caremore’s southern california 2013 product...
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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
“Internal Use Only”
• 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
“Internal Use Only”
FRAUD, WASTE & ABUSE
“Internal Use Only”
• 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.
“Internal Use Only”
FRAUD, WASTE & ABUSE
“Internal Use Only”
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.
“Internal Use Only”
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.
“Internal Use Only”
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
“Internal Use Only”
WHAT’S NEW FOR CAREMORE IN 2013
“Internal Use Only”
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
WHAT’S NEW FOR CAREMORE IN 2013
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
“Internal Use Only”
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.
“Internal Use Only”
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
“Internal Use Only”
• 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.
“Internal Use Only”
• 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.
“Internal Use Only”
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.
“Internal Use Only”
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.
“Internal Use Only”
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
“Internal Use Only”
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
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
“Internal Use Only”
CVP PRODUCT OVERVIEW Eligibility Requirements
“Internal Use Only”
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
Additional Days $0 Copay $0 Copay $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
$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
$10,000 Limit, ER and UC Combined
$10,000 Limit, ER and UC Combined
CAREMORE VALUE PLUS PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
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
CAREMORE VALUE PLUS PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
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
0% Coinsurance, $0-$499
0% Coinsurance, $0-$499
20% Coinsurance, $500 +
20% Coinsurance, $500 +
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
CAREMORE VALUE PLUS PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
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
$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
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Hearing - Exams $0 Copay $0 Copay $0 Copay
Hearing Aids $250 Allowance Every 1 year
$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
$8.00 Premium for : Optional Dental
$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
“Internal Use Only”
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
44 one way trips to PAL
150 one way trips to PAL
50 one way trips to PAL
Riverside
Limited Clinical Benefit
Not Covered
10 one way trips to PAL
Unlimited CCC
N/A
N/A
San Bernardino
Limited Clinical Benefit
Not Covered
10 one way trips to PAL
Limited Clinical Benefit
Limited Clinical Benefit
• 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.
“Internal Use Only”
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
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
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
$0 Copay/ 30 Day Supply
Tier 2 Non-Preferred Generic Drugs $5 Copay/ 30 Day Supply
$5 Copay/ 30 Day Supply
$5 Copay/ 30 Day Supply
Tier 3 Preferred Brand Drugs $25 Copay/ 30 Day Supply
$29 Copay/ 30 Day Supply
$29 Copay/ 30 Day Supply
Tier 4 Non-Preferred Brand Drugs $85 Copay/ 30 Day Supply
$85 Copay/ 30 Day Supply
$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
$10 Copay/ 30 Day Supply
$10 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)
“Internal Use Only”
HEART PRODUCT OVERVIEW Eligibility Requirements
“Internal Use Only”
CareMore’s Breathe 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 Lung Conditions: Chronic Bronchitis Emphysema Asthma Pulmonary Fibrosis Pulmonary Hypertension
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)
“Internal Use Only”
BREATHE PRODUCT OVERVIEW Eligibility Requirements
CareMore’s Reliance/ Diabetes Plan A Special Needs Plan for those suffering from diabetes
• Members must: Have Medicare Parts A & B Live in the Service Area
• Must be ONE of the following:
Insulin-dependent diabetic Oral Hypoglycemic-dependent diabetic
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)
“Internal Use Only”
RELIANCE/DIABETES PRODUCT OVERVIEW Eligibility Requirements
“Internal Use Only”
HEART, BREATHE & DIABETES 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
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
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
Additional Days $0 Copay $0 Copay $0 Copay
Skilled Nursing Facility (SNF) Day 1 - 31: $0 Copay Day 1 - 31: $0 Copay Day 1 - 31: $0 Copay
Day 32 - 100: $25 Copay
Day 32 - 100: $50 Copay
Day 32 - 100: $50 Copay
Home Health Care $0 Copay $0 Copay $0 Copay
OUTPATIENT SERVICES
Emergency Care $65 Copay $65 Copay $65 Copay
Urgent Care $0 Copay $0 Copay $0 Copay
Emergency - Urgent Care Worldwide Annual Benefit Limit
$10,000 Limit, ER and UC Combined
$10,000 Limit, ER and UC Combined
$10,000 Limit, ER and UC Combined
HEART, BREATHE & DIABETES PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
OUTPATIENT SERVICES, cont.
Primary Care Physician (PCP) $0 Copay $0 Copay $0 Copay
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
Speech Therapy $0 Copay $0 Copay $0 Copay
Chiropractic Services $0 Copay $0 Copay $0 Copay
Routine Chiropractic Not Covered Not Covered Not Covered
Occupational Therapy $0 Copay $0 Copay $0 Copay
Outpatient Mental Health $0 Copay $0 Copay $0 Copay
X-Rays $0 Copay $0 Copay $0 Copay
Outpatient CT / MRI / PET $75 Copay $100 Copay $100 Copay
HEART, BREATHE & DIABETES PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
OUTPATIENT 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
Transportation44 One Way Trips to
PAL 10 One Way Trips to
PAL Unlimited Trips to CCC
10 One Way Trips to PAL
DME and Prosthetics Line item, lease or purchase
0% Coinsurance, $0-$499
0% Coinsurance, $0-$499
0% Coinsurance, $0-$499
20% Coinsurance, $500 +
20% Coinsurance, $500 +
20% Coinsurance, $500 +
Dialysis $0 Copay $0 Copay $0 Copay
Therapeutic Shoes $0 Copay $0 Copay $0 Copay
Diabetes Supplies $0 Copay $0 Copay $0 Copay
HEART, BREATHE & DIABETES PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
ADDITIONAL SERVICES
Over-the-Counter (OTC) Program $25 allowance per month $15 allowance per month $15 allowance per month
Nutritional Consultation $0 Copay; 4 visit(s) / Year
$0 Copay; 4 visit(s) / Year
$0 Copay; 4 visit(s) / Year
Exercise and Strength Training $0 Copay $0 Copay $0 Copay
Vision Exam - Medical $0 Copay $0 Copay $0 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
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Hearing - Exams $0 Copay $0 Copay $0 Copay
Hearing Aids $250 Allowance Every 1 year
$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
$8.00 Premium for : Optional Dental
$8.00 Premium for : Optional Dental
HEART, BREATHE & DIABETES PRODUCT OVERVIEW
Rx Benefits
Medicare Part D Benefit Parameters 2013 “National” Catastrophic Level Is $4,750
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
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
Tier 1 Preferred Generic Drugs $0 Copay/ 30 Day Supply
$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
$5 Copay/ 30 Day Supply
Tier 3 Preferred Brand Drugs $25 Copay/ 30 Day Supply
$29 Copay/ 30 Day Supply
$29 Copay/ 30 Day Supply
Tier 4 Non-Preferred Brand Drugs $85 Copay/ 30 Day Supply
$85 Copay/ 30 Day Supply
$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
$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 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. 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
• Members must: Have Medicare Parts A & B Live in the Service Area
• Must have End Stage Renal Disease:
requiring dialysis
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)
“Internal Use Only”
ESRD PRODUCT OVERVIEW Eligibility Requirements
“Internal Use Only”
ESRD 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 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
Day 6 - 90: $0 Copay Day 5 - 90: $0 Copay
Additional Days $0 Copay $0 Copay
Skilled Nursing Facility (SNF) Day 1 - 31: $0 Copay Day 1 - 31: $0 Copay
Day 32 - 100: $25 Copay Day 32 - 100: $30 Copay
Home Health Care $0 Copay $0 Copay
OUTPATIENT SERVICES
Emergency Care $65 Copay Waived if Admitted
$65 Copay Waived if Admitted
Urgent Care $0 Copay $0 Copay
Emergency - Urgent Care Worldwide Annual Benefit Limit
$10,000 Limit, ER and UC Combined
$10,000 Limit, ER and UC Combined
ESRD PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY SAN BERNARDINO
OUTPATIENT SERVICES, cont.
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
ESRD PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY SAN BERNARDINO
OUTPATIENT SERVICES, cont.
Outpatient Hospital $0 Copay $50 Copay
Ambulatory Surgical Center (ASC) $0 Copay $0 Copay
Outpatient Substance Abuse $15 Copay $30 Copay
MEDICAL SERVICES & SUPPLIES
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
DME and Prosthetics Line item, lease or purchase
0% Coinsurance, $0-$499
0% Coinsurance, $0-$499
20% Coinsurance, $500 +
20% Coinsurance, $500 +
Dialysis $0 Copay $0 Copay
Therapeutic Shoes $0 Copay $0 Copay
Diabetes Supplies $0 Copay $0 Copay
ESRD PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY SAN BERNARDINO
ADDITIONAL SERVICES
Over-the-Counter (OTC) Program $25 allowance per month Not Covered
Nutritional Consultation $0 Copay; 4 visit(s) / Year
$0 Copay; 4 visit(s) / Year
Exercise and Strength Training $0 Copay $0 Copay
Vision Exam - Medical $0 Copay $0 Copay
Vision Exams - Routine $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
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Hearing - Exams $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
Liberty Dental Plan Optional Supplemental Buy Up
$8.00 Premium for : Optional Dental
$8.00 Premium for : Optional Dental
ESRD PRODUCT OVERVIEW
Rx Benefits
Medicare Part D Benefit Parameters 2013 “National” Catastrophic Level Is $4,750
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
Mail Order Available through Walgreens for 2 ½ times the monthly copay for a 90 day supply
Diabetic Insulin falls under Tier 6 benefits. Needles, Test Strips, Glucometer & Insulin = $0 copay. Tier 6 is covered in the gap.
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
“Internal Use Only”
STARTSMART PRODUCT OVERVIEW Eligibility Requirements
“Internal Use Only”
STARTSMART 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
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
Skilled Nursing Facility (SNF) Day 1 - 20: $0 Copay Day 1 - 20: $0 Copay Day 1 - 20: $0 Copay
Day 21 - 100: $50 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
$65 Copay Waived if Admitted
Urgent Care $20 Copay $20 Copay $20 Copay
Emergency - Urgent Care Worldwide Annual Benefit Limit
$10,000 Limit, ER and UC Combined
$10,000 Limit, ER and UC Combined
$10,000 Limit, ER and UC Combined
STARTSMART PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
OUTPATIENT SERVICES, cont.
Primary Care Physician (PCP) $5 Copay $5 Copay $5 Copay
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
Speech Therapy $20 Copay $20 Copay $20 Copay
Chiropractic Services $20 Copay $20 Copay $20 Copay
Routine Chiropractic $20 Copay; 12 visits/Year
$20 Copay; 12 visits/Year
$20 Copay; 12 visits/Year
Occupational Therapy $20 Copay $20 Copay $20 Copay
Outpatient Mental Health $0 - $20 Copay $0 - $20 Copay $0 - $20 Copay
X-Rays $0 Copay $0 Copay $0 Copay
Outpatient CT / MRI / PET $75 Copay $75 Copay $75 Copay
STARTSMART PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
OUTPATIENT SERVICES, cont.
Outpatient Hospital $75 Copay $75 Copay $75 Copay
Ambulatory Surgical Center (ASC) $75 Copay $75 Copay $75 Copay
Outpatient Substance Abuse $35 Copay $35 Copay $35 Copay
MEDICAL SERVICES & SUPPLIES
Outpatient Diagnostic Radiology $0 Copay $0 Copay $0 Copay
Outpatient Therapeutic Radiology 20% Coinsurance 20% Coinsurance 20% Coinsurance
Ambulance $100 Copay $100 Copay $100 Copay
Transportation Not Covered Not Covered Not Covered
DME and Prosthetics Line item, lease or purchase
0% Coinsurance, $0-$499
0% Coinsurance, $0-$499
0% Coinsurance, $0-$499
20% Coinsurance, $500 +
20% Coinsurance, $500 +
20% Coinsurance, $500 +
Dialysis 20% Coinsurance 20% Coinsurance 20% Coinsurance
Therapeutic Shoes 20% Coinsurance 20% Coinsurance 20% Coinsurance
Diabetes Supplies 20% Coinsurance 20% Coinsurance 20% Coinsurance
STARTSMART PRODUCT OVERVIEW
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
ADDITIONAL SERVICES
Over-the-Counter (OTC) Program $15 allowance per month
$15 allowance per month
$15 allowance per month
Nutritional Consultation $0 Copay; 2 visit(s) / Year
$0 Copay; 1 visit(s) / Year
$0 Copay; 1 visit(s) / Year
Exercise and Strength Training $0 Copay $0 Copay $0 Copay
Vision Exams - Medical $5 - $20 Copay $5 - $20 Copay $5 - $20 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
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Glass Lenses Copay - $20
Contacts, Frames, Lenses/Frames Copay -
$0$100 Benefit Limit per 2
years
Hearing - Exams $0 Copay $0 Copay $0 Copay
Hearing Aids Not Covered Not Covered Not Covered
Liberty Dental Plan Basic Dental Coverage Optional Supplemental only
Optional Supplemental only
Liberty Dental Plan Optional Supplemental Buy Up
$8.00 Premium for : Optional Dental
$8.00 Premium for : Optional Dental
$8.00 Premium for : Optional Dental
STARTSMART PRODUCT OVERVIEW
Rx Benefits
Medicare Part D Benefit Parameters 2013 “National” Catastrophic Level Is $4,750
BENEFITLOS ANGELES &
ORANGE COUNTY RIVERSIDE COUNTYSAN BERNARDINO
COUNTY
Rx Gap Coverage None None None
Rx ICL $2,970 $2,970 $2,970
Tier 1 Preferred Generic Drugs $5 Copay/ 30 Day Supply
$5 Copay/ 30 Day Supply
$5 Copay/ 30 Day Supply
Tier 2 Non-Preferred Generic Drugs $10 Copay/ 30 Day Supply
$10 Copay/ 30 Day Supply
$10 Copay/ 30 Day Supply
Tier 3 Preferred Brand Drugs $45 Copay/ 30 Day Supply
$45 Copay/ 30 Day Supply
$45 Copay/ 30 Day Supply
Tier 4 Non-Preferred Brand Drugs $95 Copay/ 30 Day Supply
$95 Copay/ 30 Day Supply
$95 Copay/ 30 Day Supply
Tier 5 Specialty Tier Drugs 33% Coinsurance 33% Coinsurance 33% Coinsurance
Tier 6 Select Care Drugs $10 Copay/ 30 Day Supply
$10 Copay/ 30 Day Supply
$10 Copay/ 30 Day Supply
Part B Rx - Chemo 20% coinsurance 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 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.
“Internal Use Only”
CONNECT PRODUCT OVERVIEW Eligibility Requirements
“Internal Use Only”
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
Emergency - Urgent Care Worldwide Annual Benefit Limit
$10,000 Limit, ER and UC Combined
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
Nutritional Consultation $0 Copay; 2 visit(s) / Year
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
Eye Ware UniView Vision; Eye-Med Network
LOS ANGELES COUNTY ONLY
Glass Lenses Copay - $20Contacts, Frames, Lenses/Frames Copay - $0$100 Benefit Limit per 2 years
OUTPATIENT SERVICES, cont.
MEDICAL SERVICES & SUPPLIES
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
Diabetic Insulin falls under Tier 6 benefits. Needles, Test Strips, Glucometer & Insulin = $0 copay. Tier 6 is covered in the gap.
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
“Internal Use Only”
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
• 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
“Internal Use Only” “Internal Use Only”
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)
“Internal Use Only”
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
“Internal Use Only”
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
“Internal Use Only”
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
“Internal Use Only” “Internal Use Only”
“Internal Use Only”
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”.
“Internal Use Only” “Internal Use Only”
TELEPHONIC ENROLLMENT
“Internal Use Only”
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
“Internal Use Only”
“Internal Use Only”
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
“Internal Use Only”