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Sales Training Presentation

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Title: Sales Training Presentation


1
  • 2007
  • Sales Training Presentation

2
Confidentiality Statement
  • The information contained herein is confidential
    and is the sole and exclusive property of
    American Progressive Life Health Insurance
    Company of New York and Pyramid Life Insurance
    Company and may not be used, reproduced in any
    way, transmitted or otherwise communicated, in
    whole or in part, without the prior written
    consent of American Progressive and Pyramid Life.
    The information contained herein is nonpublic and
    requires the approval of the Centers for Medicare
    Medicaid Services (CMS) of the United States
    Department of Health and Human Services and,
    therefore, may be inaccurate, incomplete and
    unreliable, but is being provided to you for your
    consideration as American Progressives and
    Pyramid Lifes preliminary indication of its
    reasonable expectation of the Medicare Advantage
    products, rates and commissions that will be
    offered in 2007 in certain counties within your
    territory. Your receipt of the information
    contained herein constitutes (i) your consent to
    maintain the information in strict confidence and
    (ii) your acknowledgement that the information is
    nonpublic, requires the approval of CMS and
    therefore may be inaccurate, incomplete and
    unreliable, and is the sole and exclusive
    property of American Progressive and Pyramid Life
    and may not be used, reproduced in any way,
    transmitted or otherwise communicated, in whole
    or in part, without the prior written consent of
    American Progressive and Pyramid Life.

3
Todays Options Sales Agents are Supported by
  • 2 billion total assets
  • 1 billion premium inforce
  • 20,000 agents representing its insurance
    subsidiaries

4
Operating Segments
Senior Market Brokerage
Career Agency
Managed Care
Administrative Services
  • Pennsylvania Life
  • Penncorp Life of Canada
  • Pyramid Life
  • American Pioneer Life
  • American Progressive Constitution Life
  • Union Bankers
  • Marquette National
  • WorldNet Services Corp
  • CHCS Services, Inc.
  • CHCS, Inc.
  • Todays Options
  • Heritage Health Services

5
Comprehensive Portfolio of Senior Market Products
HMO plans Private Fee-for-Service Special Needs Plans Individual and Group
Prescription Drug Plans Individual and Group
Medicare Supplement / Select Senior Acute Care and Dental Individual and Group
3rd Party Administration Medicare Supplement, Long Term Care, Medicare Advantage Part D ElderCare (non-risk)
Medicare Advantage
Medicare Part D
Senior Market Health Insurance
Senior Administrative Services
6
UAFC is Committed to Your Success!
  • Continual development of new products so that
    agents have the most advanced plans in the Senior
    Healthcare Market.
  • Providing agents with an array of Medicare
    products and price points to offer to seniors.
  • Todays Options is a full service Medicare
    Healthcare Product Offering more Coverage,
    Benefits, Choices and Services at a Lower
    Premium.
  • Prescription Pathway is a Medicare Approved PDP,
    offering competitive plan premiums, formulary and
    a pharmacy network of over 50,000 nationwide.

7
Todays Goals
  • Introduce Todays Options
  • Discuss marketing and sales strategies
  • Review Medicare program options
  • Review market conduct and compliance requirements
    in the sales process

8
Todays Options
Value Propositions
9
Savings
  • Medicare Advantage plans
  • result in average beneficiary
  • savings of 100 a month
  • Source www.cms.gov

10
Value Propositions
  • Private Fee-for-Service
  • Offer the best of both worlds!

HMOs
Medicare Supplements
Todays Options (PFFS)
Freedom to Choose Your own provider
Monthly Premium Savings
11
Value Propositions
  • Competitive Product
  • Easy to sell
  • Part B premium refund to beneficiaries in some
    areas!
  • Convention Credit on Todays Options production
  • Maximize your SALES OPPORTUNITIES!

12
Value Propositions
  • Guaranteed Issue
  • Affordable
  • Monthly Premium less costly than many Medicare
    Supplements.
  • Todays Options prohibits providers from balance
    billing (beneficiary usually will not receive a
    bill from the medical providers).
  • Low co-payments
  • Premier Premier Plus 5 for each PCP visit
    and 15 for each specialty care visit.
  • Value Value Plus 15 for each PCP visit and
    30 for each specialty care visit.

13
Freedom to Choose
  • Freedom to choose doctors, specialists and
    hospitals.
  • Choose any doctor, specialist or hospital.
  • No referrals needed to see a specialist.
  • Members can get services anywhere in the U.S.
  • Emergency services anywhere in the world.
  • Predictable out-of-pocket maximum
  • Who is willing to accept Todays Options terms
    and conditions

14
Medicare Private Fee-For-Service (PFFS)
  • For Medicare beneficiaries who
  • Want freedom to make their own decisions about
    doctors and hospitals
  • See a definite need for supplemental coverage
    beyond Traditional Medicare
  • Believe they pay too much for Medigap
  • Are turning 65 and have sticker shock from
    Medigap premiums
  • Struggle with paying Medigap premiums and living
    expenses at the same time

15
Medicare Private Fee-For-Service (PFFS)
Promising Future
  • Industry experts predict that PFFS plans will
    become an increasingly viable alternative to
    Traditional Medicare A B with Medicare
    Supplements.
  • A strong middle-ground between HMOs and
    Supplement plans.
  • Valuable Medicare health plan alternatives for
    rural areas or smaller metropolitan markets,
    where none existed before.

16
Comprehensive Benefits
  • Comprehensive benefits
  • Covers all services under Medicare Part A and B.
  • Offers additional benefits (i.e. routine exams in
    both plans) beyond what Medicare Parts A and B
    provide.
  • Paperless Claims
  • Most claims can be handled between plan and
    providers, so there is almost no paperwork for
    member to complete.

17
PFFS / HMO / Medigap Comparison
  • Description

Medicare Advantage PFFS Medicare Advantage HMO Medigap Insurance
Non-network Cost-sharing model and additional benefits beyond Original Medicare Network product Cost-sharing model and additional benefits beyond Original Medicare Non-network filling in gaps Picks up the deductibles and co-insurance of Original Medicare
18
PFFS / HMO / Medigap Comparison
  • Target Audience

Medicare Advantage PFFS Medicare Advantage HMO Medigap Insurance
Have Medigap or are looking to buy Medigap Have Original Medicare only because HMO was not attractive or available Wants good financial protection Value coverage and simplicity, but willing to sacrifice choice of physicians as a trade-off Urban or suburban markets where providers will contract Wants to see their own doctors Wants 1st dollar coverage for out-of-pocket costs in exchange for higher premiums
19
PFFS / HMO / Medigap Comparison
  • Beneficiary Value Proposition

Medicare Advantage PFFS Medicare Advantage HMO Medigap Insurance
Lower annual premiums than Original Medicare with Medigap High level of financial protection Premiums not tied to age Guaranteed issue Community rated premiums Good cost/value combination Good benefits beyond Original Medicare Guaranteed Issue Community rated premiums Controls choice of providers 1st dollar coverage Predictable monthly costs (premiums)
20
PFFS / HMO / Medigap Comparison
  • Providers

Medicare Advantage PFFS Medicare Advantage HMO Medigap Insurance
Any Medicare provider who is willing to accept payment from Plan at Medicare rates Contracted network selected by health plan Credentialed providers who accept payment rates and agree to plan rules Any Medicare Provider
21
Voluntary Care Management
  • Innovative Voluntary Care Management program
    proactively assists members with their healthcare
    concerns and needs.
  • Registered nurses work in collaboration with
    social workers and other healthcare
    professionals.
  • Member access to 24/7 My Nurse Line
    866-549-5048.
  • Todays Options Voluntary Care Management follows
    inpatient admissions and provides health
    education and support to our members
  • Members who choose to participate will be
    provided with best practice care plans, which
    are shared with their physician.
  • Members receive welcome home calls after an
    inpatient stay.
  • Some members will receive calls when certain
    outpatient procedures are planned in order to
    provide support and education.
  • Voluntary Care Management provides the member
    with coordination of their health care needs.

22
Todays Options
  • Medicare
  • Overview

23
What is Medicare?
  • Federal health insurance for
  • People 65 years of age and older
  • Qualified disabled people under 65 (about 9 of
    total beneficiaries)
  • People with End Stage Renal Disease (ESRD)

24
Part A Hospital Benefits
  • Pays for medical care furnished by
    Medicare-certified hospitals, skilled nursing
    facilities, home health agencies and hospices.
  • Can enroll with no premium for Part A
  • Must have worked and paid Medicare taxes for 40
    or more quarters (10 years).
  • In 2006, a patient pays an initial deductible of
    952 at the beginning of each benefit period.

25
Part B Physicians Benefits
  • Generally pays 80 of the Medicare allowed amount
    less a 124 (in 2006) annual deductible for
  • Doctors services
  • Outpatient hospital services (including ambulance
    transportation and emergency room visits)
  • Diagnostic tests, laboratory services
  • Some preventive care like mammography and pap
    smears
  • Outpatient therapy services (PT, OT, ST)
  • Durable medical equipment and supplies
  • Some home health care services for which Part A
    does not pay

26
Part C Medicare Advantage Plans
  • Medicare Advantage Plan members are still
    enrolled in Medicare.
  • The only difference is that providers payments
    come from a Private insurance company rather than
    Medicare and a Supplement carrier.
  • Includes HMOs, PPOs, PSOs, Medicare MSAs, PFFS.

27
Part C PFFS Plans
  • Freedom of choice / Availability
  • Members may go to any eligible doctor or hospital
    anywhere in the U.S. that is willing to provide
    care and accept Medicare PFFS terms and
    conditions.
  • PFFS includes the benefits of Parts A and B, plus
    additional benefits.
  • Replaces the need for Medicare Supplements
  • Members are still enrolled in Medicare
  • Eliminates most member out-of-pocket costs under
    Medicare A and B.

28
Part D Prescription Drug Plans
  • The Medicare Modernization Act (MMA) established
    PDPs
  • 38 million Medicare beneficiaries have Rx Drug
    coverage
  • 4.4 million Medicare eligibles NOT yet enrolled
    in part D.
  • From November 15, 2006 to December 31, 2006,
    Medicare Beneficiaries can enroll in Prescription
    Drug Plans.

29
Todays Options
2007 PRODUCT OVERVIEW
30
What is Todays Options?
  • Medicare Part C - Medicare Private
    Fee-For-Service Plan offered by UAFC
    subsidiaries
  • American Progressive Life and Health Insurance
    Company of NY
  • The Pyramid Life Insurance Company
  • Todays Options contracts with The Centers for
    Medicare and Medicaid Services (CMS).

31
Todays Options Overview
  • Offered in 35 states throughout the U.S.
  • Four Todays Options plans
  • Value
  • Value Plus includes drug coverage
  • Premier
  • Premier Plus includes drug coverage

32
PYRAMID STATES FOR 2007
26 States 2319 Counties 29,007,065 Medicare
Eligibles
Rates for the 2007 Benefit Plan Rates for the 2007 Benefit Plan Rates for the 2007 Benefit Plan Rates for the 2007 Benefit Plan
Value Plan Value Plan Premier Plan Premier Plan
Value Plus Premier Plus
(21.50) 10.00 0.00 45.00
12.00 44.00 35.00 80.00
48.00 80.00 72.00 117.00
Includes Prescription Drug Benefit Includes Prescription Drug Benefit Includes Prescription Drug Benefit Includes Prescription Drug Benefit
Part B premium credit to enrollee Part B premium credit to enrollee Part B premium credit to enrollee Part B premium credit to enrollee
33
Eligibility Who can join Todays Options?
  • Individuals can join Todays Options if they
  • Have both Medicare Part A and Part B.
  • Live in a state where the plan is available.
    (Obtain services anywhere in U.S.)
  • Do not have End-Stage Renal Disease (ESRD).
  • There is NO medical underwriting
  • People with Medicare who meet eligibility
    requirements may not be denied membership on the
    basis of health status.
  • Only one community rate premium per county. No
    age rating!
  • 2 Premium Tiers American Progressive
  • 3 Premium Tiers Pyramid Life

34
Premiums and Other Fees
  • Members pay
  • Monthly Medicare Part B premiums (88.50 in 2006)
  • Part B premium will vary by income in 2007
  • Monthly premium directly to Today's Options, if a
    premium is charged
  • Low co-insurance or co-payment amounts

35
VA Medical Benefits
  • A Today's Options member who is also enrolled in
    the VA Medical Benefits Plan may use either plan.
  • The individual would elect to receive his or her
    health care either through the VA system or
    through Today's Options.
  • If member is enrolled in both Todays Options and
    VA system
  • VA will not pay Todays Options services
  • Todays Options will not pay for any VA co-pays

36
Plan Options
  • Todays Options is available in Two Flavors

Value
Premier
Plus
Plus
- or -
As an added benefit, your client can select the
Plus with either plan Giving them Combined
Medicare Part-D Coverage For a total of 4 plan
options
Value Value Plus Premier Premier Plus
37
Todays Options Highlights Whats New for 2007
SAMPLE BENEFITS VALUE PREMIER
Out-of-Pocket Limit 3000 3000
Inpatient hospital Care 175 each day for days 1-4 0 each day for days 5-90 no additional co-pays covered for unlimited days each benefit period 150 for each Medicare covered stay 600 maximum out-of-pocket per year
PCP Co-Pay 15 per visit 5 per visit
Specialist Co-Pay 30 per visit 15 per visit
Outpatient Surgery Ambulatory/Hospital 100 for each visit to an ambulatory surgical center 200 for each visit to an outpatient hospital facility 25 to 50 for each visit to an ambulatory surgical center 50 to 100 for each visit to an outpatient hospital facility
Skilled Nursing Facility (SNF) 0 each day for days 1-20 100 each day for days 21-100 covered for 100 days per benefit period 0 each day for days 1-20 100 each day for days 21-100 covered for 100 days per benefit period
Emergency Care 50 for each ER visit Worldwide coverage 35 for each ER visit Worldwide coverage
Urgently Needed Care 50 for each Urgently Needed Care visit Worldwide coverage 35 for each Urgently Needed Care visit Worldwide coverage
Chiropractic and Podiatry Services 35 for each Medicare covered visit 20 for each Medicare covered visit
38
Plan Options
  • Lets compare benefits for the two basic plans

VALUE
PREMIER

39
Todays Options 2007 Benefit Matrix
  VALUE PREMIER
INPATIENT CARE    
Inpatient hospital 175 each day for days 1-4 0 each day for days 5-90 no additional co-pays covered for unlimited days each benefit period. 150 per admission, 300 per admission if you do not notify the plan there is a 600 max out of pocket limit every year.
Inpatient mental health 175 each day for day(s) 1 - 5 - 0 each day for day(s) 6-90 for a Medicare-covered stay If no notification, you pay 150 each day up to a maximum of 150 per admission 1,700 maximum out of pocket limit every year. 75 each day for day(s) 1 - 5 - 0 each day for day(s) 6-90 for a Medicare-covered stay, if no notification, you pay50 each day, up to maximum of 250 per admission 1,250 max out of pocket limit every year.
SNF 0 each day for day(s) 1 - 20, 100 each day for days 21 - 100 for a stay in a Skilled Nursing Facility. No prior hospital stay is required. 0 each day for day(s) 1 - 20, 100 each day for days 21 - 100 for a stay in a Skilled Nursing Facility. No prior hospital stay is required.
Home Health 15 coinsurance 15 coinsurance
Hospice Covered by Medicare Covered by Medicare
40
Todays Options 2007 Benefit Matrix
OUTPATIENT CARE  VALUE PREMIER
PCP Office Visits 15 copay 5 copay
Specialist Office Visits 30 copay 15 copay
Chiropractic 35 copay 20 copay
Podiatry 35 copay 20 copay
Outpatient Mental Health 50 coinsurance 50 coinsurance
Outpatient Substance Abuse 50 coinsurance 50 coinsurance
Outpatient Surgery You pay 100 for each Medicare-covered visit to an ambulatory surgical center if no notification, you pay 200. You pay 200 for each Medicare-covered visit to an outpatient hospital facility if no notification, you pay 400. You pay 25 for each Medicare-covered visit to an ambulatory surgical center if no notification, you pay 50. You pay 50 for each Medicare-covered visit to an outpatient hospital facility if no notification, you pay 100.
Ambulance 100 copay 50 copay
Emergency Care 50 co-pay waived if admited within 72 hours, worldwide coverage 35 co-pay waived if admited within 72 hours, worldwide coverage
41
Todays Options 2007 Benefit Matrix
Outpatient Care Cont BASIC PREMIER
Urgent Care 50 copay 35 copay
Outpatient Rehab 30 copay 15 copay
DME Diabetic Supplies You pay 20 of the cost for each Medicare-covered item. If you do not notify the plan of an equipment or device purchase over 750, you will have to pay 50 of the allowed charges. You pay 20 of the cost for each Medicare-covered item. If you do not notify the plan of an equipment or device purchase over 750, you will have to pay 50 of the allowed charges.
Prosthetic Devices You pay 20 of the cost for each Medicare-covered item. If you do not notify the plan of an equipment or device purchase over 750, you will have to pay 50 of the allowed charges. You pay 20 of the cost for each Medicare-covered item. If you do not notify the plan of an equipment or device purchase over 750, you will have to pay 50 of the allowed charges.
Diagnostic, Lab and X-rays You pay - 0 for each Medicare-covered clinical/diagnostic lab service. - 10 for each Medicare-covered radiation therapy service to maximum of 150 per visit. - 10 for each Medicare-covered X-ray up to 150 per visit. You pay - 0 for each Medicare-covered clinical/diagnostic lab service. - 10 for each Medicare-covered radiation therapy service to maximum of 150 per visit. - 10 for each Medicare-covered X-ray up to 150 per visit.
42
Todays Options 2007 Benefit Matrix
Additional Benefits VALUE  PREMIER 
Outpatient Rx Not covered by plan (See Value PLUS) Not covered by plan (See Premier PLUS)
Part B Drugs The member pays 20 of the eligible expenses. Drugs include, but not limited to chemotherapy medications. The member pays 20 of the eligible expenses. Drugs include, but not limited to chemotherapy medications.
Dental no benefit no benefit
Hearing 30 for Medicare covered benefits 30 for 1 routine exam per year 15 for Medicare covered benefits 15 for 1 routine exam per year
Vision 30 for Medicare covered benefits 30 for 1 routine exam per year 15 for Medicare covered benefits 15 for 1 routine exam per year
Routine Physical Exams 1 per year 0 copay 1 per year 0 copay
43
PLUS Adds Part D Benefits
All the Benefits from the Premier or Value Plan,
Plus
  Value or Premier BASIC Value Plus Premier Plus
Part D Co-pay No Part D coverage Co-pays 7 Tier 1 31 Tier 2 63 Tier 3 30 Tier 4 Co-pays 7 Tier 1 31 Tier 2 63 Tier 3 30 Tier 4
Part D Initial Coverage Limit N/A  2400 2400
Donut Hole Coverage N/A  No Yes (generics only)
Part D Deductible N/A  None None
Mail Order N/A Yes 90-day for 2x co-pay Yes 90-day for 2x co-pay
Does not apply to out-of-pocket maximum
44
Todays Options Preventative Services
  • Zero Co-pay for
  • Bone Mass Measurement
  • Colorectal Screening Exams
  • Pneumonia and Flu Vaccines
  • Screening Mammograms
  • Pap Smears and Pelvic Exams
  • Prostate Screening

45
Todays Options
  • Sales and Enrollment

46
Election Periods and 2007 Effective Dates
Coverage Period When Effective Date Who
Initial Coverage Period (ICP) 3 months before, month of 65th birthday, and 3 months after entitled to Part A and B 1st day of month entitlement to Part A and Part B T-65s
Annual Coordinated Election Period (AEP) 2006 AEP is November 15th 2006 through December 31st 2006 January 1st, 2007 All Medicare Eligibles
Open Election Period (OEP) ENDS MARCH 31, 2007 for Medicare Advantage 1st day of month after plans receipt of completed enrollment form. Individuals are allowed one additional change
Special Election Period (SEP) Beneficiary moves, plan termination, etc. Determined by CMS Depends on the situation
Lock-in Period After March 31, 2007 Lock-in Period After March 31, 2007 Lock-in Period After March 31, 2007 Lock-in Period After March 31, 2007
47
Annual Enrollment Periods (AEP)
During AEP Beneficiaries Can Switch from the following During AEP Beneficiaries Can Switch from the following Changing To Changing To Changing To Changing To Changing To Changing To
During AEP Beneficiaries Can Switch from the following During AEP Beneficiaries Can Switch from the following MA-PD Combo PFFS-PD Combo Original Medicare Stand Alone PDP MA Only PFFS Only Original Medicare
Currently Have MA-PD Combo Y Y Y Y Y Y
Currently Have PFFS-PD Combo Y Y Y Y Y Y
Currently Have Original Medicare Stand Alone PDP Y Y Y Y Y Y
Currently Have MA Only Y Y Y Y Y Y
Currently Have PFFS Only Y Y Y Y Y Y
Currently Have Original Medicare Y Y Y Y Y Y
Medicare Advantage Lock In After March 31, 2007
members are locked into their selected plan
48
Open Enrollment Periods (OEP)
During OEP Beneficiaries Can Switch from the following During OEP Beneficiaries Can Switch from the following Changing To Changing To Changing To Changing To Changing To Changing To
During OEP Beneficiaries Can Switch from the following During OEP Beneficiaries Can Switch from the following MA-PD Combo PFFS-PD Combo Original Medicare Stand Alone PDP MA Only PFFS Only Original Medicare
Currently Have MA-PD Combo Y Y Y N N N
Currently Have PFFS-PD Combo Y Y Y N N N
Currently Have Original Medicare Stand Alone PDP Y Y N N N N
Currently Have MA Only N N N Y Y Y
Currently Have PFFS Only N N N Y Y Y
Currently Have Original Medicare N N N Y Y Y
Medicare Advantage Lock In After March 31, 2007
members are locked into their selected plan
49
Todays Options
Step 1 Enrollment
50
Todays Options
51
Todays Options
52
Todays Options
53
Todays Options
54
Todays Options
55
Todays Options
56
Todays Options
57
Todays Options
Step 2 Acknowledgement Form and Verification Call
  • Complete New Member Acknowledgement Form
  • Member Verification Call from Home
    1-877-275-1088 press 1
  • Saturday 9 a.m. 6 p.m.
  • Mon.-Fri. 8 a.m. Midnight
  • Sunday Noon 6 p.m.
  • All times Eastern
  • Verification Call Center representative confirms
    members understand the items reviewed in the
    acknowledgement form
  • (write in call confirmation in top corner of
    acknowledgement form)

58
Todays Options
Step 3 Post-Enrollment Request For Provider
Information form
59
Enrollment Process Effective Date
  • Agent will write in proposed effective date on
    enrollment form, section 9, and advise enrollee.
  • If the completed enrollment form is received at
    Todays Options office before the end of the
    month, the effective date is the first of the
    next month.

60
Documentation
  • Documentation Requested for Enrollment
  • Request primary residence
  • Drivers license, voters registration
  • Ask where SSA check is sent
  • Verify Medicare card information
  • (template on enrollment form)
  • Verify name
  • Sex
  • Health insurance number
  • Parts A and B
  • Current payment options
  • Bank Draft
  • Deduction date is approximately the 7th of each
    month.
  • Social Security Deduction
  • Monthly Direct Bill
  • Credit Card

61
Submitting Enrollment Forms
  • All enrollment forms should be submitted directly
    to the company or to your Manager/Agency Office
    within 24 hours of receipt
  • Fax App
  • Mail

62
Enrollment Process Agency Office Responsibilities
  • Log applications
  • Check accuracy of agent number
  • Overnight shipping

63
New Member Welcome Process
  • Welcome Call (five days after Todays Options
    member is made active).
  • Acknowledgement Letter - includes Todays Options
    Membership ID card (within seven days).
  • Enrollment does not confirm that client is a
    member of Todays Options, only CMS can confirm
    enrollment.
  • Welcome Package - includes CMS confirmation
    letter, EOC (policy) and sales survey (within
    four-six weeks).
  • Health Risk Assessment (HRA) Call (Within 30
    days).

64
Todays Options
  • PROVIDERS

65
Provider Relations
  • Accessing Benefits
  • To use providers anywhere in the United States,
    Todays Options members must
  • Simply present Todays Options ID card
  • Upon acceptance, provider will bill Todays
    Options and the member pays all applicable
    co-pays and co-insurance.
  • If provider does not accept, the provider can
    bill member. The member should mail the bill to
    Todays Options for payment
  • The bill will be paid in full, less the
    applicable member co-pays and co-insurance.

66
Outreach Strategy for Educating Provider Community
  • Provider Relations Outreach Strategy for 2007
  • Send a letter to Providers and Hospitals in our
    new states
  • Provides information about Todays Options
    (subject to CMS approval)
  • Visit/contact key providers regularly regardless
    if they accept Terms and Conditions
  • Todays Options pays 100 of Medicare Allowable
    Rates (less applicable co-pays/co-insurance)
  • Even Medicare doesnt pay 100!
  • Providers do not have to track down balance due
    from Med Supp / HMO Plan.
  • No contracts-because we contract with Medicare.
  • Provider does not have a contract with us.

67
Providers Key
  • Providers are considered Deemed when, prior to
    providing services, they
  • Have knowledge that a Medicare beneficiary is
    enrolled in Todays Options
  • Have a reasonable opportunity to obtain
    Todays Options Terms and Conditions and
  • Subsequently provide services to the Todays
    Options member

68
Provider Relations
  • A provider who does not accept the Terms and
    Conditions can
  • Decline to treat the member.
  • Treat the member and accept payment from plan (as
    payment in full).
  • Only treat members in an emergency situation.
  • Contact Todays Options Marketing Staff for a
    list of providers we know do not accept Todays
    Options.

69
Provider Relations Contacts
PROVIDER RELATIONS DIRECTOR Lynn Gasorowski
Name Coverage Area Fax Number 800/Ext.
Tracey Arnold North Carolina, South Carolina 704-766-1265 800-360-5735 Ext. 8201
Robert Jeppsen Utah 801-955-5318 800-360-5735 Ext. 8202
Mary Enos Virginia, North Carolina 434-689-2169 800-360-5735 8203
Thomas Melville Oregon 503-841-5457 800-360-5735 Ext. 8204
Andrew Clark NewYork, Pennsylvania, Vermont 845-339-0220 800-332-3377 Ext 161
Susan Charczenko Maine, New Hampshire 207-892-2256 800-337-3377 Ext. 181
Kellie Hamilton Indiana 317-455-1425 800-360-5735 Ext. 8206
Anthony Girgenti Arizona 602-993-5891 800-360-5735 Ext. 8205
Jeff Schulz Wisconsin, Iowa, Minnesota 515-265-4963 800-360-5735 Ext. 8426
Kathleen Ibarguen Provider Relations Call Center Lead   800-360-5735
70
Todays Options
  • Appeals,
  • Grievances
  • and Claims

71
Appeals
  • Benefit Determination
  • Denial of payment for services member or provider
    believes should have been covered.
  • Termination of coverage by the Plan.
  • Filing The Appeal
  • Todays Options
  • Medicare
  • Social Security Administration
  • Railroad Retirement Board

72
Grievances
  • Grievance Procedure applies in instances such as
  • Provider/Plan performance, such as wait times,
    adequacy of facilities, staff behavior, etc.
  • Quality of care or access to services
  • Involuntary disenrollment
  • Sales process complaints
  • Administrative complaints
  • Not subject to Medicare appeals process
  • Complaints do not involve claims determination

73
Grievances
  • How to Avoid Grievances
  • Know and understand the product.
  • Properly explain all benefits and processes.
  • Make sure member understands that Todays Options
    is not a Medicare Supplement (Statement of
    Understanding).
  • Be responsive to members inquiries.
  • Be professional!

74
Claims
  • Claims Process
  • Providers submit claims directly to Today's
    Options using the same rule as Medicare A and B
  • To the appropriate Todays Options P.O. box
  • Electronic coming soon
  • Todays Options processes claims following
    Medicare Part A and B guidelines.
  • Todays Options pays the equivalent of Medicare
    allowable rates less applicable plan co-payments.

75
Voluntary Disenrollment During Election Periods
  • Can disenroll through Todays Options (Preferred
    way), SSA or 1-800-MEDICARE.
  • If the enrollee wants to cancel after an
    enrollment form is processed and submitted to
    CMS, the member must notify the plan in writing
    of the request to disenroll (signed and dated).
    Send notification to
  • Pyramid P.O. Box 3237, Scranton, PA 18505.
  • American Progressive P.O. Box 4109 Scranton, PA
    18505
  • The Member will return to Medicare Parts A B,
    unless the member chooses a new MA plan
  • If the member enrolls in a new MA plan while
    still in a MA plan, the member will be
    automatically disenrolled from old plan and
    enrolled in new plan without duplication or delay
    in coverage
  • Non payment of premium
  • Disenrolled after proper notice (two notices)
    90-day grace period
  • Becomes effective the first of the month after
    the MA organization receives completed form

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Involuntary Disenrollment
  • Must disenroll if Todays Options member
  • Moves outside service area for more than six
    months
  • Loses entitlement to either Part A or Part B
  • Dies (Age-out)
  • Plan contract is terminated or discontinues
    operation
  • Plan can disenroll member if
  • Member is disruptive (very rare)
  • Member provides fraudulent information or
    facilitates fraudulent use of membership card

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Medicare Supplement availability after dropping
Medicare Advantage
  • Subject to Lock-in
  • If the member disenrolls from Todays Options,
    often the member is entitled to purchase specific
    Medicare Supplement policies without regard to
    health status.
  • Involuntary disenrollment (Member moves, plan
    leaves service area), member is entitled to
    purchase any Medicare Supplement Plan A, B, C, or
    F sold in state.
  • First time enrolled in Medicare Part C If it is
    the first time a member is enrolled in a MA plan
    and the member voluntarily disenrolls within 12
    months, they can purchase the same Med Supp
    policy they had before, if it is still available
    from the same Med Supp insurer. If not available,
    member may buy any Med Supp Plan A, B, C, or F
    sold in state.
  • Newly Medicare eligible Eligible for Medicare
    at age 65, and disenrolls within 12 monthsthey
    are entitled to purchase any Medicare Supplement
    policy sold in the state.
  • Member must apply for Medicare Supplement policy
    no later than 63 days after coverage terminates
    under Todays Options.

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Todays Options
  • Compliance

79
Compliance
  • Confidentiality and
  • Protecting Information (HIPAA)
  • Information regarding Today's Options business
    activities is considered confidential and
    proprietary to the Company.
  • Employees and agents are entrusted with
    confidential and privileged information that may
    not be released without proper authorization.
  • Employees and agents must comply with HIPAA
    requirements regarding the disclosure of
    Protected Health Information (PHI).
  • Employees and agents are responsible for properly
    using information stored and produced by all
    Today's Options information systems.

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Compliance
  • Sales Audit Program
  • New Member Acknowledgement form
  • In-home Verification Call
  • Welcome Call feedback
  • Disenrollment Trends
  • Sales Satisfaction Survey results
  • Grievance totals and trends
  • In-person monitoring of sales calls (ride-alongs)
  • Regulatory complaints

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Medicare Advantage / PDP Deadly Sins
  1. Door to door marketing / solicitation.
  2. Representing yourself as an agent of CMS, Social
    Security or Medicaid.
  3. Advising consumers that they must purchase plans
    as directed by Medicare
  4. Creating and using sales or marketing collateral
    that are have not had prior CMS approval.
  5. Offering gifts or other inducements to enroll
    that are greater than nominal (15) value
  6. Health Screening members
  7. Retrospective Enrollment -- back dating
    enrollment forms
  8. Prospective enrollment effective date is always
    the first day of the month following completion
    of the enrollment form
  9. Presentations or sales in Dr's office (or
    anywhere health care services are dispensed)
  10. Selling a Medicare supplement to a Medicare
    Advantage Member

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Must Use / May Not Use / May Use Todays Options
Eligibility
Must May Not May
Indicate that members must be enrolled in Medicare Parts A and B. Say Seniors unless term appears or is stated with and all other Medicare eligible Beneficiaries. State that Anyone with Medicare living in the Service Area may apply.
Indicate that all Medicare Beneficiaries with Parts A and B may apply. Say Medicare Advantage Plan designed especially for seniors. Say Medicare entitled by age or disability.
Mention the ESRD exclusion when mentioning No health screening. Say Individuals age 65 and over. Say Medicare Beneficiaries or Medicare enrollees.
The monthly premium payment must be accompanied by a statement that Todays Options members must continue to pay Medicare Part B premium, as well. (88.50 in 2006) State that Todays Options is a Medicare Advantage Private Fee For Service Plan with a Medicare Contract. Say No other premium or deductibles. Superlatives, such as Highest Rated, Best Plan, etc. Make unsubstantiated comparisons with other Medicare Advantage Plans. Say no paperwork. Say recommended or endorsed by Medicare. Imply that Todays Options has a unique or custom arrangement with the Federal Government or Medicare. State that Todays Options is a special Health Plan. State The Todays Options premium payment per month is in addition to the monthly Medicare Part B premium. Say Virtually no paperwork, Hardly any paperwork. Say No physicals required.
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Fraud, Waste and Abuse
  • All employees and agents are responsible to
    report any suspected health care fraud to the
    Today's Options Special Investigations Unit,
    Compliance Officer, General Counsel or CMS
    immediately upon notification.
  • The Company will protect your identity as much as
    reasonably possible. Report Fraud at
  • UAFC fraud hotline (800) 853-0186
  • Medicare 1-800-MEDICARE

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Corrective Action and/or Discipline
  • Agents who violate any of the Companys
    Compliance requirements, violate related
    corporate policies or procedures, violate CMS or
    State Insurance regulations or anyone who
    knowingly fails to report violations, or any
    agent or manager, who fails to oversee compliance
    by those he or she supervises, is subject to
    disciplinary actions including termination of
    contracts and/or termination of right to sell
    Todays Options.

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Todays Options Agent Certification Process
Online Certification Option
  • Product/Compliance Overview
  • Testing 80 Passing Grade
  • Annual Recertification Process
  • Online exam
  • www.PyramidLife.webce.com

86
Your Next Steps
  • Become licensed.
  • Complete training and certification.
  • October 1, 2006 begin pre-selling.
  • November 15, 2006 accept enrollment forms.

87
Glossary of Terms
  • PDP Prescription Drug Plan
  • CMS The Centers for Medicare and Medicaid
    Services
  • Enrollee/Member Policyholder
  • Enrollment Form Application
  • Evidence of Coverage Policy
  • MA Medicare Advantage
  • MA-PD Medicare Advantage-Prescription Drug plan
  • Service Area Area where a Medicare Plan is
    available.
  • PFFS Medicare Private Fee-For-Service Plan
  • DME Durable Medical Equipment
  • Appeal Applies when a payment or service is
    denied.
  • Grievance Applies when a member is unhappy with
    plan services or performance.

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Todays Options Contact Numbers
PYRAMID LIFE Pre-sales Inquiries 800-360-5735 press 2 TTY 800-461-5376 Member Services 1-866-568-8921 TTY 1-888-844-5530 Sales Agent Support Line 800-777-1126 ext. 9 Enrollment verification number 1-877-275-1088 Press 1 Web address www.pyramidlife.com
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