt
• Nuts
Marketing Activities
Door-To-Door Solicitation Prohibitions
Marketing agents may not:
– Solicit beneficiaries door-to-door prior to receiving an
invitation from the beneficiary to provide assistance
in the beneficiary’s residence.
– Return uninvited to an earlier “no show”
appointment.
Marketing agents may:
– Market and distribute and accept enrollment
applications in common areas of health care
settings: e.g., cafeteria, rec. room, conference room
Marketing in Healthcare Settings
• Marketing is permitted in common areas:
– Cafeterias, community or recreational rooms,
conference rooms.
– In retail stores, areas other than where patients
wait for service, pick up prescriptions or talk to
pharmacy providers.
• Marketing, Selling or Distributing/Accepting
Enrollments NOT permitted in:
– Waiting rooms, exam rooms, hospital patient
rooms, dialysis centers, pharmacy counter
areas
Marketing Materials - Approval
• Agents/brokers must use only plan materials and
scripts approved by CMS when speaking with
prospective clients and describing benefits.
• CMS reviews marketing materials submitted by
the plan sponsor to ensure they:
– Are not materially inaccurate,
– Are not misleading, and
– Do not otherwise make material
misrepresentations.
Broker Compensation Agreements
Compensation schedules must:
• Be specified in a written contract.
• Provide reasonable compensation that is in line with industry
standards for services provided (Fair Market Value).
• Include commissions, gifts, and bonuses.
• Not include payments outside of the compensation schedule set
forth in the written contract.
Rate of payment:
• Must be related to a reasonable measure of service provided.
• May vary among plans (e.g., MA plan, MA-PD plan, or a PDP).
• May not vary based on the health status or risk profile of a
beneficiary.
New Compensations Guidelines
• New rules designed to:
– Reduce “churning” - the inappropriate
movement of beneficiaries from plan to plan.
– Promote fair market value
– Prohibit “cherry-picking”
– Eliminate compensation that varies based on
reaching enrollment targets.
NOTE: Special Needs Plans are permitted to market to
individuals based on the eligibility requirements of the plan
New Compensation Guidelines
• Commission payable to all agents/brokers/
representatives must be for an initial year, and five
subsequent renewal years.
• The first year commission cannot be greater than
200% of the second or any subsequent year’s
commission.
• Plans may introduce new compensation structures for
each year for that year’s new sales, subject to annual
market commission caps as established by CMS.
• Plans may not change compensation structures during
the plan year.
New Compensations Guidelines
• Plans may pay commission up front, but compensation
is earned in months 4-12 of the plan year. If the
enrollee leaves prior to 4 months, no compensation is
payable. If the enrollee leaves after 3 months, then
compensation is paid on a pro-rated basis.
• After the 2009 year, any new sales where a beneficiary
is moved between “like” plans (i.e. MA-PD to MA-PD)
will be paid at renewal level.
• CMS will direct plans as to whether first year or
renewal compensation is payable, based on
beneficiary enrollment data.
Optima Compensation Compliance Plan
• Optima will comply with all the new CMS
guidelines.
• Beginning in 2010, Optima will pay
commissions on a monthly basis to assure
compliance with CMS guidelines.
State Reporting Laws
• The plan sponsor must report to the state the
following information:
– The identity and other information of a
broker/agent who is marketing the
organization’s plan(s).
– The termination for cause of a broker’s/agent’s
employment or contract.
Reporting Violations to State Agencies
• Plan sponsors are required to report a suspected
violation of a state’s licensing, registration, certification,
insurance, or other law.
• States may take action against marketing
representatives and insurance producers for alleged
violations of state marketing representative licensing
laws.
• This requirement applies to any individual performing
marketing on behalf of a PDP sponsor or MA
organization, whether the individual is an employee, an
independent agent contracting with a PDP or MA
organization, or a downstream contractor.
Continuous Oversight
• Plan sponsors have developed ways to monitor broker/agent
performance and compliance.
• These include:
– Telephone calls to new members to ensure that they
understand the terms of the Part D plan;
– Broker/agent phone call monitoring and review to ensure
compliance with appropriate marketing practices;
– Targeted “ride-alongs” conducted by plan sponsor employees
based on complaints;
– Attending community meetings to evaluate presentations;
and/or
– Monitoring of disenrollment rates and complaints for each
broker/agent.
CMS Responsibilities
• CMS Responsibilities include:
– Communication of services and eligibility
– Regulation and auditing of Medicare Advantage plans
• Optima must be 95% compliant in all areas to pass
the audit
• The CMS audit includes but is not limited to:
enrollment procedures, claims processing, member
services, appeals, sales and marketing, medical
management and provider issues
• Secret shopper activities (CMS will increase in
2010)
Marketing Guidelines
• Penalties can be imposed
– CMS can impose up to $25,000 for each time
Optima misrepresents or falsifies information
provided to an individual or entity.
• In the event that broker misrepresentation
results in CMS penalizing Optima, Optima
will pass such penalty to the offending broker
– CMS can impose up to $100,000 each time
Optima misrepresents or falsifies information
provided to CMS.
MIPPA Contained New Guidelines
• The Medicare Improvements for Patients and
Providers Act of 2008
• Passed by Congress to address reported
problems.
• Congress charged CMS with drafting and
implementing guidelines
• Some provisions have delayed implementation
dates.
MIPPA Focus
• Much of MIPPA focused on PFFS and marketing
guidelines - why?
• Congress believes PFFS Plans have provider
access and quality problems.
• Many reports of market misconduct, especially by
independent agents.
PFFS Plans Must Develop Networks
• By 2011, most PFFS Plans must develop provider
networks.
• This applies if existing plan operates in an area
with at least 2 network-based plans.
• Deeming will not be allowed in lieu of network.
• In counties with no or only one network-based
plan, PFFS deeming allowed.
• Mixed model plans (network & deeming) are not
allowed.
PFFS Plans Must have Quality Programs
• Beginning in 2010, PFFS Plans must have
ongoing Quality Improvement Programs, just like
HMO’s and PPO’s.
• CMS goal to have “confident, informed consumers
through transparent public reporting on health plan
performance.”
Change In Disclosure Requirements
• CMS now requires both MA and PDP plans to
disclose plan information:
– At the time of enrollment
– 15 days prior to the Annual Election Period
• Annual Notice of Change and Evidence of
Coverage to members by 10/31 each year
Marketing Materials and Guidelines
• ALL marketing materials must be approved by
Optima and CMS
• Marketing materials include:
– general circulation brochures
– enrollment & disenrollment forms
– member handbooks
– newsletters
– letters or notes to members about anything
(including handwritten thank you notes)
Selling Optima Medicare Plans
• Brokers may schedule appointments with beneficiaries
beginning in October, and brokers may leave an application
with the beneficiary, following a sales presentation.
• Brokers cannot take a completed application away from a
presentation until November 15.
• Brokers can submit enrollment forms to Optima beginning
November 15th.
• If a beneficiary mails a completed enrollment application to
Optima prior to November 15, we may take it and process it
for a November 15 submission date.
• The earliest effective date a member may have is January
1, 2010.
Section 3
Marketing and Training
Expectations
Marketing and Training Expectations
• CMS takes the sales process very seriously, and
takes broker training and compliance very
seriously. Optima is required to monitor and train
brokers much like internal sales employees are
monitored and trained.
• In order to comply with CMS expectations, Optima
will monitor and inform brokers of problems
detected during the sales process.
• All broker marketing errors are communicated to
the broker and recorded in the broker/agency file.
Marketing and Training Expectations
• The following marketing errors will result in
immediate termination from the program:
– Forgery
– High pressure tactics
– Fraudulent misrepresentation
– Door to door solicitation
– Offering gifts or payments to induce enrollment
– Failure to process cancellation
– Using advertising that is not approved by Optima and CMS
• If 5 broker errors are detected within a 12 month
period, the broker will lose appointment to sell
Optima plans.
Marketing and Training Expectations
• When an broker has 3 errors, a written report may
be generated. The report includes:
– the number of sales the broker has generated,
– if the broker is making repeat errors,
– how many broker sales terminated within 90 days
– documentation that Optima had a verbal discussion
with the broker.
• All of this information is available to CMS during the
auditing process.
• Upon attending another certification class, the broker
may resume selling Optima plans.
Marketing and Training Expectations
• The following Marketing errors may cause Optima
to contact a broker:
– Not certified to sell Optima plans
– Neglect to sign as 3rd party individual who assisted
with the enrollment form
– Proposed effective date unavailable due to
improper processing
– Enrollment form is received more than 15 days after
the signature date
– Missing appropriate Power of Attorney or Translator
Witness Form
Marketing and Training Expectations
• Following are Marketing errors that cause formal
contact from Optima to the broker:
– Applicant states that the broker misrepresented the
Optima plan
– Applicant doesn’t qualify for the plan for reasons
such as:
• Applicant does not live in the service area
• Applicant has not enrolled in Medicare Part B
– Enrollment form changes have not been initialed by
the applicant
Marketing and Training Expectations
• Examples of Errors:
– Name on the front of the application is different than the
signature of the applicant
– Name of the beneficiary is incorrect or missing
– Medicare effective dates are missing or incorrect
– HIC# is missing or incorrect
– Applicant did not initial section 3 or 4 of the enrollment form
– Health history question section is incomplete
– Residential address is missing or incorrect
– Incorrect or missing zip code
– Incorrect or missing birth date
– Incorrect or missing gender
– Incomplete or missing phone number
Broker/Agent Disclosure Requirements
When conducting marketing to enroll beneficiaries,
brokers and agents must disclose to beneficiaries that
they are:
• Contracted with the sponsor they are representing;
and
• Compensated based on the person’s enrollment in
the plan.
This disclosure must be in writing.
Section 4
Enrolling In Medicare Advantage
and Part D Plans
Restrictions for Enrolling In PDPs
• Medicare beneficiaries may be enrolled in only one Part D
plan at a time.
• If enrolled in an MA coordinated care plan(like Optima
Medicare Preferred Plus) or MA PFFS plan that includes
Medicare prescription drugs, the enrollee may not enroll in
a PDP unless they disenroll from the HMO, PPO, or MA
PFFS plan.
• Enrollees in PFFS without prescription drug coverage or an
MA Medical Savings Account (MSA) plan may enroll in a
PDP.
• Enrollees in a 1876 Cost plan may enroll in a PDP (not
available in Optima service area).
Restrictions for Enrolling in MA-PDs
• The Medicare prescription drug benefit of a MA-
PD is only available to members of the MA-PD
plan.
• If a beneficiary is already enrolled in a MA-PD
plan, the enrollee must receive their Medicare
prescription drug benefit through that plan.
Who May Decide to Enroll?
• Presentations must be made directly to the prospective
enrollee, and/or their legal representative.
• Decisions to enroll in a plan must be made by people of sound
mind who are capable of understanding the plan benefits.
• CMS will recognize State laws that authorize persons to effect a
Part D enrollment or disenrollment request for Medicare
beneficiaries. These include:
– Court-appointed legal guardians, persons having durable power of
attorney for health care decisions, or individuals authorized to
make health care decisions under state surrogate consent laws,
provided they have authority to act for the beneficiary in this
capacity.
• A spouse or family member cannot decide for and/or sign for
another without a legal authority.
• If both spouses cannot attend the sales presentation, you may speak
to and enroll the present spouse and schedule a follow-up appointment
for the absent spouse.
Special Concerns for Enrollment
• Enrolling the incompetent: only three acceptable
means:
– Durable Power of Attorney
– Guardian
– Parent of an Unmarried Disabled Adult Child
• A Translator Witness is needed when enrolling the:
– Hearing impaired
– Visually impaired
– Non-English-speaking
Beneficiary Information
It is important to be aware of your individual client’s circumstances. For
example:
• What is the client interested in?
– Medicare Advantage, Medicare Advantage with prescription drugs, or
stand-alone prescription drug coverage.
• What health coverage do they have now?
– Original Medicare,
• Only or with Medigap
– Medicare Advantage plan,
– Medicaid, or
– Employer/union sponsored plan.
• Do they currently have drug coverage?
• When is the current coverage was effective?
• Has the client already made changes for the current calendar year?
Election Periods
Beneficiaries may only enroll in or change plans during an
election period that occurs at specific times of the year.
Previous Medicare health plan elections will impact
what Medicare choices are now available.
– Initial Election Period (IEP) – Beneficiary
Dependent
– Annual Election Period (AEP) – November 15 to
December 31
– Open Enrollment Period (OEP) – January 1 to
March 31
– Special Enrollment Period (SEP) – Beneficiary
Dependent
Initial Election Period (IEP)
• Beneficiary dependent – based on date the beneficiary becomes
eligible for Medicare
• Generally concurrent with IEP for Part B - during the period that
starts three months before the month he/she turns age 65 and
ends three months after the month he/she turns age 65.
• If a beneficiary does not join during the IEP, and does not have
current drug coverage that is creditable, he/she may have a
penalty. The premium cost will go up at least 1% per month for
every month that he/she waits to join. Like other insurance, the
individual will have to pay this penalty as long as they have
Medicare prescription drug coverage.
– Note: Low Income Subsidy members are not subject to the
Late Enrollment Penalty.
• Individuals have one IEP to use, once enrollment is effective, the
IEP is used.
Election Periods
• Annual Election Period (AEP)
– November 15 – December 31
– Beneficiaries may add or drop MA and/or drug coverage
– Beneficiaries may switch to a different plan offering drug
coverage:
• From a PDP to a different PDP,
• From MA-PD to a different MA-PD,
• From a PDP to an MA-PD or vice versa, or
• To a Cost Plan offering Part D
– Beneficiaries have one AEP to use; once the enrollment is
effective, the AEP has been used.
• Open Enrollment Period (OEP)
– From January 1 through March 31 beneficiaries may make one
change to how they receive their Medicare health benefits, but
they may not add or drop drug coverage. The following two tables
outline the changes they may make.
Medicare Open Enrollment Period Rules
If a beneficiary HAS drug coverage he/she must keep drug coverage during an
OEP.
If current coverage includes During an OEP they could choose to:
prescription drugs.
MA-PD* Change to another MA-PD*
Switch to Original Medicare and a PDP
Original Medicare and a PDP Switch to a MA-PD*
*PFFS plans with drug coverage are included in the definition of MA-PD.
Medicare Open Enrollment Period Rules
If a beneficiary has NO drug coverage, he/she cannot switch to a Plan with
drug coverage during an OEP.
If their current coverage does not During an OEP they could choose to:
include prescription drugs.
MA only* Change to another MA only*
Switch to Original Medicare Only
Original Medicare Only Switch to a MA Only*
* PFFS plans without drug coverage are included in the definition of MA plans.
Special Enrollment Period (SEP)
• Special Enrollment Periods are based on a
beneficiary’s circumstances.
• An SEP generally allows an individual to:
– disenroll,
– change plans, or
– sometimes to enroll.
• CMS has identified in its Manual a number of
circumstances in which a beneficiary can have a
special enrollment period.
SEPs - Some Typical Circumstances
• Medicaid
– Individuals who receive assistance from Medicaid can change
plans at any time.
– If a person loses his/her Medicaid benefits, he/she has a three
month period to make an enrollment decision.
• Moving
– If a person has a service area based plan (MA, MAPD, PDP)
and moves outside the service area, he/she can apply the
month prior to the move and up to 2 months after the move.
– The individual may choose an effective date of up to 3 months
after the month in which the enrollment form is received, but
may not be earlier than the date of the permanent move.
SEPs - Some Typical Circumstances
• Misrepresentation
– CMS may grant the individual an SEP if a plan
representative materially misrepresented the plan during
marketing.
• Involuntary loss of creditable coverage
(coverage at least as good as Medicare)
– Involuntary loss, including a reduction in the level of
coverage
– Begins with the month in which the individual is advised
of the loss of creditable coverage and ends 60 days after
either the loss occurs or the individual received notice,
whichever is later.
SEPs - Some Typical Circumstances
• Institutionalized Individuals
– For an individual who moves into, resides in, or
moves out of a:
• Skilled nursing facility (SNF) or nursing facility (NF);
• Intermediate care facility for the mentally retarded
(ICF/MR);
• Long Term psychiatric hospital or unit;
• Rehabilitation hospital or unit; or
• Long-term care hospital or swing-bed hospital.
– Effective dates: first of the month following the month in
which the enrollment/disenrollment request is received,
but not prior to the month residency begins. Up to 2
months after he/she moves out of the facility.
SEPs - Some Typical Circumstances
• Employer Group Health Plan (EGHP) changes
– For individuals enrolling in employer group/union-sponsored
Part D plans,
– For individuals to disenroll from a Part D plan to take
employer/union-sponsored coverage of any kind, and
– For individuals disenrolling from employer/union-sponsored
coverage to enroll in a Part D plan.
– The SEP EGHP may be used when the EGHP would
otherwise allow the individual to make changes to their EGHP
plan choice.
– Effective date of enrollment or disenrollment: up to 3 months
after the month in which the request is made. However, the
effective date may not be earlier than the date the EGHP (or
PDP sponsor, as appropriate) received the completed
enrollment or disenrollment request.
Medicare Enrollment Guidelines
• Health questions may not be asked unless it is a question of
eligibility.
• Appointments may not be avoided due to the health or financial
status of the beneficiary.
• Plans and agents/brokers cannot work with a provider to direct any
beneficiary to a particular plan, e.g., only the healthier members of
a medical practice.
• If a paper enrollment form is used, it must be signed.
• If the beneficiary is not competent to enroll, a legal representative
must sign the enrollment form for the beneficiary.
Medicare Enrollment Guidelines
• The legal representative must attest on the form that they
have the authority to make healthcare decisions under
State law to effect the enrollment request on behalf of the
beneficiary.
• Proof of legal representation includes court-appointed legal
guardianship or power of attorney for healthcare.
• If an Agent or Broker helps the beneficiary fill out the enrollment
request, they must also sign the enrollment form and indicate their
relationship to the individual.
• Agents or Brokers must not:
– Give advice on legal documents;
– Give in to pressure from a family member who wants to enroll
a beneficiary without legal authority.
Medicare Health Care Plan Premium
Payment
Members can pay their premiums by:
• Automatic bank withdrawal
• Billing Statement
• Withholding from Social Security Administration check (note: due
to many problems with this process, we do not recommend this
for clients)
IMPORTANT: Agents cannot collect plan premiums at the time of
enrollment.
Plans will verify enrollment via a phone call or other means.
Post Enrollment Materials for the
Beneficiary
• After the plan receives the application, the plan
sponsor provides the member with:
– A notice acknowledging receipt of the complete enrollment
request providing the expected effective date of enrollment;
– A copy of the completed enrollment form;
– The plan sponsor’s rules;
– The member’s rights and responsibilities;
– Evidence of health insurance coverage so that he/she may
begin using the plan services as of the effective date.
– ID card or information about how to obtain services prior to the
receipt of an ID card.
• NEW: A verification call must be made within 10 days of
receiving the enrollment form, per new CMS Marketing Guidelines
Section 5
Optima Medicare (PPO) Plans and
Benefits
Optima Medicare Plans
• Optima’s plans are Medicare Advantage Preferred
Provider Organization plans
• Members can receive benefits in or out-of-network
• Optima Medicare plans provide benefits equivalent
to Original Medicare, plus additional benefits
• Optima Medicare plans are filed annually with
CMS, and become effective on January 1 of each
year - they are calendar year plans.
Optima Medicare Plans are PPO Plans
• Unlike an HMO, members can choose providers in or
out of network. Out of Network providers are just like
any provider - they may choose to participate in
Medicare or not. Optima pays out of network providers
the Medicare allowable fee schedule, just like Original
Medicare or Medicare Supplement plans.
• If a non-network provider wants a member to pay up-
front, Optima will reimburse the member at the
Medicare allowable fee schedule
• With an Optima plan, members have freedom to travel,
thanks to out of network coverage.
Optima Medicare Plans 2010 Plans and
Benefits
• In 2010, Optima will offer four plan designs:
2010 Medicare Plan Optima Medicare Optima Medicare Optima Medicare Optima Medicare
Choices Preferred Preferred Plus Value Value Plus
Monthly Premium $90.00 $148.00 $0.00 $0.00
Inpatient Benefits
2010 Medicare Plan Optima Medicare Optima Medicare Optima Medicare Optima Medicare
Choices Preferred Preferred Plus Value Value Plus
Non- Non- Non- Non-
Benefits Network Network Network Network Network Network Network Network
Inpatient Benefits
$100 $100 $100 $100 $200 $200 $200 $200
Copay per Copay per Copay per Copay per copay per copay per copay per copay per
day, days day, days day, days day, days day, days day, days day, days day, days
Inpatient Hospital Care 1-5 1-5 1-5 1-5 1-5 1-5 1-6 1-6
$100 $100 $100 $100 $200 $200 $200 $200
Copay per Copay per Copay per Copay per copay per copay per copay per copay per
day, days day, days day, days day, days day, days day, days day, days day, days
Inpatient Mental Health 1-5 1-5 1-5 1-5 1-5 1-5 1-6 1-6
$60 $60 $60 $60 $120 $120 $120 $120
copay per copay per copay per copay per copay copay copay copay
day, days day, days day, days day, days days 4 - days 4 - days 4 - days 4 -
Skilled Nursing Facility 4-100 4-100 4-100 4-100 100 100 100 100
Home Health Care $0 $15 $0 $15 $0 $15 $0 $15
Outpatient Benefits
2010 Medicare Plan Optima Medicare Optima Medicare Optima Medicare Optima Medicare
Choices Preferred Preferred Plus Value Value Plus
Non- Non- Non- Non-
Benefits Network Network Network Network Network Network Network Network
Outpatient Services
Outpatient $250 per $250 per
Surgery/services $0 admit $0 admit 20% 30% 20% 30%
$50 per $50 per $50 per $50 per
Ambulance Services trip trip trip trip 20% 30% 20% 30%
$50 per $50 per $50 per $50 per $50 per $50 per $50 per $50 per
Emergency Care visit visit visit visit trip trip trip trip
$10 per $10 per $10 per $10 per $10 per $10 per $10 per $10 per
Urgently Needed Care visit. visit visit. visit visit visit visit visit
Outpatient Rehabilitation $15 per $15 per 20% 30% 20% 30%
Services $0 visit $0 visit copay copay copay copay
Durable Medical 20% 20% 20% 30% 20%
Equipment & Prosthetics $0 copay $0 copay copay copay copay 30%
$0 per $15 per $0 per $15 per
visit, $50 visit, $100 visit, $50 visit, $100
for MRI, for MRI, for MRI, for MRI,
CT and CT and CT and CT and
Diagnostic Tests, X-Rays, PET PET PET PET 20% 30% 20% 30%
and Lab Services scans. scans scans. scans copay copay copay copay
Physician Benefits
2010 Medicare Plan Optima Medicare Optima Medicare Optima Medicare Optima Medicare
Choices Preferred Preferred Plus Value Value Plus
Non- Non- Non- Non-
Benefits Network Network Network Network Network Network Network Network
Physician Services
Doctor Office Visits $10 $15 $10 $15 $10 30% $10 30%
Chiropractic Services $10 $15 $10 $15 $10 30% $10 30%
Podiatry Services $10 $15 $10 $15 $10 30% $10 30%
$15 per $15 per
$0 annual annual $0 annual annual
Physical Exams exam exam exam exam
$10 per 20% for $10 per 20% for 30% for 30% for
visit for post- visit for post- $25 for post- $25 for post-
routine cataract routine cataract post- cataract post- cataract
eye eyeware. eye eyeware. cataract eyeware. cataract eyeware.
exam. 20% for exam. 20% for eyewear, 30% for eyewear, 30% for
$25 for Medicare- $25 for Medicare- $30 per Medicare- $30 per Medicare-
post- covered post- covered Medicare- covered Medicare- covered
cataract eye cataract eye covered eye covered eye
Vision Services eyewear. exams. eyewear. exams. eye exam exams. eye exam exams.
Preventive Services
2010 Medicare Plan Optima Medicare Optima Medicare Optima Medicare Optima Medicare
Choices Preferred Preferred Plus Value Value Plus
Non- Non- Non- Non-
Benefits Network Network Network Network Network Network Network Network
Preventive Tests and
Services
Bone Mass Measurement $0 $0 $0 $0 $0 $0 $0 $0
Colorectal Screening
Exams $0 $0 $0 $0 $0 $0 $0 $0
Immunizations $0 $0 $0 $0 $0 $0 $0 $0
Mammograms $0 $0 $0 $0 $0 $0 $0 $0
Pap Smears and Pelvic
Exams $0 $0 $0 $0 $0 $0 $0 $0
Prostate Cancer
Screening Exams $0 $0 $0 $0 $0 $0 $0 $0
Part B and Part D Drug Coverage
2010 Medicare Plan Optima Medicare Optima Medicare Optima Medicare Optima Medicare
Choices Preferred Preferred Plus Value Value Plus
Non- Non- Non- Non-
Benefits Network Network Network Network Network Network Network Network
Prescription Drug
Coverage
10% 20% 10% 20% 20% 30% 20% 30%
Part B Prescription Drugs copay copay copay copay copay copay copay copay
not not not not
Part D Prescription Drugs covered covered $4/$30/$60/30% covered covered $4/$30/$60/30%
Optima plans
• Broker Confirmation Statement
– By completing the training and certification course I agree that
I understand:
• What a MA-PD or Part D Plan is and how it works
• The broker requirements, and will abide by the guidelines
• The marketing errors that can lead to termination
• The errors that can lead to marketing issues
• The product and the benefits
• Member’s eligibility
• The enrollment and disenrollment process
Optima Plans
Congratulations!
You have completed the Optima certification
course. You are now eligible to take the
examination. Please access the Optima exam at
this time.
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