2018 B ROKER R ECERTIFICATION T RAINING S OUTH F LORIDA Simply - - PowerPoint PPT Presentation
2018 B ROKER R ECERTIFICATION T RAINING S OUTH F LORIDA Simply Healthcare Plans, Inc. is a Medicare-contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits
Simply Healthcare Plans, Inc. is a Medicare-contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends
2
This presentation contains proprietary information. It is intended for recertification purposes only, use by
use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use
for solicitation purposes.
Thank you for joining us today! We appreciate your support and partnership during 2017. Together, we were able to help thousands of Medicare beneficiaries in the communities we serve. Our promise to you for 2018: a) Robust value propositions b) Competitive compensation c) Ongoing training year round d) Local agent support
3 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
4 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
5 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
throughout Florida.
community, physicians and hospitals.
locally by friendly, knowledgeable Simply representatives who treat you with the respect you deserve and provide you with the level of service you expect.
6 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Simply Healthcare Plans, Inc. - H5471 - 2017 Medicare Star Ratings* The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and
compare our plan's performance to other plans. For 2017, Simply Healthcare Plans, Inc. received the following Overall Star Rating from Medicare. Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us Monday through Friday, 8:00 a.m. - 8:00 p.m. Eastern at 1-888-577-0212 (toll-free) or 711 (TTY). Current members please call 1-877-577-0115 (toll-free) or 711 (TTY).
4.5 out of 5 Stars
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from
7 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
8 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Medicare
Simply
Medicaid
Amerigroup Simply Better Health
Long Term Care Florida Healthy Kids Clear Health Alliance
9 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Miami-Dade
Santa Rosa Walton Holmes Bay Jackson Gulf Liberty Gadsden Leon Wakulla Franklin Taylor Madison Dixie Baker Union Levy Alachua Bradford Clay Duval Nassau Putnam St. John’s Marion Flagler Volusia Citrus Lake Seminole Hernando Pasco Orange Polk Indian River Manatee Hardee DeSoto Highlands St. Lucie Martin Palm Beach Charlotte Glades Lee Hendry Collier Broward
Broward Polk
Santa Rosa Walton Holmes Bay Jackson Gulf Liberty Gadsden Leon Wakulla Franklin Taylor Madison Dixie Baker Union Levy Alachua Bradford Clay Duval Nassau Putnam St. John’s Marion Flagler Volusia Citrus Lake Seminole Hernando Pasco Orange Polk Indian River Manatee Hardee DeSoto Highlands St. Lucie Martin Palm Beach Charlotte Glades Lee Hendry Collier Broward
Hillsborough Pinellas Pasco Hernando Palm Beach Osceola Orange Seminole
10
2017 Current Service Area 2018 Service Area Expansion
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
11 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
12 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Agent Allegations can be received from two sources; Internal Complaints, which are received directly by the organization (SHP) or CTM’s which are complaints received by CMS and then forwarded to the organization.
response may be required in as little at 24 hours. The agent responses need to be thorough and address all pertinent issues.
Prospect Manager.
investigation is completed in its entirety and the case has been closed. If the contact is incoming (from beneficiary to the agent) the agent should attend and inform management immediately At some point almost every agent will have an allegation filed against them. That does not mean that the allegation of misconduct is true
your help to do that.
Violation Process – Review
13 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Unfounded – No wrongdoing verified, agent followed Marketing Guidelines. Inconclusive – Not enough evidence obtained to come to a determination. Depending on the situation, compliance and the sales department may determine that re-training or a corrective action should be
procedures are re-enforced. Founded (lesser) – Agent is found to be responsible for a negligent violation. Usually the consequences
founded CTM will usually result in some form(s) of corrective action to the agent or more stringent consequences like suspension or even termination. Founded (major) – Is a serious offense in where the agent is found to be responsible for willful violation
the plan and the incident will be reported to the appropriate channels. * Deficiencies may be observed in all four of the possible outcomes. Although a case may be determined Unfounded there may be room for improvement in certain aspects of the agents performance.
Allegations of Misconduct - Possible Outcomes
14 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Marketing
Benefits/ Access
Provider Network
Enrollment
15 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
16
Use approved marketing materials – Double check the sales kit. It is the right thing to do, avoid CTMs!
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
17
Use approved marketing materials – Double check the sales kit. It is the right thing to do, avoid CTMs!
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Short Term Disenrollments and Cancellations
Reviewing Cancellation and Disenrollment Activity Cancellation and Disenrollment activity by agent will be conducted on a monthly basis by reviewing the Agent Cancellation and Disenrollment Activity Report. Agents that are found to be above the market averages on either category will be documented and should discuss possible causes with respective managers. High levels of early, voluntary cancellation and rapid disenrollment, relative to other agents can be indicative of a performance problem with an agent and will require corrective action. Documenting Corrective Actions or Training The Cancellation and Disenrollment Activity Form will be completed and used to document discussions with agents who demonstrate higher than average levels on the
will be signed by the manager and agent.
18 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
The field evaluation consists of comprehensive questions that measure the accuracy of the information disclosed by the Sales Agent, the effectiveness of individual technique and overall efficiency of the presentation. Simply Healthcare Broker Agents could receive a request to complete a scheduled evaluation of their sales presentation. These evaluations are conducted while presenting the plan options to a prospective enrollee or a mock presentation. These evaluations can be performed for reasons that include, but are not limited to:
including but not limited to; unfounded/inconclusive investigations for agents.
19 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
You have read and signed Simply’s 2018 Sales and Marketing Code of Ethics. The following provides additional information to help you understand our interpretation of new CMS and regulatory agency guidance.
In the event an allegation of misconduct is placed against an agent, the agent will provide a detailed, written response to the complaint within 5 business days of notification of the complaint. Additionally, the agent will not contact beneficiaries that have made a complaint without prior approval from Simply’s Compliance Department. Takeaway: Agents MUST reply to any allegation/request for a statement – Agent Allegations, Agent Misconduct, Department of Insurance requests, Critical Inquiry….failure to do so may result in disciplinary action, up to and including termination.
Absolute statements (e.g., “the best”, “highest ranked”, “rated number one”) are prohibited unless they are substantiated with supporting data and approved by Simply and/or CMS. Agents shall not use any form of pressure, scare tactics in their presentation. Takeaway: Do not make unsubstantiated statements! Never pressure a prospect.
20 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
“Agents agree to use the CMS approved Simply Healthcare Sales Presentation in its entirety when presenting a Simply Healthcare MAPD plan to ensure full disclosure plan benefits, limitations, and cost sharing to all prospective enrollees and will present all required CMS disclaimers during the presentation. Willful violation may subject the agent to disciplinary action up to and including termination.” Takeaway: CMS and Simply require an agent to present the sales presentation in its entirety for HMO plans! CMS and Simply also require full disclosure of information. This is one of the major reasons behind Agent Allegations and disciplinary action.
Agents will use only Simply and CMS or approved materials, as applicable, to market to prospective enrollees. In addition, all communications to current members, e.g. letters, flyers, mailers, etc., must also be approved by Simply and CMS prior to their use. Agents will not modify or alter approved materials for their use in member communications or the marketing and sales of MAPD plans. Takeaway: ALWAYS use approved materials.
21 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Section 70.4.1 – Educational and Marketing Events What changed?
qualified beneficiaries, during the Annual Enrollment Period (AEP). Previous guidance had required the cessation of current year marketing activities beyond October 1 of the plan year.
Impact
Plans/Part D Sponsors are not required to upload educational, formal and/or informal marketing/sales events in HPMS. Plans/Part D Sponsors must keep accurate records
reserves the right to request event information at any time.
What changed? Impact
and Marketing Events.
100’s of events (and related modifications and/or cancellations) is no longer required.
22 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Section 60.4 Formulary and Formulary Change Notice Requirements What changed?
in hard copy, which may be abridged (see section 60.4.1 guidance on the abridged formulary), or a distinct and separate notice (in hard copy) describing where enrollees can find the formulary online and how enrollees can request a hard copy formulary. This notice must be a stand-alone document (i.e., not bound with other materials) and may be included in the same mailing envelope as the Annual Notice of Change/Evidence of Coverage (ANOC/EOC).
Impact
formulary in the Pre-Enrollment Kit for 2018.
23 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Reminder from last year - Limitations on Distribution of Marketing Materials and Activities What changed?
qualified beneficiaries, during the Annual Enrollment Period (AEP). Previous guidance had required the cessation of current year marketing activities beyond October 1 of the plan year.
Impact
qualified beneficiaries, during the Annual Enrollment Period (AEP). Previous years guidance had required the cessation of current year marketing activities beyond October 1 of the plan year.
What changed?
direct mail and other marketing campaigns during AEP.
during the AEP timeframe.
campaigns for age-in beneficiaries beyond October 1, 2017, for November 1 or December 1, 2017 effective beneficiaries.
Impact
24 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
1. Scope Of Appointment
2. Simply Medicare Sales Presentation
3. Sales kit Presentation – NEW 2018 SALES KIT – ONE BOOKLET
4. Enrollment
5. After the sale
25 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
26 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
A completed SOA is not open-ended permission for future contact. It is only valid for the duration of that transaction or 90 days from the prospect signature date on SOA.
27
Same day appointment allowed Same day appointment allowed Same day appointment allowed
MAIL OUT WALK-IN IN-BOUND TELEPHONIC SOA
Mail out from a prospect call Walk-In to a provider’s office
SOA Confirmation Provided
Mail out from an event Walk-In during a presentation Mail out from business reply Walk-In to an event Mail out from Request Plan Information Form Walk-In to a business office
EFFECTIVE OCTOBER 1 2018
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Recorded Scope of Appointment
Call
1-877-577-0113 With Potential Enrollee on the Line Have Your Broker/Agent ID Ready Get Confirmation Number from Simply Representative
Application
Write Scope Lead ID number on the application
28
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Y0114_18_31963_R_
Simply Healthcare Plans, Inc. is a Medicare-contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends
WILL BE RELEASED BY OCTOBER 1, 2017
October 1 – October 14 October 15 – December 7 January 1 – February 14 February 15 – December 31 2017 2017 2018 2018 Pre-Enrollment Annual Election Annual Disenrollment Lock-In Compare your healthcare coverage
If you’re eligible, you may join, change, or switch Medicare Advantage (MA) plans or Prescription Drug Plan (PDP) Medicare Advantage (MA) plan enrollees have an annual
disenroll from an MA plan and return to Original Medicare During this period, you must keep the coverage you chose unless you qualify for a SEP
30 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
NOT guide the enrollee to sign or date the application.
and December 7. Application may be mailed by enrollee or picked up agent during this period.
redone and the agent will be subject to an internal investigation. Only 2018 applications accepted during this time will be for ICEP or IEP election types.
contract.
31 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Simply Healthcare Plans sales office within 48 hours of the agent taking possession.
documentation (SOA, Acknowledgement of Receipt and Pre- Qualification Form for chronic condition if applicable).
responsibility of al Simply Healthcare employees and representatives.
– Incorrect Medicare number – Invalid election type – Insufficient documentation to qualify for a SEP – Non-par provider – Enrollee does not qualify for the plan chosen
32 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
33
No gender
2018 Enrollment Form – Review the Changes
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
34
No gender
2018 Enrollment Form – Review the Changes, Cont.
PCP Selection Moved to Page 3
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
35
Eliminated “FOR OFFICE USE ONLY” section
2018 Enrollment Form – Review the Changes, Cont.
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
36
2018 Diabetes Assessment Form – No Changes
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
2018 Simply Healthcare Plans
Simply Complete (HMO Dual Eligible SNP)* Dade and Polk Counties – All Medicaid Levels All other Counties – QMB+, SLMB+, FBDE Levels
Miami-Dade Broward/Palm Beach Orange/Osceola/Seminole Hills/Pinellas/Pasco/Hernando Polk Simply More (HMO) Simply More (HMO) Simply More (HMO) Simply More (HMO) Simply More (HMO) Simply Level (HMO SNP) Simply Level (HMO SNP) Simply Level (HMO SNP) Simply Level (HMO SNP) Simply Level (HMO SNP) Simply Complete (HMO DE SNP)* Simply Complete (HMO FDE SNP)* Simply Complete (HMO FDE SNP)* Simply Complete (HMO FDE SNP)* Simply Complete (HMO DE SNP)* Simply Advantage (NEW) (HMO PDE QMB SNP) Simply Advantage (NEW) (HMO PDE QMB SNP) Simply Advantage (NEW) (HMO PDE QMB SNP)
37 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
38
2018 Simply Healthcare Plans
Medicare Savings Programs (MSP)
With respect to Medicaid, an individual is eligible for either full or partial benefits. Dual eligibles whose benefits are limited (partial) include: 1. Qualified Medicare Beneficiary (QMB, or “quimby”); 2. Specified Low-Income Medicare Beneficiaries (SLMB, or “slimby”); 3. Qualifying Individuals (QI); and 4. Qualified Disabled Working Individuals (QDWI). These four categories are referred to as Medicare Savings Programs (MSP). If an individual qualifies for QMB, SLMB, or QI, he or she automatically qualifies to get Extra Help paying for Medicare prescription drug coverage. Qualification can vary by state. This program provides a Low Income Subsidy (LIS) for qualifying individuals.
For more information on Extra Help/LIS, visit www.socialsecurity.gov/prescriptionhelp.
This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes. Y0114_17_27708_I 06/03/2016
39
Medicare Savings Programs (cont.)
Those eligible for full Medicaid benefits are called Full Benefit Dual Eligible (FBDE). At times, individuals may qualify for both limited coverage of Medicare cost-sharing as well as full Medicaid benefits. Remember “Quimby” and “Slimby”? Each of those Medicare Savings Programs has a second level of benefit coverage: QMB Plus (QMB+) and SLMB Plus (SLMB+). For help verifying Medicaid eligibility call Simply Social Services Department 877.577.0212
This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes. Y0114_17_27708_I 06/03/2016
2018 Simply Healthcare Plans
Medicare Member Services (Member should be on the phone line when calling this number) 877.577.0115 877.577.0114 (fax) Broker Agent Helpline Scope of Appointment (SOA) 877.577.0113 Social Services Department 877.577.0212 Simply Simple Unit – Broker Support for Escalated Cases
DL-MS_SimplySimpleUnit-Users@simplyhealthcareplans.com
Miami –Dade
Part D $8000 ICL on Simply More and Simply Level $0 copay for Rx Tier 1,2,3 & Low Copay for Rx tier 4 Unlimited Transportation Comprehensive Dental + Complete or partial dentures Up to $60 OTC Benefit Gym Membership- Silver Sneakers PERS (Personal Emergency Response System) All Plans Chronic Meal Benefit – Complete/Comfort $0 copay for PCP and Specialist Vision Benefits $350 Hearing Benefits up to $1500 per year
42
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Plan Name Simply More Simply Level Simply Complete Plan Type (HMO) (HMO SNP) (HMO SNP) Contract/PBP H5471-002 H5471-012 H5471-001 Service Area/Counties Miami-Dade Miami-Dade Miami-Dade Year 2017 2018 2017 2018 2017 2018 Premium $0 $0 $0 $0 $0 $0 Premium Rebate N/A N/A N/A N/A N/A N/A MOOP $3,400 $3,400 $3,400 $3,400 $500 $500 Deductible $0 $0 $0 $0 $0 $0 Inpatient Acute Care $0 $0 $0 $0 $0 $0 Inpatient Mental Health/Substance Abuse $0 $0 $0 $0 $0 $0 Skilled Nursing Facility (SNF) $0 $0 $0 $0 $0 $0 Emergency Services $25 $25 $25 $25 $0 $0 waived if admitted YES YES YES YES N/A N/A Urgent Care Center $0 $0 $0 $0 $0 $0 Worldwide Emergency Services $25/$50,000 per year $25/$50,000 per year $25/$50,000 per year $25/$50,000 per year $0/$50,000 per year $0/$50,000 per year Primary Care Physician $0 $0 $0 $0 $0 $0 Occupational Therapy Rehab (Includes CORF) $0 $0 $0 $0 $0 $0 Specialist Physician $0 $0 $0 $0 $0 $0 Podiatry Medicare-Covered $0 $0 $0 $0 $0 $0 Routine Supplemental $0/Unlimited $0/Unlimited $0/Unlimited $0/Unlimited $0/Unlimited $0/Unlimited Physical and Speech Therapy Rehab (Includes CORF) $0 $0 $0 $0 $0 $0 Laboratory $0 $0 $0 $0 $0 $0 Diagnostic Procedures and Tests Freestanding $0 $0 $0 $0 $0 $0 Outpatient Hospital $50 $50 $50 $50 $0 $0 Diagnostic Radiology/Advanced Imaging Freestanding $0 $0 $0 $0 $0 $0 Outpatient Hospital $50 $50 $50 $50 $0 $0 Basic Radiology/X-Rays Freestanding $0 $0 $0 $0 $0 $0 Outpatient Hospital $50 $50 $50 $50 $0 $0 Outpatient Hospital Surgery $50 $50 $50 $50 $0 $0 Ambulatory Surgical Center $0 $0 $0 $0 $0 $0 Ambulance Emergent $0 $0 $0 $0 $0 $0 Medicare-Covered Non-Emergent $0 $0 $0 $0 $0 $0 Diabetes Supplies (Strips/Lancets/Glucometer) $0 $0 $0 $0 $0 $0 Diabetic Therapeutic Shoes and Inserts $0 $0 $0 $0 $0 $0 Over-the-Counter Items $35 monthly $60 monthly $35 monthly $55 monthly $51 monthly $55 monthly Chronic Meal Benefit N/C N/C N/C N/C 3 meals per day for 12 days 3 meals per day for 12 day Post-Discharge Meal Benefit 10 meals 10 meals 10 meals 10 meals 10 meals 10 meals Simply Aide (At Home Recovery) N/C N/C N/C N/C Yes Yes Personal Emergency Response N/C YES N/C YES Yes Yes
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Plan Name Simply More Simply Level Simply Complete Plan Type (HMO) (HMO SNP) (HMO SNP) Contract/PBP H5471-002 H5471-012 H5471-001 Service Area/Counties Miami-Dade Miami-Dade Miami-Dade Year 2017 2018 2017 2018 2017 2018 Comprehensive Dental
Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline Medically necessary surgical procedures Includes analgesia Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline Medically necessary surgical procedures Includes analgesia Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year Medically necessary surgical procedures Includes analgesia Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year Medically necessary surgical procedures Includes analgesia Vision Exams Supplemental Eyewear (Glasses/Contacts) Allowance $300 $350 $300 $350 $300 $350 Hearing Exams Hearing Aids $750 per ear/per year $1,500 per year (up to 2) $750 per ear/per year $1,500 per year (up to 2) $750 per ear/per year $1,500 per year (up to 2) Part D Prescription Drugs Deductible $0 $0 $0 $0 $400 waive T1, T2 $405 waive T1, T2 Initial Coverage Limit (ICL) $7,000 $8,000 $8,000 $8,000 $3,700 $3,750 TrOOP $4,950 $5,000 $4,950 $5,000 $4,950 $5,000 Tier 1 $0 $0 $0 $0 $0 $0 Tier 2 $0 $0 $0 $0 $0 $0 Tier 3 $0 $0 $0 $0 $45 / LIS Copay $45 / LIS Copay Tier 4 $20 $5 $15 $10 $75 pref/$80 stnd/LIS Copay $75 pref/$80 stnd/LIS Copay Tier 5 33% 33% 33% 33% 25% / LIS Copay 25% / LIS Copay Mail Order Coverage T1 - T5 T1 - T5 T1 - T5 T1 - T5 T1 - T5 T1 - T5 Gap Coverage T1, T2 T1, T2 T1, T2, Dbx drugs T1, T2, Dbx drugs T1, T2 T1, T2 Part D Excluded Drugs yes yes yes yes yes yes
44 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Broward
$0 or low copay for Rx Drugs $0 PCP copay / Low specialist copay New Partial DE SNP – QMB Level Unlimited Transportation - Simply More & Simply Complete Strong Simply Level (Diabetic SNP) – Year round marketing Gym Membership- Silver Sneakers PERS (Personal Emergency Response System)- Simply Complete/Advantage OTC Benefit- Up to $31.00 per month Vision – Up to $300 towards eyewear Hearing Benefits - $1500 per year Comprehensive Dental – Dentures and Partials (All plans)
46
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Plan Name Simply More Simply Level Simply Complete Plan Type (HMO) (HMO SNP) (HMO SNP) Full Duals only Contract/PBP H5471-051 H5471-054 H5471-050 Service Area/Counties Broward Broward Broward Year 2017 2018 2017 2018 2017 2018 Premium $0 $0 $0 $0 $0 $0 Premium Rebate N/A N/A N/A N/A N/A N/A MOOP $6,700 $6,700 $3,400 $6,700 $3,400 $3,400 Deductible $0 $0 $0 $0 $0 $0 Inpatient Acute Care $0 $0 $95 days 1-8 $75 days 1-5 $0 $0 Inpatient Mental Health/Substance Abuse $0 $0 $95 days 1-8 $75 days 1-5 $0 $0 Skilled Nursing Facility (SNF) $55 days 21-100 $55 days 21-100 $20 days 8-20 $40 days 21-100 $0 days 1-20 $40 days 21-100 $0 $0 Emergency Services $75 $75 $75 $75 $0 $0 waived if admitted YES YES YES YES N/A N/A Urgent Care Center $15 $15 $0 $0 $0 $0 Worldwide Emergency Services $75/$50,000 per year $75/$50,000 per year $75/$50,000 per year $75/$50,000 per year $0/$50,000 per year $0/$50,000 per year Primary Care Physician $0 $0 $0 $0 $0 $0 Occupational Therapy Rehab (Includes CORF) $15 $15 $15 $15 $0 $0 Specialist Physician $15 $10 $20 $15 $0 $0 Podiatry Medicare-Covered $0 $0 $0 $0 $0 $0 Routine Supplemental $0/12 visits $0/12 visits $0/12 visits $0/unlimited $0/12 visits $0/12 visits Physical and Speech Therapy Rehab (Includes CORF) $15 $15 $15 $15 $0 $0 Laboratory $0 $0 $0 $0 $0 $0 Diagnostic Procedures and Tests Freestanding $0 $0 $0 $0 $0 $0 Outpatient Hospital $100 $100 $100 $100 $0 $0 Diagnostic Radiology/Advanced Imaging Freestanding $0 $0 $0 $0 $0 $0 Outpatient Hospital $100 $100 $100 $100 $0 $0 Basic Radiology/X-Rays Freestanding $0 $0 $0 $0 $0 $0 Outpatient Hospital $100 $100 $100 $100 $0 $0 Outpatient Hospital Surgery $100 $100 $100 $100 $0 $0 Ambulatory Surgical Center $0 $0 $0 $0 $0 $0 Ambulance Emergent $250 $250 $150 $150 $0 $0 Medicare-Covered Non-Emergent $250 $250 $150 $150 $0 $0 waived if admitted YES YES YES YES N/A N/A Diabetes Supplies (Strips/Lancets/Glucometer) $0 $0 $0 $0 $0 $0 Diabetic Therapeutic Shoes and Inserts $0 $0 $0 $0 $0 $0 Over-the-Counter Items $25 monthly $25 monthly $15 monthly $15 monthly $25 monthly $31 monthly Chronic Meal Benefit N/C N/C N/C N/C N/C N/C Post-Discharge Meal Benefit 10 meals 10 meals 10 meals 10 meals 10 meals 10 meals Simply Aide (At Home Recovery) N/C N/C N/C N/C N/C N/C Personal Emergency Response N/C N/C N/C N/C YES YES
47 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Comprehensive Dental
Simply More 2017 Simply More 2018 Simply Level 2017 Simply Level 2018 Simply Complete 2017 Simply Complete 2018
Option 2B $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 2B $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year. Medically necessary surgical procedures Includes analgesia Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year. Medically necessary surgical procedures Includes analgesia Vision Exams
Simply More 2017 Simply More 2018 Simply Level 2017 Simply Level 2018 Simply Complete 2017 Simply Complete 2018
Supplemental Eyewear (Glasses/Contacts) Allowance $125 $300 $100 $275 $200 $250 Hearing Exams Hearing Aids $500 per ear/per year $1,500 per year (up to 2) $500 per ear/per year $1,500 per year (up to 2) $750 per ear/per year $1,500 per year (up to 2) Part D Prescription Drugs
Simply More 2017 Simply More 2018 Simply Level 2017 Simply Level 2018 Simply Complete 2017 Simply Complete 2018
Deductible $0 $0 $0 $0 $400 waive T1, T2 $405 waive T1, T2 Initial Coverage Limit (ICL) $3,700 $3,750 $3,700 $3,750 $3,700 $3,750 TrOOP $4,950 $5,000 $4,950 $5,000 $4,950 $5,000 Tier 1 $0 $0 $0 $0 $0 $0 Tier 2 $5 $0 $5 $0 $0 $0 Tier 3 $35 $25 $35 $35 $45 / LIS Copay $45 / LIS Copay Tier 4 $75 $75 $75 $75 $90 pref / $95 stnd / LIS Copay $90 pref / $95 stnd / LIS Copay Tier 5 33% 33% 33% 33% 25% / LIS Copay 25% / LIS Copay Mail Order Coverage T1 - T5 T1 - T5 T1 - T5 T1 - T5 T1 - T5 T1 - T5 Gap Coverage T1, T2 T1, T2 T1, T2, Dbx drugs T1, T2, Dbx drugs T1, T2 T1, T2 Part D Excluded Drugs yes yes yes yes yes yes
48 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
BROWARD Simply Advantage
Plan Name Simply Advantage (New Plan 2018) Plan Type (HMO SNP) QMB only Contract/PBP H5471-061 Service Area/Counties Broward Year 2018 Premium $0 Premium Rebate N/A MOOP $3,400 Deductible $0 Inpatient Acute Care $0 Inpatient Mental Health/Substance Abuse $0 Skilled Nursing Facility (SNF) $0 Cardiac Rehab/Intensive Cardiac Rehab Freestanding $0 Outpatient Hospital $0 CORF $0 Pulmonary Rehab Freestanding $0 Outpatient Hospital $0 CORF $0 Emergency Services $0 waived if admitted N/A Urgent Care Center $0 Worldwide Emergency Services $0/$50,000 per year Partial Hospitalization (Adult Day-care for Mental Health) $0 Hospice Original Medicare Home Health Services $0 Primary Care Physician $0 Chiropractic Medicare-Covered $0 Routine Supplemental $0/6 visits Occupational Therapy Rehab (Includes CORF) $0 Specialist Physician $0 Mental Health Non-Physician Group Sessions $0 Individual Sessions $0 Podiatry Medicare-Covered $0 Routine Supplemental $0/12 visits
49 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Psychiatric Services Group Sessions $0 Individual Sessions $0 Physical and Speech Therapy Rehab (Includes CORF) $0 Laboratory $0 Diagnostic Procedures and Tests Freestanding $0 Outpatient Hospital $0 Diagnostic Radiology/Advanced Imaging Freestanding $0 Outpatient Hospital $0 Basic Radiology/X-Rays Freestanding $0 Outpatient Hospital $0 Therapeutic Radiology/Radiation Therapy/Nuclear Medicine Freestanding $0 Outpatient Hospital $0 Outpatient Hospital Surgery $0 Ambulatory Surgical Center $0 Hospital Observation $0 Outpatient Substance Abuse Services Group Sessions $0 Individual Sessions $0 Blood Services $0 Ambulance Emergent $0 Medicare-Covered Non-Emergent $0 waived if admitted N/A Routine Supplemental Transportation 24 one-way Durable Medical Equipment High Cost Items $0 All Other Items $0 Prosthetic Devices $0 Medical Supplies $0 Diabetes Supplies (Strips/Lancets/Glucometer) $0 Diabetic Therapeutic Shoes and Inserts $0 Renal Dialysis Dialysis Center Freestanding $0 Outpatient Hospital $0 Acupuncture N/C Over-the-Counter Items $31 monthly
BROWARD Simply Advantage
50 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Chronic Meal Benefit N/C Post-Discharge Meal Benefit 10 meals Simply Aide (At Home Recovery) N/C Personal Emergency Response YES Routine Physical Exams Welcome to Medicare (IPPE) $0 Annual Wellness Visits $0 Supplemental Routine Physicals N/C Abdominal Aortic Aneurysm Screening $0 Alcohol Misuse Screening $0 Bone Mass Measurement Screening $0 Cardiovascular Screening $0 Colorectal Cancer Screening $0 Depression Screening $0 Diabetes Screening $0 HIV Screening $0 IBT for Cardiovascular Disease $0 IBT for Obesity $0 Immunizations Flu Shot $0 Pneumonia $0 Hepatitis B $0 Other Non-Covered $0 Mammography Screening $0 Medical Nutrition Therapy (ESRD and Diabetes) $0 Pap Smears and Pelvic Screening $0 Prostate Cancer Screening $0 STI/STD Screening $0 Smoking and Tobacco Use Cessation $0 Health/Wellness - Health Education Yes Health/Wellness - Nutrition Education N/C Health/Wellness - Nursing Hotline N/C Silver Sneakers Gym Membership Yes Kidney Disease Education Services $0 Diabetes Self-Management Training $0 Chemotherapy Drugs Physician Office $0 Outpatient Hospital $0 Pharmacy $0 Medicare Part B Drugs Physician Office $0 Outpatient Hospital $0 Pharmacy $0
BROWARD Simply Advantage
51 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Preventive Dental Copayment $0 Oral Exam 2 Prophylaxis 2 X-Ray/Bitewings 3 Comprehensive Dental Medicare-Covered Dental $0 Supplemental Copayment $0 Restorative 2 Endodontics/Periodontics/Extraction s 1 Prosthodontics/Surgery/Other 2 Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year. Medically necessary surgical procedures Includes analgesia Vision Exams Medicare-Covered Exam $0 Medicare-Covered Glaucoma Screening $0 Routine Supplemental Exam $0 Supplemental Eyewear (Glasses/Contacts) Allowance $300 Medicare Eyewear After Cataract Surgery $0 Hearing Exams Medicare-Covered Exam $0 Routine Supplemental Exam $0 Routine Fitting Evaluation $0 Hearing Aids $1,500 per year (up to 2) Point of Service (POS) N/C Part D Prescription Drugs Deductible $405 waive T1, T2 Initial Coverage Limit (ICL) $3,750 TrOOP $5,000 Tier 1 $0 Tier 2 $0 Tier 3 $45 / LIS Copay Tier 4 $90 pref / $95 stnd / LIS Copay Tier 5 25% / LIS Copay Mail Order Coverage T1 - T5 Gap Coverage T1, T2 Part D Excluded Drugs yes
BROWARD Simply Advantage
52 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Palm Beach
$0 or low copay for Rx Drugs $0 PCP copay / $10 specialist copay New Partial DE SNP – QMB Level Unlimited Transportation - Simply More/Complete/Advantage Strong Simply Level (Diabetic SNP) – Year round marketing Gym Membership- Silver Sneakers PERS (Personal Emergency Response System)- Simply Complete/Advantage OTC Benefit- Up to $44.00 per month Vision – Up to $300 towards eyewear Hearing Benefits up to $1500 per year Comprehensive Dental – Dentures and Partials
54
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Plan Name Simply More Simply Level Simply Complete Simply Advantage Plan Type (HMO) (HMO SNP) (HMO SNP) Full Duals only (HMO SNP) QMB only Contract/PBP H5471-057 H5471-059 H5471-058 H5471-063 Service Area/Counties Palm Beach Palm Beach Palm Beach Palm Beach Year 2018 2018 2018 2018 Premium $0 $0 $0 $0 Premium Rebate N/A N/A N/A N/A MOOP $6,700 $6,700 $3,400 $3,400 Deductible $0 $0 $0 $0 Inpatient Acute Care $50 days 1-8 $50 days 1-8 $0 $0 Inpatient Mental Health/Substance Abuse $50 days 1-8 $50 days 1-8 $0 $0 Skilled Nursing Facility (SNF) $0 days 1-20 $55 days 21-100 $0 days 1-20 $40 days 21-100 $0 $0 Cardiac Rehab/Intensive Cardiac Rehab Freestanding $0 $0 $0 $0 Outpatient Hospital $0 $0 $0 $0 CORF $0 $0 $0 $0 Pulmonary Rehab Freestanding $0 $0 $0 $0 Outpatient Hospital $0 $0 $0 $0 CORF $0 $0 $0 $0 Emergency Services $75 $75 $0 $0 waived if admitted YES YES N/A N/A Urgent Care Center $15 $0 $0 $0 Worldwide Emergency Services $75/$50,000 per year $75/$50,000 per year $0/$50,000 per year $0/$50,000 per year Partial Hospitalization (Adult Day-care for Mental Health) $0 $0 $0 $0 Hospice Original Medicare Original Medicare Original Medicare Original Medicare Home Health Services $0 $0 $0 $0 Primary Care Physician $0 $0 $0 $0 Chiropractic Medicare-Covered $0 $0 $0 $0 Routine Supplemental $0/12 visits $0/12 visits $0/6 visits $0/6 visits Occupational Therapy Rehab (Includes CORF) $15 $15 $0 $0 Specialist Physician $10 $10 $0 $0
55 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
PALM BEACH
56
Mental Health Non-Physician Group Sessions $15 $15 $0 $0 Individual Sessions $15 $15 $0 $0 Podiatry Medicare-Covered $0 $0 $0 $0 Routine Supplemental $0/12 visits $0/unlimited $0/12 visits $0/12 visits Psychiatric Services Group Sessions $15 $15 $0 $0 Individual Sessions $15 $15 $0 $0 Physical and Speech Therapy Rehab (Includes CORF) $15 $15 $0 $0 Laboratory $0 $0 $0 $0 Diagnostic Procedures and Tests Freestanding $0 $0 $0 $0 Outpatient Hospital $100 $100 $0 $0 Diagnostic Radiology/Advanced Imaging Freestanding $0 $0 $0 $0 Outpatient Hospital $100 $100 $0 $0 Basic Radiology/X-Rays Freestanding $0 $0 $0 $0 Outpatient Hospital $100 $100 $0 $0 Therapeutic Radiology/Radiation Therapy/Nuclear Medicine Freestanding $0 $0 $0 $0 Outpatient Hospital $60 $60 $0 $0 Outpatient Hospital Surgery $100 $100 $0 $0 Ambulatory Surgical Center $0 $0 $0 $0 Hospital Observation $0 $0 $0 $0 Outpatient Substance Abuse Services Group Sessions $50 $50 $0 $0 Individual Sessions $50 $50 $0 $0 Blood Services $0 $0 $0 $0 Ambulance Emergent $250 $150 $0 $0 Medicare-Covered Non-Emergent $250 $150 $0 $0 waived if admitted YES YES N/A N/A
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
PALM BEACH
57
Routine Supplemental Transportation unlimited 24 one-way Unlimited unlimited Durable Medical Equipment High Cost Items 20% 20% 0% 0% All Other Items 0% 0% 0% 0% Prosthetic Devices 20% 20% 0% 0% Medical Supplies 20% 20% 0% 0% Diabetes Supplies (Strips/Lancets/Glucometer) $0 $0 $0 $0 Diabetic Therapeutic Shoes and Inserts $0 $0 $0 $0 Renal Dialysis Dialysis Center Freestanding 0% 0% 0% 0% Outpatient Hospital 20% 20% 0% 0% Acupuncture N/C N/C N/C N/C Over-the-Counter Items $25 monthly $15 monthly $40 monthly $40 monthly Chronic Meal Benefit N/C N/C N/C N/C Post-Discharge Meal Benefit 10 meals 10 meals 10 meals 10 meals Simply Aide (At Home Recovery) N/C N/C N/C N/C Personal Emergency Response N/C N/C YES YES Routine Physical Exams Welcome to Medicare (IPPE) $0 $0 $0 $0 Annual Wellness Visits $0 $0 $0 $0 Supplemental Routine Physicals N/C N/C N/C N/C Abdominal Aortic Aneurysm Screening $0 $0 $0 $0 Alcohol Misuse Screening $0 $0 $0 $0 Bone Mass Measurement Screening $0 $0 $0 $0 Cardiovascular Screening $0 $0 $0 $0 Colorectal Cancer Screening $0 $0 $0 $0 Depression Screening $0 $0 $0 $0 Diabetes Screening $0 $0 $0 $0 HIV Screening $0 $0 $0 $0 IBT for Cardiovascular Disease $0 $0 $0 $0 IBT for Obesity $0 $0 $0 $0 Immunizations Flu Shot $0 $0 $0 $0 Pneumonia $0 $0 $0 $0 Hepatitis B $0 $0 $0 $0
Other Non-Covered $0 $0 $0 $0
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
PALM BEACH
58
Mammography Screening $0 $0 $0 $0 Medical Nutrition Therapy (ESRD and Diabetes) $0 $0 $0 $0 Pap Smears and Pelvic Screening $0 $0 $0 $0 Prostate Cancer Screening $0 $0 $0 $0 STI/STD Screening $0 $0 $0 $0 Smoking and Tobacco Use Cessation $0 $0 $0 $0 Health/Wellness - Health Education Yes Yes Yes Yes Health/Wellness - Nutrition Education N/C N/C N/C N/C Health/Wellness - Nursing Hotline N/C N/C N/C N/C Silver Sneakers Gym Membership Yes Yes Yes Yes Kidney Disease Education Services $0 $0 $0 $0 Diabetes Self-Management Training $0 $0 $0 $0 Chemotherapy Drugs Physician Office 20% 20% 0% 0% Outpatient Hospital 20% 20% 0% 0% Pharmacy 20% 20% 0% 0% Medicare Part B Drugs Physician Office 0% 0% 0% 0% Outpatient Hospital 20% 20% 0% 0% Pharmacy 20% 20% 0% 0% Preventive Dental Copayment $0 $0 $0 $0 Oral Exam 2 2 2 2 Prophylaxis 2 2 2 2 X-Ray/Bitewings 3 3 3 3 Comprehensive Dental Medicare-Covered Dental $0 $0 $0 $0 Supplemental Copayment $0 $0 $0 $0 Restorative 2 2 2 2 Endodontics/Periodontics/Extractions 1 1 1 1 Prosthodontics/Surgery/Other 2 2 2 2 Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 2 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Up to 6 simple or surgical extractions per year (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/reline every year Medically necessary surgical procedures Includes analgesia Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year. Medically necessary surgical procedures Includes analgesia Option 1 $0 copayment for: 2 Exams 2 Prophylaxis cleanings 2 Series of bitewing films 1 Panoramic film 2 Amalgam or resin fillings Unlimited for simple or surgical extractions (in 1 or more visits) 1 Set complete or partial dentures every five years 1 Denture adjustment/ reline every year. Medically necessary surgical procedures Includes analgesia
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
PALM BEACH
59 Vision Exams
Simply More Simply Level Simply Complete Simply Advantage
Medicare-Covered Exam $0 $0 $0 $0 Medicare-Covered Glaucoma Screening $0 $0 $0 $0 Routine Supplemental Exam $0 $0 $0 $0 Supplemental Eyewear (Glasses/Contacts) Allowance $200 $200 $250 $250 Medicare Eyewear After Cataract Surgery $0 $0 $0 $0 Hearing Exams Medicare-Covered Exam $0 $0 $0 $0 Routine Supplemental Exam $0 $0 $0 $0 Routine Fitting Evaluation $0 $0 $0 $0 Hearing Aids $1,000 per year (up to 2) $1,000 per year (up to 2) $1,500 per year (up to 2) $1,500 per year (up to 2) Point of Service (POS) N/C N/C N/C N/C Part D Prescription Drugs
Simply More Simply Level Simply Complete Simply Advantage
Deductible $0 $0 $405 waive T1, T2 $405 waive T1, T2 Initial Coverage Limit (ICL) $3,750 $3,750 $3,750 $3,750 TrOOP $5,000 $5,000 $5,000 $5,000 Tier 1 $0 $0 $0 $0 Tier 2 $0 $0 $0 $0 Tier 3 $20 $35 $45 / LIS Copay $45 / LIS Copay Tier 4 $75 $75 $90 pref / $95 stnd / LIS Copay $90 pref / $95 stnd / LIS Copay Tier 5 33% 33% 25% / LIS Copay 25% / LIS Copay Mail Order Coverage T1 - T5 T1 - T5 T1 - T5 T1 - T5 Gap Coverage T1, T2 T1, T2, Dbx drugs T1, T2 T1, T2 Part D Excluded Drugs yes yes yes yes For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
LIS Prescription Drug Benefits 2018
LIS LEVEL
DEDUCTIBLE
Prior to the Coverage GAP During the Coverage GAP Catastrophic Generic / Tier 1-2 Preferred Multisource/ Tier 3-4 Other/ Specialty Generic or Brand Tier 5 Generic / Tier 1-2 Preferred Multisource/ Tier 3-4 Other/ Specialty Generic or Brand Tier 5 Generic / Tier 1-2 Preferred Multisource/ Tier 3-4 Other/ Specialty Generic or Brand Tier 5 LIS 1 $0 $0 - $3.35 $0 - $8.35 $3.35-$8.35 $0 - $3.35 $0 - $8.35 $3.35-$8.35 $0 $0 $0 LIS 2 $0 $0 - $1.25 $0 - $3.70 $1.25-$3.70 $0 - $1.25 $0 - $3.70 $1.25-$3.70 $0 $0 $0 LIS 3 (Institutionalized) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 LIS 4 $83
Lesser of copay or 15% Co-Insurance Lesser of copay or 15% Co-Insurance Lesser of copay or 15% Co-Insurance Lesser of copay
Co-Insurance Lesser of copay
Co-Insurance Lesser of copay
Co-Insurance
$3.35 $8.35 $8.35
60
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
Vendor Services Provided Service Area/Markets DentaQuest Dental All Medicare Counties Premier Eye Ophthalmology All Medicare Counties Premier Eye Optometry All Medicare Counties Independent Living Systems Meals All Medicare Counties Beacon Health Mental Health All Medicare Counties Integrated Home Care Home Health-DME-Home Infusion All Medicare Counties Silver Sneakers Gym & Fitness Clubs All Medicare Counties Quest Lab Services All Medicare Counties HearUSA Hearing & Audiology All Medicare Counties TMS Transportation CFL/ECFL Medicare counties MCT Transportation Miami-Dade & Broward County only ChiroAlliance Chiropractic Services All Medicare Counties IPC Hospitalists Mostly S. FLA Navarro Discount Pharmacy OTC All Medicare Counties (mailing order) and walking location available only in Miami-Dade & Broward county HN-1 Outpatient therapy All Medicare Counties
61 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
62
General Dentistry Oral Surgery Pedodontist Orthodontist
Benefits differ by line of business & product and authorization may be required depending on course of treatment.
DentaQuest
Simply Medicare
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
2017 - 2018 Compensation – New Beneficiaries – Turning 65 or First Time MAPD – Current Beneficiaries – Changing MAPD Plan – Commission Proration –MAPD Plan Change, Other Health Plan to Simply Healthcare Plans – Commission Schedule – 30 Days After Policy Effective Date
63 For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
2017 BROKER COMPENSATION Commission Simply will only pay commission on qualified enrollments. Qualified is defined as an enrollment for which an enrollment application has (i) been reviewed and validated by Simply; and (ii) approved and confirmed by CMS. The following commission rates will be paid by Simply to Broker or its Broker Agents, as the case may be, for each Individual enrolled as a Medicare Enrollee in a Simply Plan, but only to the extent such Simply Plan is included under this Agreement and, in each case, only if the Individual is enrolled by Broker or a Broker Agent. Commission shall be paid solely on Individuals enrolled by Broker or a Broker Agent in a Simply Plan as deemed effective and paid by CMS with a membership effective date of January 1, 2017 - December 1, 2017. New Medicare Enrollee Commission $443 Existing Medicare Enrollee Commission $222 Renewal Commission $18.50 per month Broker or its Broker Agents, as the case may be, shall receive New Medicare Enrollee Commission for Medicare Enrollees who have enrolled in Medicare for the first time and for Medicare Enrollees who were previously enrolled in a Medicare plan of an “unlike plan type,” as that term is described in the Marketing Guidelines. Broker or its Broker Agents, as the case may be, shall receive Existing Medicare Enrollee Commission for Medicare Enrollees who were previously enrolled in a Medicare plan of a “like plan type,” as that term is described in the Marketing Guidelines. Subject to the provisions of Section 2.4.1, 2.4.2, 2.4.3 and 6.2.4, Broker or its Broker Agents, as the case may be, shall receive Renewal Commission for as long as the applicable Medicare Enrollee remains continuously enrolled in a Simply Plan. Subject to any return of commission, as described in Section 6.4 of the Agreement, the Chart below explains the amount of pro-rated commission Broker or its Broker Agents, as the case may be, will receive for Existing Medicare Enrollees depending on the effective enrollment month of the beneficiary into a plan in the first calendar year.
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
2018 BROKER COMPENSATION
Commission Simply will only pay commission on qualified enrollments. Qualified is defined as an enrollment for which an enrollment application has (i) been reviewed and validated by Simply; and (ii) approved and confirmed by CMS. The following commission rates will be paid by Simply to Broker or its Broker Agents, as the case may be, for each Individual enrolled as a Medicare Enrollee in a Simply Plan, but only to the extent such Simply Plan is included under this Agreement and, in each case, only if the Individual is enrolled by Broker or a Broker Agent. Commission shall be paid solely on Individuals enrolled by Broker or a Broker Agent in a Simply Plan as deemed effective and paid by CMS with a membership effective date of January 1, 2018 - December 1, 2018. New Medicare Enrollee Commission $455 Existing Medicare Enrollee Commission $228 Renewal Commission $19.00 per month
For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.
66
Have a great 2018 AEP!!!
Broker Support Department 1-877-577-0113 October 1 – February 14 7 days a Week 8 a.m. - 8 p.m. February 15 – September 30 Monday – Friday 8 a.m. - 8 p.m.
67