janis e. carter health net health net medicare advantage sales & product training proprietary...
TRANSCRIPT
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Janis E. Carter
Health Net
Health Net Medicare Advantage
Sales & Product Training
Proprietary & Confidential, Restricted Distribution. For training purposes only, not to be used for Sales & Marketing activity.
Plan Year 2015
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Maricopa AE /Maricopa AE Pima AE
Dionna Naugle Jeff Romero Pat Parisella
(602) 541- 6298
m
(602) 717-7299
Jeffrey.Q.Romero
@healthnet.com
(520) 306-7360
Patrizia.X.Parisella
@healthnet.com
E4L Maricopa Support P4P
Call Your Account Executive if You Need SALES Support:
• Product training / sales tools and resources to help you sell
• Benefits training / answers to advanced benefits questions
• Answers to product / network clarification (not provider searches)
• Marketing ideas / Business strategies
• CMS-approved marketing toolkit / generic marketing material development)
Your Account Executives
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Health NetRecognized Leader in Health Care
•Health Net is among the nation’s largest publicly traded managed health care companies with offices in Arizona, California, Washington, Oregon
•Health Net provides health benefits to more than 5.4 million people nationwide
•Strategic repositioning based on financial performance
•Local presence- Easily accessible to our partners and members (Local Sales Team and Local Advocate Team/ Case Management)
•Strong member satisfaction (Members stay with HN on average 7 years)
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• Broker Resources
• 2015 Contracting
• Beneficiary Reminders
• Network Partner Updates
• Understanding Our Networks
• Benefits and Market-Specific Information
• Optional Gold Buy-Up Plans
• Website Enhancements
• Commission Updates
Welcome to Health Net’s2015 Product & Compliance
Training!
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BROKER RESOURCES
Hours of Operation During AEP
1. Broker Services Mon-Fri 9am-6pm2. Member Services Mon-Fri 8am-5pm3. Pharmacy Dept. Mon-Fri 8am-530pm
Corporate Presentation 5
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• Health Net Contracting (accessing AHIP website / Compliance Training)
• Medicare eligibility (Part A & Part B confirmation) / LIS / AHCCCS eligibility
• Ordering Supplies- Broker Pick Up (Approx Sept 30th @ Health Net)
• Looking up a provider and Network affiliation
• Benefit questions / Clarification on copays, etc.
• Broker change of address or name change
THESE CALLS WILL BE REDIRECTED :
Confirmed Enrollment ---Email Broker Services
Ordering a New Health Net card for a member- Call MEMBER SERVICES
Commission inquiries- [email protected]
Broker Services: AZ 1-866-459-1212([email protected])
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• Help Looking up drugs on our formulary
• Questions about generic versions of brand drugs
• Questions about copays / tier classifications
• Assistance calculating approximate drug costs
Pharmacy Line 1-800-410-6565Assistance with Pharmacy/Drug-Related Questions
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• This is the number members can call for assistance.
• You CAN do a 3-way call with the member, and if the member provides permission, you can assist with their inquiries.
• Assistance with claims information, changing a PCP, etc.
• Member Assistance – claims information, referrals, etc. (NOTE: You will need to have a HIPPA form on file
• Ordering a New Health Net Card
Member Services 1-800-977-7522
Assistance with Customer Service and Claims-Related Questions:
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Pam White,Health Net
2015 Updates & Reminders
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• The Statement of Understanding (SOU) form is not going to be available in 2015.
• A new broker checklist will be in the enrollment kit. Example:
No Statement of Understanding 2015
Eligibility and Enrollment
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Sample Document
NEW
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• Health Net prefers paper applications faxed to 1-877-693-2202.
• AMBER APPLICATION ENROLLMENT FAX: 855-795-7575
• You can submit an online application. Contact Broker Services for a online link. Reminder Online submission allowed for in person
enrollment.
(Confirmation of receipt will be sent to broker on application within 48 hours, call broker services if confirmation was not received. )
• Enrollment applications will be pended for a maximum of 21 days or until the end of the month if the beneficiaries’ Part A and Part B cannot be verified through MARx and we cannot reach the beneficiary by phone. If the beneficiary doesn’t submit a copy to HN within the pended time frame, the application will be cancelled.
Reminder Enrollment Form Submission
Eligibility and Enrollment
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• This section MUST be filled out correctly and legibly. Illegible information might delay commission payment.
• Labels are optional but strongly suggested. Ask you General Agency for Label assistance.
• If labels are to include your NPN number: NEW!
NEWEnrollment Form – Health Net Office Use Only Section
Eligibility and Enrollment
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- A completed application should contain the following documents:
Application Package SummaryReminder
1. Batch (fax) cover sheet
2. Scope of Appointment (we accept all carriers’/generic SOAs)
3. Completed Application
4. Completed Prequalification Form (For Chronic SNP plans)
Be sure to submit the application to Health Net within 24 hours of the broker received date!
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Pam White,Health Net
2015 Contracting
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2015 Contracting Checklist
Health Net NEW Producers:
2015 Individual Producer Contract Or Appendix A (if working with Agency/GA/FMO)Completed W-9Copy of Health & Life License
2015 AHIP Exam Certificate (online)HNT 2015 Compliance Training (online) HNT 2015 Product Training (online)
***Submit all of your documents to your GA
or Broker.Contracting.Medicare
@healthnet.com
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2015 Contracting Checklist
Health Net Returning Producers:
AHIP (online)AHIP Compliance & FWA (online)HNT 2015 Product Training- HN.com
***NOTE***Brokers will need to be in
good standing (AHIP-certified, product trained and currently licensed in Arizona) to receive renewals for sales from 2009–
2014.
Deadline to be in good standing: December 31, 2014
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Plan & Network Changes Darrin Smith- Medicare Sales
Manager
Corporate Presentation 17
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2015 Plan Terminations
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The following plans will be terminated in the counties referenced. Members of the following plans will receive a non-renewal letter:
Ruby 4 plan in Maricopa and Pinal Counties
Ruby 1 plan in Pima County
2015 Service Area ReductionsThe following plans will not be offered in the counties referenced. Members who reside in these counties will receive a non-renewal letter.
Green (MA Only)- Non-renewed in Pima County
Jade & Jade Cardio- Non-renewed in Pima County
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Network Terminations– Effective 1/1/2015North South
Maricopa, Pinal Counties Pima County Banner Health Network (BHN) Direct Network in Maricopa Only
Arizona Community Physicians (ACP)
Members currently enrolled with the above providers will not be disenrolled from their plan due to the providers being terminated. Members will receive a letter from Health Net that explains their options:
No Action – during AEP member will automatically be moved to a different PPG and/or PCP but will remain on currently elected plan. Action – the member has the option to change their PPG and/or PCP to one different than the one assigned to him/her.
Disenroll – the member can disenroll from Health Net.
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Corporate Presentation 20
Claims Incurred Jan – July 2014
Inpatient Acute Statewide:Only 13% of all inpatient acute admissions took place at a Banner facility in 2013
Maricopa county:Only 23% of inpatient acute admits took place at a Banner facility
Pinal county: 39% of inpatient acute admits took place at a Banner facility.
73% of the Banner admits for Maricopa members were admitted via the ER
72% of the Banner admits for Pinal members were admitted via the ER.
Statistics Impacting HN’s model for a Tailored Network
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Highly Confidential & Proprietary 21
2015 Provider Specific Plans (PSPs)
What is a Provider Specific Plan?
A provider specific plan is a Medicare Advantage (MA) plan that limits plan members to a subset of contracted providers from our full provider network located in the plan's service area PSPs must pass the CMS network adequacy requirement to ensure availability of providers including: PCPs, specialists, labs, hospital facilities, etc.
PCPs may only refer members to other providers or facilities affiliated within the PPG
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Highly Confidential & Proprietary 22
2015 Provider Specific Plan (PSP) Networks
Health Net Ruby Select (HMO)
North South
Maricopa, Pinal Pima
Network Specific
Marana Health Center
Saguaro Physicians
El Rio Santa Cruz Neighborhood Health Center
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Pam White,Health Net
Beneficiary Impact
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COMMUNICATION STRATEGY
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① CMS Template Letters: Sept 18th - Oct 1st
② Health Net SAR Letter: Oct 5th
③ Outbound Call: Oct 10th -30th
Service Area
Reductions
PCP Changes
① PCP Change Letters: Oct 1st
② Health Net PCP Change Letter: Oct 5th
③ Outbound Call: (option available)
PLUS: Strong communication with our partners(Brokers, Direct sales, Inside Sales/Optum, AZPC, Member Service Team)
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Corporate Presentation 25
AZ PC Updates 2015
Janice McGill- Director of Marketing
Marie Cremisino- Director of Provider Network
*COLLABORATING FOR SUCCESS*
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• Provider Contracting Updates
• Member outreach
• Website development- AZPC.com
What is in store for 2015?
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Convenient
Cost effective (compared to ER copay)
STAR measures initiative
Senior discount days
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Provider Search Tool Senior Advantage
Club New Partnerships
NEW WEBSITE LAUNCH
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Gilbert Urgent Care Center
Casa Grande Primary Care Center
AZPC Centers
706 N. McQueen Road 1811 E. McMurray Street
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Corporate Presentation 30
**Walk-Ins, Acute Care, Immediate Care 9am – 7pm Monday – Sunday, including
holidays.
Immediate Care Servives:Head-to-Toe ALL General X-Ray, Dexa ScanSVN Breathing Treatment, EKGOxygen ConcentratorsPropaq/Heart Monitoring IV FluidsWound Care/DressingSutures, SplintingToe nail care/removalCatheterization Vitamin B InjectionVaccines (Hep A, B, TDAP, PCV-13, Pneumovax, TB)Vitals, Incision and DrainageIV Therapy (Antibiotics, Insulin, Steroids)Durable Medical Equipment (DME)Post Hospital Visits
$0 Copay Ruby Select
Members
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“I always like to look on the optimistic side of life, but I am realistic enough to know that life is a complex
matter.”
Walt Disney
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PRIMARY FOCUS:BUILDING THE NETWORK
Over 780 Primary Care Physicians
Maricopa 740
Pinal 30
House Call PCPs 8
38 New HN Direct PCP Groups= 105
Over 1,370 Specialists & Ancillary Maricopa 1,340
Pinal 34…and counting
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***2013 ONLY***
UNDERSTANDING THE NETWORKS
AE: Dionna Naugle
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Health Net MAPD – HMO Plans & Specialist ***MARICOPA COUNTY ***
AZPC Network
Ruby Select, Ruby 1, Jade, Green,
Amber
AZPC (Specialists &
Hospitals)
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Health Net MAPD – HMO Plans & Specialist ***PINAL COUNTY ***
Ruby Select, Ruby 1, JADE , GREEN
AZPC Network
Direct or AZPC (Specialists & Hospital)
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“What will happen now that Banner
bought the Casa Grande Hospital?”
•Members have the ability to go to the Casa Grande Hospital
•ELECTIVE surgery CAN be conducted at the Casa Grande Hospital
•Worldwide Coverage Emergency Coverage
PINAL: Common Questions
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Health Net MAPD – HMO Plans & Specialist ***PIMA COUNTY ONLY***
Carondelet NetworkMarana Health
CenterSaguaro PhysiciansEl Rio Santa Cruz
Neighborhood Health
Ruby Select Contracted Network (Specialists &
Hospitals)
RUBY 4RUBY SELECT
Marana Health Center
Saguaro Physicians
El Rio Santa Cruz Neighborhood
Health
Direct Network
Direct Network
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Health Net MAPD – HMO Plans & Specialist ***COCHISE COUNTY ***
Direct Network
Green & Ruby 4
Direct Network
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Health Net MAPD – HMO Plans & Specialist ***SANTA CRUZ COUNTY***
Ruby 1, Ruby 4, Green
Direct Network
Direct Network
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PLAN SERVICE AREA
MARICOPA
PINAL
PIMA
SANTA CRUZ
COCHISE
RUBY SELECT X X XRUBY 1 X X XRUBY 4 X X XGREEN X X X XJADE X XJADE Cardio X XAMBER Maricopa X
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2015 HOSPITALS
• AZ Heart Hospital • AZ Orthopedic Surgical Hospital• AZ Spine & Joint Hospital• Arrowhead Community Hospital• Chandler Regional Center• John C Lincoln – Deer Valley• John C Lincoln – North Mountain• Maryvale Hospital• Mercy Gilbert Medical Center• Mountain Vista Medical Center• Paradise Valley Hospital• Phoenix Baptist Hospital• St Joseph’s Hospital• St Luke’s Medical Center• Surgical Specialty Hospital of AZ• Tempe St. Luke’s Medical Center• West Valley Hospital• Wickenburg Community Hospital
• OASIS• Oro Valley Hospital• Northwest Medical Center• Tucson Medical Center• University Physicians
Hospital• University Medical Center• St Mary’s Hospital• Benson Hospital• Bisbee Hospital• Southeast Arizona Medical• Sierra Vista Regional Center• Northern Cochise Hospital• Casa Grande Medical Center• Carondelet Holy Cross
Hospital
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Health Net 2015Pharmacy Enhancements
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2015 AZ Medicare 43
Preferred (Low-Copay) Pharmacy Network• The preferred (low-copay) network will be published on HealthNet.com
October 1st.
• Members will also learn about the preferred (low-copay) network in the information they receive after choosing Health Net during open enrollment.
• Members will receive a pharmacy directory which contains all network retail pharmacies. Preferred pharmacies will have a preferred (low-copay) network indicator.
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Preferential copays for Tiers 1-4
Albertson’s Osco
CVS Sam’s Club
Fry’s Xpress Care
Walmart
Plus large list of local pharmacies.
Standard copays for Tiers 1-4
Walgreens Food City
Safeway KMart
Target Basha’s
Costco
Plus large list of local pharmacies.
PreferredPharmacy examples:
StandardPharmacy examples:
Mail Order CVS Pharmacy
Health Net continues to offer copay savings for 90 day mail order fills for Tiers 1-3
HN’s RETAIL PHARMACIES*Ruby Select members have the ability
to use either Pharmacy Network*
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2015 Drug Tiers
Details
Tier 1 GENERIC preferred
Tier 2 GENERIC non-preferred
Tier 3 BRAND preferred
Tier 4 BRAND non-preferred
Tier 5 SPECIALTY drugs retail
Tier 6
$0 copay!
SELECT CARE drugs retail
includes some brand & generic
drugs used to treat specific chronic
conditions
What Drugs Are in Tier 6?(Related to Star Ratings Drugs)
• Sulfonylureas** (ex: GLIPIZIDE ER)• Meglitinide Analogues** (ex: NATEGLINIDE)• Insulin Sensitizing Agents** (ex: PIOGLITAZONE HCL) • Incretin Mimetic Agents (GLP-1 Receptor Agonists)** (ex. BYDUREON)• HMG CoA Reductase Inhibitors** (ex. ATORVASTATIN CALCIUM) • Dipeptidyl Peptidase-4 (DPP-4) Inhibitors** (ex. TRADJENTA) • ACE Inhibitors** (ex. BENAZEPRIL HCL)• Angiotensin II Receptor Antagonists** (ex: CANDESARTAN CILEXETIL) • Alpha-Glucosidase Inhibitors** (e: ACARBOSE) • Antidiabetic Combinations** (ex: GLIPIZIDE/METFORMIN HCL) •Antihypertensive Combinations** (ex: AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE)• Biguanides** (ex: METFORMIN HCL)
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2015 AZ Medicare 46
Value & Classic FormulariesCLASSIC FORMULARY VALUE FORMULARY
RUBY SELECT X
RUBY 1 X
RUBY 4 X
JADE X
JADE CARDIO X
AMBER X
Both contain a tier for certain drugs associated with Stars. These will be offered at $0 copays
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Benefit Highlights 2015
Jeff Romero, Account Executive
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On ALL of Our Plans…Benefit Member Pays
Emergency care visit $65 per visit (waived if admitted)
Urgent care visit $20 copayment
Home health care $0 copayment
Durable medical equipment 20% coinsurance
Clinical/Diagnostic lab $0 copayment
Diagnostic radiological services (CT Scans, MRI/MRA, PET Scans)
$125-$200
20% coinsurance for therapeutic radiology services
Part D Prescription Drug coverage (except Green)
Worldwide Emergency coverage
Health Club Benefits (SilverSneakers)
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RUBY SELECT- Maricopa, Pinal (N) - Pima (S)
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RUBY SELECT- BENEFITS
DETAILSR Select N - $0/mo
($3400)
Maricopa/Pinal
R Select S - $0/mo ($3800)
Pima
PCP $0 $0
SPECIALIST $20 $30
INPATIENT HOSPITAL $150/day, days 1–5 $150/day, days 1–5
Outpatient Hospital
ASC
$25 - NON surgical service
$125 - surgical service
$0 - NON surgical service
$75 - surgical service
$25 - NON surgical service
$150- surgical service
$0 - NON surgical service
$100- surgical service
Inpatient Mental
Health
$150/ day, days 1-5 $175/day, days 1–5
Skilled Nursing
Facility
$0/day, days 1–20;
$100/day, days 21–
100
$0/day, days 1–20;
$100/day, days 21–
100
Ambulance (land/air) $240/one-way trip $250/one-way trip
Lab/ X-rays $0/ $10 $0/ $15
PT/ Cardiac Rehab $10/ $15 $20/ $20
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RUBY SELECT - Prescription Drug Benefits
Benefit (30 days supplies) Ruby Select (N)- Ruby Select (S)-
Annual Deductible $0 $0
Tier 1 – GENERIC preferred $0 $0
Tier 2 – GENERIC non-preferred $15 $12
Tier 3 – BRAND preferred $44 $44
Tier 4 – BRAND non-preferred $95 $95
Tier 5 – SPECIALTY 33% 33%
Tier 6 - some brand & generic drugs used to treat chronic conditions
$0 $0
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RUBY 1- Maricopa, Pinal ($49/month)- Santa Cruz ($57/month)
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RUBY 1 - BENEFITSDETAILS RUBY 1 - $49/mo ($5300)
(Maricopa, Pinal)
RUBY 1 - $57/mo ($5300) (Santa Cruz)
PCP $5 $5
SPECIALIST $35 $35
INPATIENT HOSPITAL $215/day, days 1–6 $215/day, days 1–6
Outpatient Hospital
ASC
$25 - NON surgical service
$200 - surgical service
$0 - NON surgical service
$175 - surgical service
$0 - NON surgical service
$175 - surgical service
$0 - NON surgical service
$125 - surgical service
Inpatient mental
health
(Limit 190 days
per lifetime)
$215/ day, days 1-5 $215/day, days 1–6
Skilled Nursing
Facility
(100 days /benefit
period*)
$0/day, days 1–20;
$100/day, days 21–
100
$0/day, days 1–20;
$100/day, days 21–
100
Ambulance (land/air) $285/one-way trip $270/one-way trip
Lab/ X-rays $0/ $25 $0/ $25
Therapy/Rehab $25 $25
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RUBY 1 - Prescription Drug Benefits
Benefit ( 30 days supplies) Ruby 1-Preferred Ruby 1-Standard
Annual Deductible $0 $0
Tier 1 – GENERIC preferred $2 $7
Tier 2 – GENERIC non-preferred $15 $20
Tier 3 – BRAND preferred $35 $45
Tier 4 – BRAND non-preferred $85 $95
Tier 5 – SPECIALTY 33% 33%
Tier 6 - some brand & generic drugs used to treat chronic conditions
$0 $0
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RUBY 4- Pima, Cochise, & Santa Cruz
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RUBY 4- BENEFITSDETAILS RUBY 4 - $0/mo ($6700)
(Pima, Cochise, Santa Cruz)
PCP $10
SPECIALIST $50
INPATIENT HOSPITAL $345/day, days 1–5
Outpatient Hospital
ASC
$35 - NON surgical service $275 - surgical service
$0 - NON surgical service $250 - surgical service
Inpatient mental health (Limit 190 days
per lifetime)
$285/day, days 1–6
Skilled Nursing Facility $0/day, days 1–20;
$100/day, days 21–100
Ambulance (land/air) $295/one-way trip
Lab/ X-rays/ Therapy or Rehab
$0/ $35/ $40
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RUBY 4 - Prescription Drug Benefit
Benefit ( 30 days supplies) Ruby 4-Preferred Ruby4-Standard
Annual Deductible $0 $0
Tier 1 – GENERIC preferred $0 $5
Tier 2 – GENERIC non-preferred $15 $20
Tier 3 – BRAND preferred $35 $45
Tier 4 – BRAND non-preferred $85 $95
Tier 5 – SPECIALTY 33% 33%
Tier 6 - some brand & generic drugs used to treat chronic conditions
$0 $0
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GREEN – MA ONLY(No prescription drug coverage)
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GREEN MA - BENEFITS
DETAILS GREEN - $0/mo ($6700) (Maricopa, Pinal, Cochise, Santa Cruz)
PCP $5
SPECIALIST $35
INPATIENT HOSPITAL $195/day, days 1–8
Outpatient Hospital
ASC
$0 - NON surgical service $175 - surgical service $0 - NON surgical service $125 - surgical service
Inpatient Mental Health $175/day, days 1–8
Skilled Nursing Facility (100
days /benefit period*)
$0/day, days 1–20; $100/day, days 21–100
Ambulance (land/air) $300/one-way trip
Lab/ X-ray $0/ $35
Therapy / Rehab $25
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AMBER – Maricopa OnlyLow Income Plan (Medicare/AHCCCS)
FULL DUAL ONLY!SLMB and QI1 CANNOT join the Amber Plan.
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FULL DUAL – SNP You Must Complete an AHCCCS Status Verification prior to submission
BENEFITS- $4100 MOOP AMBER - D-SNP - Maricopa
MEDICAL COPAYS $0
PRESCRIPTION DRUG COPAYS
LIS copays (LIS 2) $1.20/$3.60 & (LIS 1)
$2.65/$6.60
DENTAL (PPO)
$0 Deductible $0 Preventive/Diagnostic
$2,000 Annual Maximum Benefit
VISION $100 allowable Frames/Contacts / 2 yrs
HEARING
$1000 Allowance on pair of hearing aids/3 yrs $0 Annual Routine Hearing Exam
$0 Fittings / 3 yrs
TRANSPORTATION $0 copay – 24 one-way trips
HEALTH CLUB BENEFITS $0 – Silver Sneakers
CASE MANAGEMENT Case Management assistance
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2015 Amber Plan - Benefit Highlights
Dental Plan
Dental PPO
Network
Maximum allowable
(calendar year)
Deductible
(calendar year)
Preventive and diagnostic
Comprehensive services
Major dental
services
$2,000 in-network and out-of-network
combined
$0 in-network and out-of-network combined
In-network: Mbr pays $0 Out-of-network: Mbr pays
20%
In-network: Mbr pays 50% Out-of-network: Mbr pays
50%
In-network: Mbr pays 50% Out-of-network: Mbr pays
50%
Vision
Exam – Routine (refractive) (1
per year)
Frame (standard) (every 2 years)
Lens (standard) (every 2 years)
Contacts (every 2 years)
In-network: $10 per visit Out-of-network: $35 allowable
In-network: $100 allowance; 20% off balance over $100 Out-of-network: $45 allowable
$0 copay
Conventional in-network – $100 allowance; 15% off balance over $100
Disposable in-network – $100 allowance; then balance over $100
Out-of-network: Conventional OR disposable – $80 allowance
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Jade- Special Needs Plan Maricopa & Pinal Counties
• Diabetes • Chronic Heart Failure• Cardiovascular Disorders
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Jade CardioMaricopa, Pinal
CHRONIC CONDITIONS:
1. Cardiac Arrhythmias2. Coronary Artery Disease3. Peripheral Vascular Disease4. Chronic Venous Thromboembolic Disorder
*Must be one of these specific cardiovascular diseases to be eligible
JadeMaricopa, Pinal
CHRONIC CONDITION:
Diabetes (Type I or type II; Do not have to be insulin/medication
dependent)
AND/OR
Chronic Heart Failure (Must specifically have CHF)An attestation form is submitted to the member’s PCP as we
need to obtain verification of the condition(s) on a post-enrollment basis.
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JADE/JADE CARDIOVASCULAR C-SNP DETAILS
JADE / JADE C - $0/mo ($3400) (Maricopa, Pinal)
PCP $0
SPECIALIST $20
INPATIENT HOSPITAL $175/day, days 1–8
Outpatient Hospital
ASC
$25 - NON surgical service $175 - surgical service $0 - NON surgical service $150 - surgical service
Inpatient Mental Health $175/day, days 1–8
Skilled Nursing Facility (100 days /benefit period*)
$0/day, days 1–20; $100/day, days 21–100
Ambulance (land/air) $350/one-way trip
Lab/ X-ray (Flat Film) $0/ $25
Cardiac/ PT Therapy $0/ $10
Oxygen Copay $0
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JADE / JADE CARDIO - Part D
Benefit ( 30 days supplies)Jade/Cardio-
PreferredJade/Cardio-
Standard
Annual Deductible $0 $0
Tier 1 – GENERIC preferred $0 $5
Tier 2 – GENERIC non-preferred $15 $20
Tier 3 – BRAND preferred $35 $45
Tier 4 – BRAND non-preferred $85 $95
Tier 5 – SPECIALTY 33% 33%
Tier 6 - some brand & generic drugs used to treat chronic conditions
$0 $0
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Example SNP Pre-Qualification FormMember must indicate what Dr diagnosed them with
disease. If the chronic condition cannot be verified, the member
will be enrolled two months after the effective date with SEP eligibility to enroll in another plan.
67
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Transportation Benefits
TOTAL TRANSIT # 877-986-7419
AMBER – 24 one-way trips
JADE PLANS – 6 one-way trips
• To / from medical appointments• Will stop at Pharmacy; not counted as additional trip• Family member / caregiver can accompany member and is not counted as an additional trip• Members should call 72 HRS in advance • English & Spanish speakers
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Pam White,Health Net
Gold Buy-Up Options
Optional Supplemental BenefitsRuby 1, Ruby 4, Ruby Select, Green, Jade and Jade Cardiovascular members
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Gold Option 1 $49/mo
Dental (PPO) (Major Dental
Services Included)
Vision ($250 eyewear allowance/2
yrs)
Chiropractic / Acupuncture (24 visits/year
@ $15 copay/visit)***NO CHANGES FROM LAST YEAR***
ENROLLMENT: NEW MEMBERS: within the first month of enrollment (use app form)EXISTING MEMBERS: can only add during Oct 15 – Jan 31; (Jan or
Feb 1 eff)
DISENROLLMENT: ALL MEMBERS: Members can disenroll at any time of the year by sending a signed, dated letter to Member Services
Gold Option 2 $25/mo
Dental (PPO) (Basic /
Comprehensive ONLY)
Vision ($100 eyewear allowance/2
yrs)
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2015 Gold Option #1 - Benefit Highlights
Dental plan
Dental PPO Network
(in-and out-of-network benefits)
Maximum allowable (calendar year)
Deductible (calendar year) *
Preventive and diagnostic services
General comprehensive/Basic services
Major dental services (oral surgery, endodontics, prosthodotics, crowns, dentures, etc)
$1,000 in-network and out-of-network combined
$50 in-network AND $100 out-of-network
In-network: Mbr pays $0 Out-of-network: Mbr pays 20%
In-network: Mbr pays 20% Out-of-network: Mbr pays 40%
In-network: Mbr pays 30% Out-of-network: Mbr pays 50%
Vision
Exam - Routine (refraction)
(1 per year)
Frames, lens and lens options package
(every 2 years)
Contacts
(every 2 years)
In-network: $10 per visit Out-of-network: $45 allowable
In-network: $250 allowance; 20% off balance over $250
Out-of-network: $250 allowance; then 100% of balance
Conventional – in-network: $250 allowance
15% off balance over $250
Disposable – in-network: $250 allowance;
then balance over $250
Conventional and disposable – out-of-network:
$250 allowance; then balance over $250
Chiropractic
Acupuncture
Office visitVisit limits (Chiro and acupuncture combined)
$15 per visit24 visits per calendar year
$49 monthly premium
• Deductible applies to ALL services; in- and out-of-network..
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2015 Gold Option #2 - Benefit Highlights$25 monthly premium
• Deductible applies to ALL services; in- and out-of-network.
Dental plan
Dental PPO Network (in- and out-of-network benefits)
Maximum allowable (calendar year)
Deductible (calendar year)
Preventive and diagnostic services
Comprehensive services
Periodontal services
Major dental services (oral surgery, endodontics, prosthodotics, crowns, dentures, etc)
$1,000 in-network and out-of-network combined
$50 in-network and out-of-network combined
In-network: Mbr pays $0 Out-of-network: Mbr pays 20%
In-network: Mbr pays 20% Out-of-network: Mbr pays 40%
In-network: Mbr pays 20% Out-of-network: Mbr pays 40%
NOT COVERED
Vision
Exam – routine (refractive) (1 per year)
Frame (standard)
(every 2 years)
Lens (standard)
(every 2 years)
Contacts
(every 2 years)
In-network: $10 per visit Out-of-network: $35 allowable
In-network: $100 allowance; 20% off balance over $100
Out-of-network: $45 allowable
$0 copay
Conventional in-network – $100 allowance;
15% off balance over $100
Disposable in-network – $100 allowance;
then balance over $100
Out-of-network: Conventional OR disposable – $80 allowance
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SilverSneakers FitnessVenue-Based Program Component
Fitness membership that includes:
Access to over 12,000 fitness locations nationwide SilverSneakers classes taught by certified instructors A Home-based Fitness Program (Silver Steps) A SilverSneakers Program AdvisorSM for guidance
and assistance New health plan members will receive their personalized
membership card to be used to enroll in the program Access to www.SilverSneakers.com for facility locations
and comprehensive, easy-to-use wellness resources. 73
SilverSneakers® Fitness is Included FREE on Every
2015 Health Net Plan!
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Geoffrey GomezHealth Net
Healthnet.com
Provider Search and Online Enrollment
September 9, 2014
Jocelyn Weiss
Manager, Web Solutions
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Agenda
76
① You Spoke, We Listened: Provider Search Enhancements
② Making Your Job Easier: Online Enrollment Tools
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Provider Search: What you told us
77
Let me search by more than just location
• During AEP, filter by plan year for accurate results.
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Provider Search: We listened
78
You will be able to search by location and plan year (during AEP) as well as filter by provider name, provider ID or plan name
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Provider Search: We listened
79
Location searches will have multiple options – Address, Zip Code, City, County or State.
If an address is entered, we ask for a radius selection. If any other location is entered we will not.
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Provider Search: We listened
80
After entering a location and plan year, the user may also add one of three filter types – Provider Name, Provider ID or Plan Name
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Provider Search: We listened
81
The list of available plans is based on the location entered. Only those plans offered in that area will be shown in the list.
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Provider Search: We listened
82
All filters should be on one page.
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Provider Search: We listened
83
All filters will be on one page instead of three.
We also highlighted top search bar to make it easier to use
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Provider Search: What you told us
84
Should have an option to view Medical Group results based on where affiliated physicians are located (servicing location) rather than where the medical group is physically located.
Users will be able to choose to view Medical Group results based on Servicing Location or Physical Location. Default will be Servicing Location
Default will be Servicing Location
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Users will be able to choose to view Medical Group results based on Servicing Location or Physical Location. Default will be Servicing Location
Provider Search: We listened
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Provider Search: What you told us
86
•Fix print results/plan providers – don’t make me wait hours for a PDF to be sent via email
•Print Results and Print Plan Providers will display a printable web page instead of a PDF
•It will be available immediately (although large result sets may take a few minutes to)
•Email Results will email a link to the web page, not a PDF
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Provider Search: What you told us
87
Simplify how we select a plan – there are just too many in the drop down list
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Provider Search: We listened
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We will add a filter for Plan Type
Standard Medical PlansMedicare PlansState Health PlansExchange Plans
Selecting the Medicare Plans filter will only display Medicare Plans in the drop down.
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Provider Search: Timeline
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All of these changes will go live the night of Thursday, October 23
Until then, the current Provider Search tool will be available, although updated to include all the 2015 provider networks
Broker Services will provide more communications, including a detailed training presentation, as we get closer to implementation
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Online Enrollment
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Did you know….
You can enroll members online using your laptop or tablet?Using the online tool
• Promotes accuracy
• Ensures all required data is captured
• Results in faster application processing
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Online Enrollment
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To access the online enrollment tool
From healthnet.com hover over “Shoppers” and select “Plans for Medicare Beneficiaries” from the fly out menu
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Online Enrollment
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To access the online enrollment tool
Then select “Medicare Advantage Plans”
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Online Enrollment
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To access the online enrollment tool
Verify your zip codeDuring AEP, verify your plan yearSelect one of the menu items to view available plans
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Online Enrollment
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To access the online enrollment tool
From the plan results,click on the Apply Nowbutton to go to the Online Enrollment form.
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Online Enrollment
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The first step is to identify that you are a Sales Producer and complete the information that allows us to tie you to the sale.
Tip: The applicant needsto be with you to use theonline enrollment tool
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Online Enrollment
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Then the online tool walks you through each step of the enrollment process, providing a progress bar so you can always see where you are:
The screens are tailored to the plan and mirror the printed forms
The tool allows you to upload required documents and provides error messaging when you miss a required field or provide data in a bad format – helping ensure complete and accurate forms are submitted
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Commission Updates 2015
Darrin Smith- Sales Manager
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Broker UpdatesInitial MA Enrollment $408Renewal MA Enrollment $204
Commissions for 1/1/15 effective policies will be paid out approximately January 10th
Legacy commissions – plans that were written prior to 2009. Commissions will be paid out the
month after the anniversary month of enrollment.
Plans written in 2009 and forward, will be paid out around the second week of February 2014.
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Thank You Health Net Partners!