2018 Agent Training Medicare Advantage Plans

Transcription

1 2018 Agent Training Medicare Advantage Plans

2 Agent/Agency Appointment Requirements General Eligibility & Marketing Requirements The Application Process & Medicare Choices Original Medicare Medicare Supplement, Advantage & Rx Plans ATRIO Health Plans for 2018 Premium and Benefit Changes 2017 vs Plan Highlights for each service area Medicare Extra Help - Low Income Subsidy Premiums Where to Get More Information Important Compliance Information Fraud/Waste/Abuse Next Step: Agent Product Testing Online

3 Agent Packets Items to Review, Sign & Return Agent Attestation of CMS Marketing Guidelines Confidentiality Agreement ATRIO Plan Highlights CMS Marketing Do s & Don ts Agent Monitoring and Oversight Agent Appointment Requirements Code of Conduct Contract-Plan Numbering Scheme ATRIO Miscellaneous 3

4 Medicare Eligibility People age 65 or older, Health Insurance for: People under 65 with certain disabilities for more than 24 months, or People any age with End-Stage Renal Disease (permanent kidney failure) or Lou Gehrig s Disease (ALS) 4

5 Enrollment Periods Annual (Open) Enrollment Period (AEP) October 15 th through December 7 th Beneficiaries may add/drop coverages, change carriers or plans, or go to-from Original Medicare and Medicare Advantage. Elected changes take effect on January 1 st. Initial Eligibility Period The 7 months surrounding your 65 th birthday (3 1 3) Special Enrollment Periods for qualifying events Loss of other group coverage (up to 8 mos after loss) Medi-gap plan ends (63 days) Move out of Medicare Advantage service area (60 days) Move out of Part D service area or plan ends (60 days) If beneficiary is institutionalized 5-Star Plans: one time option to enroll in from Dec 8 th Nov 30 th 5

6 Special MA Disenrollment Period Between January 1 February 14, if a beneficiary is in a Medicare Advantage Plan, they can leave their plan and switch to Original Medicare. If they switch to Original Medicare during this period, they ll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Their coverage will begin the first day of the month after the plan gets their enrollment request. During this period, beneficiaries can t: Switch from Original Medicare to a Medicare Advantage Plan. Switch from one Medicare Advantage Plan to another. Switch from one Medicare Prescription Drug Plan to another. Join, switch, or drop a Medicare Medical Savings Account Plan. 6

7 Late Enrollment Penalties Beneficiaries must enroll in Medicare Parts B & D when initially eligible. If enrolled at a later date and do not have continuous qualifying (creditable) coverage, late enrollment penalties may apply. Any penalty that applies is permanent. Part B: Premium increases 10% for each full 12 month period there was no Part B or other qualifying coverage. Part D: 1% of the Part D National Base Beneficiary Premium for every month there was no coverage (e.g., the 2017 Part D NBBP is $35.02). 7

8 Enrollment Effective Dates Initial Enrollment Period turning age 65: If you sign up for Part A / B in this month Three months prior to your 65 th birthday The month you turn 65 Your coverage starts: The first day of your birthday month (or the 1 st of the month prior if your birthday is on the 1 st ) 1 month after you sign up 1 month after you turn 65 2 months after you sign up 2 months after you turn 65 3 months after you sign up 3 months after you turn 65 3 months after you sign up During the Jan 1-Mar 31 General Enrollment Period July 1 SEP, Part D, MA: Always the 1 st of the month following application 8

9 Enrollment Anti-discrimination Plans may not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location. Only SNPs may limit enrollment to dual-eligibles, institutionalized individuals, or individuals with severe or disabling chronic conditions. Basic services and information must be made available to individuals with disabilities, upon request. 9

10 Dis-enrollments Optional Dis-enrollments Premiums are not paid timely (subject to grace period/good cause) Individual engages in disruptive behavior Individual provides fraudulent information on enrollment form or permits abuse of enrollment card Required Dis-enrollments Individual moves outside the plan service area Individual loses entitlement to Medicare parts A or B Death Individual no longer meets plan eligibility requirements (e.g., Special Needs Plan) 10

11 Marketing Requirements Agent Key Responsibilities Understand application of Medicare Marketing Guidelines Understand Plan benefits and authorization guidelines Know HIPAA Privacy requirements and potential risks Know how to access & use STAR ratings Know standards for prohibited marketing practices and understand potential consequences of engaging in these Understand difference between Education vs Sales events Understand Scope of Appointment form and process in connection with individual marketing appointments Understand the guidelines concerning gifts and food Know guidelines for marketing in a health care setting Understand agent compensation types, amounts & cycles 11

12 Marketing Oversight ATRIO conducts all marketing activities according to CMS Marketing Guidelines: Marketing activities are those that are meant to steer, or attempt to steer, potential enrollees toward a plan or a limited set of plans. Marketing materials are those which are targeted to Medicare beneficiaries ATRIO will provide approved materials which are identified by a unique marketing material ID number. STAR ratings can be accessed at Medicare.gov or at ATRIOhp.com Only reference individual measures in conjunction with overall Plan rating (e.g., Customer Service vs Plan) 12

13 Marketing Standards Prohibited Marketing Activities Do not make unsolicited contact or ask for referrals Do not conduct health screenings at sales events Do not provide cash or monetary rebates Gifts must be nominal ($15 or less) No meals, ever! Snacks and refreshments only Potential consequences Reporting requirements Disciplinary actions Termination Forfeiture of future compensation 13

14 Scope of Appointment Document PRIOR to any one-on-one appointment with a beneficiary, when reasonably possible If not, complete form at start of appointment & state why Restricts agent scope of discussion of products beyond what beneficiary originally wanted If beneficiary wants to discuss another product, agent must have a separate form signed by the Beneficiary in advance Boxes must be initialed by Beneficiary, not checked Do not market non-health care related products Do not solicit referrals Entities must retain Scope form for a minimum of 10 years post contract termination 14

15 Sales & Education Activities Sales events are either: Formal structured audience style with presentation Informal e.g., table, booth, kiosk with informal Q&A Advance notice requirement to CMS of Sales events eliminated All sales scripts & slides must have CMS approval Understand the appropriate promotion of events Basic Do s and Don ts (refer to MMG for complete list): Don t require information as a prerequisite for event Don t use personal contact info for raffles or drawings Don t use absolute superlatives or misleading statements When a beneficiary is given an enrollment form, must also give plan ratings information and Summary of Benefits 15

16 Agent Compensation Medicare Advantage Plans Compensation Type Initial Year $443 $455 Renewal Year $222 $228 Compensation year is Jan 1 through Dec 31, regardless of beneficiary enrollment date Renewal Year is Jan 1 following initial enrollment ATRIO pays initial commission in full in the month of initial enrollment; renewal commissions are paid on a monthly basis Recoupment must occur for months a member is not in the plan 16

17 The Application Process Note: Applicants cannot have End-Stage Renal Disease (only medical underwriting restriction) Agents cannot solicit or accept AEP applications prior to the start of the Annual Enrollment Period With beneficiary, complete the following: ATRIO Plan Election (application) form (CMS approved) Attestation of Eligibility (non-aep), and Scope of Appointment (outside group sales meeting) Attach a photocopy of Medicare ID card, if possible 17

18 The Application Process Date stamp the application on the same day it was received and fax or deliver in person to ATRIO w/in 24 hrs. If applicant is Low Income Subsidy (LIS) qualified, please include a copy of their Social Security Administration letter of approval 18

19 The Application Process Online enrollment is available at ATRIOhp.com Agents CANNOT complete online enrollments for beneficiaries over the phone ATRIO conducts outbound Enrollment Verification calls on all agent assisted applications 19

20 Medicare Choices Remain on Original Medicare Parts A & B, and Elect to enroll in a stand-alone Part D Rx plan (and pay a monthly premium), and/or Elect to enroll in a Medicare Supplement plan (and pay a monthly premium) OR Elect to enroll in a Medicare Advantage plan Choose a Medical-only Plan, or Choose a Medical and Prescription Drug Plan (Enrollment in a Medicare Advantage plan requires that beneficiaries enroll in Medicare Part B and pay their Part B premium. Plan choices may include a monthly premium.) 20

21 Original Medicare Coverage Part A: Hospital Coverage (and Skilled Nursing Facility, Home Health, Hospice and Blood) Part B: Professional Services (doctors and other outpatient health care professionals and services, including Preventive Services) Part D: Prescription Drug Coverage More information about Medicare and plan options can be found online at: 21

22 Original Medicare is a Fee for Service plan and covers many health care services and drugs You use your red, white & blue Medicare ID Card to access services You see doctors and other health care providers who accept Medicare Shared Costs Original Medicare You pay your share of the cost of care you receive (Deductibles, Copayments and Coinsurance) Medicare pays its share of the costs Note: Original Medicare does not have an annual maximum member liability amount 22

23 2017 Medicare Cost Share Part A (Hospital) Premium: Generally, no cost to beneficiary Beneficiary benefit cost share: $1,316 Deductible for days1-60 $329 Daily Copayment for days $658 Daily Copayment for days (60 lifetime reserve days) After deductible and copays, Beneficiary pays 20% and Medicare pays 80% Part B (Doctors and other outpatient services) Premium: Generally, beneficiary pays $ Beneficiary benefit cost share: $ Deductible for Professional Services Note! These cost share amounts may change for Thereafter, beneficiary pays 20% and Medicare pays 80% Note: There is no annual maximum out-of-pocket liability protection with Original Medicare

24 Medicare Supplement Plans These are supplemental insurance plans designed to help cover your Medicare cost share amounts: Deductibles, Copayments and Coinsurance Also referred to as Medigap Plans These are health insurance policies sold by private insurance companies You pay a monthly premium to the private insurance company 24

25 Medicare Supplement Plans CMS requires standardized policies (Plans A-N) Not all benefit plans are available in all areas These plans are typically accepted by providers who accept original Medicare Oregon follows the Birthday Rule beneficiaries have 30 days from their birthday to switch plans without regard to their medical history 25

26 Medicare Advantage Plans Private health plan options made available under Part C of the Medicare program Beneficiaries who can join: Must have Parts A & B (continue to pay Part B premium) Must reside in the plan s service area Must not have ESRD (renal failure) Beneficiaries continue to have access to ALL Medicarecovered health care, including out of area urgent and emergency care Many plans offer more comprehensive coverage and extra services (i.e., Vision, Dental, Wellness) Plans may include additional premiums 26

27 Medicare Advantage Plans Plan types include: HMOs, POSs, PPOs, SNPs and PFFS Generally, you see providers who are contracted and participate directly with the MA Plan Some plans provide coverage for services from out-of-network providers; higher cost share may apply Some plans may require a Referral to see out-of-network providers Plans may require certain services to be pre-authorized 27

28 Medicare Prescription Plans Insurance to cover your prescription drug costs You must choose a plan and pay a premium Your Choices: Remain with Original Medicare and enroll in a stand-alone Prescription Drug Plan (PDP) from a private company, Enroll in a Medicare Advantage Plan that includes prescription drug coverage If you have low income, you may be eligible for assistance to help pay your drug premium and cost sharing. We ll address Medicare s Extra Help program later in the presentation. or 28

29 General Medicare Beneficiary Protections Protections apply to both Original Medicare and Medicare Advantage plans (medical & drug coverages) Provider access ensures a sufficient network of appropriate providers for population served Balance billing providers are not allowed to bill beneficiaries for charges in excess of plan allowances Plans responsible to ensure coordination of care Provider qualifications plans must credential Beneficiaries right to make Grievances and Appeals 29

30 Medicare Beneficiary Rights & Responsibilities Beneficiary Rights To be treated with respect and fairness To have timely access to covered services & drugs Privacy protection of personal health information Right to be involved in their healthcare decisions Access to plan information regarding benefits & providers Right to make complaints & grievances Beneficiary Responsibilities To know their benefits and authorization requirements To inform plan of other insurance coverage(s) To inform providers of their enrollment in our plan To share information with their providers To pay what they owe for premiums & cost sharing 30

31 We are a local Medicare Advantage plan that is sponsored by local providers Counties Douglas Josephine/Jackson Klamath (*) Marion/Polk ATRIO Health Plans Sponsor Umpqua Health (DCIPA & Mercy Medical Center) Primary Health of Josephine County Cascade Health Alliance WVP Health Authority (* including: 97601, 97602, 97603, 97604, 97621, 97622, 97623, 97624, 97625, 97626, 97627, 97632, 97633, 97634, ) Our plans are available to beneficiaries who have both Parts A & B and reside in our service area 31

32 ATRIO Health Plans We offer PPO plans Some Medical-only coverage (MA plans) Some with both Medical and Prescription Drug coverage (MAPD plans) We offer Special Needs Plans (HMO) (D-SNPs) to applicants who have full dual eligibility for both Medicare and Medicaid Full Dual OHP plans are: QMB Plus, OHP Plus and SLMB Plus Partial Duals are NOT eligible for this plan and include OHP enrollment types QMB, SLMB, QI and QDWI these people are eligible to enroll in an ATRIO PPO plan. 32

33 2018 Plan Changes 33

34 Douglas County 34

35 Douglas County Gold Rx Plan Changes Description 2017 In-Network / Out-of-Network 2018 In-Network / Out-of-Network Gold Rx Premium $180 $189 Ambulance $100 $150 Emergency $65 $100 Dialysis 15% / 20% 20% / 30% Outpatient Surgery Hospital $200 / $325 $225 / $325 Maximum Out of Pocket Limit $2,500 / $3,500 $3,000 / $3,500 Prescription Drugs Stage 2 Limit (Initial Coverage Period) $3,700 $3,750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% True Out of Pocket - $4,950 Generics-56% / Brands 65% True Out of Pocket - $5,000 Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $

36 Douglas County Silver & Silver Rx Plan Changes Description 2017 In-Network / Out-of-Network 2018 In-Network / Out-of-Network Silver & Silver Rx Premiums $59 / $113 $65 / $122 Ambulance Silver Silver - $200 Silver - $150 Emergency $65 $100 Durable Medical Equipment 15% / 30% 20% / 30% Dialysis 15% / 30% 20% / 30% Outpatient Surgery Hospital Silver - $200 / $325 Silver Rx - $225 / $325 20% / 30% Outpatient Surgery ASC 20% / 30% $225 / $325 Silver Rx Prescription Drugs Deductible (Tiers 3, 4, 5 only) $0 $75 Stage 2 Limit (Initial Coverage Period) $3,700 $3,750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% Generics-56% / Brands 65% Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $

37 Douglas County Bronze & Bronze Rx Plan Changes Description 2017 In-Network / Out-of-Network Bronze & Bronze Rx Premiums Bronze - $0 Bronze Rx - $ In-Network / Out-of-Network Bronze - $0 Bronze Rx - $0 Specialist Visit Bronze Rx - $15 / $50 Bronze Rx - $25 / $50 Emergency $65 $100 Outpatient Surgery ASC Bronze Rx - 20% / 30% Bronze Rx - $225 / $325 Bronze Rx Prescription Drugs Deductible (Tiers 3, 4, 5 only) $0 $100 Specialty Medications (Tier 5) 33% 31% 37

38 Douglas County Plans Plans Premium ATRIO Bronze (PPO) $0.00 ATRIO Bronze Rx (Umpqua) (PPO) $0.00 ATRIO Silver (PPO) $65.00 ATRIO Silver Rx (PPO) $ ATRIO Gold Rx (PPO) $ ATRIO Special Needs Plan (HMO) (D-SNP) $

39 Preventive Services All 2018 Plans Preventive Care Service Cost Share Annual Physical Exam $0 Bone Mass Measurement $0 Colorectal Screenings $0 Immunizations $0 Mammograms $0 Pap Smears $0 Pelvic Exams $0 Prostate Exams $0 Smoking Cessation $0 (Please see an Evidence of Coverage booklet for a complete list of covered preventive services.)

40 Douglas County 2018 Medical Plans Bronze Bronze Rx Silver & Silver Rx Gold Rx Deductible * $110 $230 $50 $0 In-Network Maximum Out of Pocket Combined Maximum Out of Pocket $3,400 $3,400 $3,200 $3,000 $5,100 $5,100 $4,700 $3,500 * The deductible does not apply to Preventive Services, In-network Office Visits and Diabetic Supplies, Emergency Room, Urgent Care and any Extra Benefits.

41 Douglas County 2018 Medical Plans Benefit Bronze Bronze Rx (In-network / Out-of-network) Silver & Silver Rx Gold Rx PCP Visits $15* / $40 $15* / $40 $15* / $30 $15 / $25 Specialist $25* / $50 $25* / $50 $15* / $40 $15 / $30 Diabetic Supplies $0* / $0 $0* / $0 $0* / $0 $0 / $0 Lab 15% / 25% 15% / 25% $0 / $0 $0 / $0 X-Ray 20% / 30% 20% / 30% 15% / 30% 15% / 20% CT/PET/MRI 20% / 30% 20% / 30% 15% / 30% 15% / 20% DME 20% / 30% 20% / 30% 20% / 30% 15% / 20% Part B Drugs 20% / 30% 20% / 30% 15% / 30% 15% / 20% (* Plan deductible does not apply.)

42 Douglas County 2018 Medical Plans (In-network/Out-of-network) Benefit Bronze Bronze Rx (Umpqua) Silver & Silver Rx Gold Rx Inpatient Hospital: Acute $275 / $375 Days 1-7 $300 / $400 Days 1-7 $200 / $325 Days 1-8 $200 / $325 Days 1-8 Skilled Nursing (Days 1-100) $20/$100 (1-20) $65/$100 (21-100) $20/$100 (1-20) $65/$100 (21-100) $20/$75 (1-20) $65/$75 (21-100) $20/$75 (1-20) $65 /$75 (21-100) Outpatient Surgery (Hospital) Outpatient Surgery (ASC) 20% / 30% 25% / 40% 20% / 30% $225 / $325 20% / 30% $225 / $325 $225 / $325 $200 / $325

43 Douglas County 2018 Medical Plans Benefit Bronze Bronze Rx (Umpqua) Silver & Silver Rx Gold Rx Emergency Room $100 * $100 * $100 * $100 Urgent Care $35 * $15 * $15 * $15 Ambulance 20% 20% Silver-$150 Silver Rx-$200 $150 * Deductible does not apply. Worldwide coverage for Emergency/Urgent Care. Emergency Room and Urgent Care cost shares are waived if admitted within 24 hrs.

44 Douglas County 2018 Plans - Extra Covered Services (In-network/Out-of-network) Benefit Silver & Silver Rx Gold Rx Routine Eye Exam (every calendar year) Vision Hardware (every two years) Preventive Dental (every calendar year) Health Club Reimbursement Routine Chiropractic Routine Podiatry Routine Hearing $15 / $40 $15 / $30 Silver - $150 Silver Rx - $100 n/a $200 $15 / $15 $500 maximum $500 $500 n/a n/a n/a $15 / $15 $500 maximum $15 / $25 $500 maximum $15 / $25 $300 maximum

45 Douglas County 2018 Prescription Drug Benefits Tier Bronze Rx (Umpqua) Silver Rx Gold Rx Rx Deductible (Tiers 3,4,5) - $100 $75 $0 Preferred Generic 1 $10 * $6 * $4 Generic 2 $20 * $15 * $10 Preferred Brand 3 $45 $40 $35 Non-Preferred Brand 4 $95 $85 $75 Specialty Meds 5 31% 29% 33% Select Care Drugs 6 $0 * $0 * $0 * - Deductible waived. Our 90-day supply cost share is only 2x the monthly cost share.

46 Douglas County Four Stages of Rx Coverage Plan Deductible Bronze Rx - $100 * / Silver Rx - $75 * TRUE Out of Pocket = $5,000 All costs paid by the Member Only 1 2 Initial Coverage Period Copays / Coinsurance * - Deductible waived Tier Desc Br Rx S Rx G Rx 1 PG $10 * $6 * $4 2 G $20 * $15 * $10 3 PB $45 $40 $35 4 NPB $95 $85 $75 5 Spec 31% 29% 33% 6 Select $0 * $0 * $0 3 COVERAGE GAP Member pays no more than 35% for Brand name drugs and 44% for Generics 4 CATASTROPHIC COVERAGE Cost Share = Greater of: Generics - $3.35, Brand - $8.35, or 5% Once total drug costs reach $3,750 Total Drug Costs = Deductible + Coinsurance + Plan Payments

47 Josephine/Jackson Counties 47

48 Josephine/Jackson Counties 2018 Medical Plan Changes (In-network/Out-of-network) Description Gold Rx Premium $165 Plan Eliminated Silver Rx Premium $103 $112 Emergency Room $65 $100 Dialysis 15% / 30% 20% / 30% Outpatient Surgery Hospital $225 / $325 20% / 30% Outpatient Surgery ASC 20% / 30% $225 / $325 Silver Premium $54 Plan Eliminated Bronze Rx Premium $0 $9 Deductible $185 $250 Emergency Room $65 $100 Outpatient Surgery ASC 20% / 30% $225 / $325 Bronze Premium $0 Plan Eliminated 48

49 Josephine/Jackson Counties 2018 Prescription Drug Plan Changes Bronze Rx & Silver Rx Rx Deductible Bronze Rx - $150 (all Tiers) Silver Rx - $0 Bronze Rx - $150 (Tiers 3, 4, 5 only) Silver Rx - $0 Stage 2 Limit (Initial Coverage Period) Stage 3 Discounts (Coverage Gap) Stage 4 Copays (Catastrophic Coverage) $3,700 $3,750 Generics 49% / Brands 60% True Out of Pocket - $4,950 Generics-56% / Brands 65% True Out of Pocket - $5,000 Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $8.35

50 Josephine/Jackson Counties 2018 Plans Plans Premium ATRIO Bronze Rx (Rogue) (PPO) $9.00 ATRIO Silver Rx (PPO) $ ATRIO Special Needs Plan (D-SNP) (HMO) $0.00

51 Preventive Services All 2018 Plans Preventive Care Service Cost Share Annual Physical Exam $0 Bone Mass Measurement $0 Colorectal Screenings $0 Immunizations $0 Mammograms $0 Pap Smears $0 Pelvic Exams $0 Prostate Exams $0 Smoking Cessation $0 (Please see an Evidence of Coverage booklet for a complete list of covered preventive services.)

52 Josephine/Jackson Counties 2018 Plans Bronze Rx Silver Rx Deductible * $250 $50 In-Network Maximum Out of Pocket $3,400 $3,200 Combined Maximum Out of Pocket $5,100 $4,700 * The deductible does not apply to Preventive Services, In-network Office Visits, Diabetic Supplies, Emergency Room, Urgent Care or any Extra Benefits.

53 Josephine/Jackson Counties 2018 Plans (In-network/Out-of-network) Benefit Bronze Rx Silver Rx PCP Visits $35* / $40 $15* / $30 Specialist $45* / $50 $15* / $40 Diabetic Supplies $0* / $0 $0* / $0 Lab 15% / 25% $0 / $0 X-Ray 20% / 30% 15% / 30% CT/PET/MRI 20% / 30% 15% / 30% DME 20% / 30% 15% / 30% Part B Drugs 20% / 30% 15% / 30% (* Plan deductible does not apply.)

54 Josephine/Jackson Counties 2018 Plans (In-network/Out-of-network) Benefit Bronze Rx Silver Rx Inpatient Hospital: Acute Skilled Nursing (Days 1-100) $275 / $375 Days 1-7 $20/$100 (1-20) $65/$100 (21-100) $200 / $325 Days 1-8 $20/$75 (1-20) $65/$75 (21-100) Outpatient Surgery - Hospital 20% / 30% 20% / 30% Outpatient Surgery ASC $225 / $325 $225 / $325

55 Josephine/Jackson Counties 2018 Plans Benefit Bronze Rx Silver Rx Emergency Room $100 * $100 * Urgent Care $35 * $15 * Ambulance 20% $200 * Deductible does not apply. Worldwide coverage for Emergency/Urgent Care. Emergency Room and Urgent Care cost shares are waived if admitted within 24 hrs.

56 Josephine/Jackson Counties 2018 Plans - Extra Covered Services Benefit Routine Eye Exam (every calendar year) Silver Rx In-network / Out-of-Network $15 / $40 Health Club Reimbursement $500

57 Josephine/Jackson Counties 2018 Prescription Drug Coverage Tier Bronze Rx Silver Rx Rx Deductible (Tiers 3, 4, 5) - $150 $0 Preferred Generic 1 $10 * $6 Generic 2 $20 * $15 Preferred Brand 3 $45 $40 Non-Preferred Brand 4 $95 $85 Specialty Meds 5 29% 33% Select Care Drugs 6 $0 * $0 * Deductible waived. Our 90 day supply cost share is only 2x the monthly cost share.

58 Josephine/Jackson Counties Four Stages of Rx Coverage Annual Rx Deductible Bronze Rx - $150 * / Silver Rx - $0 TRUE Out of Pocket = $5,000 All costs paid by the Member Only 1 2 Initial Coverage Period Copays / Coinsurance * - Deductible waived Tier Desc Bronze Rx Silver Rx 1 PG $10 * $6 2 G $20 * $15 3 PB $45 $40 4 NPB $95 $85 5 Spec 29% 33% 6 Select $0 * $0 3 COVERAGE GAP Member pays no more than 35% for Brand name drugs and 44% for Generics 4 CATASTROPHIC COVERAGE Cost Share = Greater of: Generics - $3.35, Brand - $8.35, or 5% Once total drug costs reach $3,750 Total Drug Costs = Deductible + Coinsurance + Plan Payments

59 Klamath County 59

60 Description Gold Rx Premium $180 $189 Ambulance $100 $150 Emergency $65 $100 Dialysis 15% / 20% 20% / 30% Outpatient Surgery Hospital $200 / $325 $225 / $325 Maximum Out of Pocket Limit $2500 / $3500 $3000 / $3500 Prescription Drugs Klamath County Gold Rx Plan Changes (In-network/Out-of-network) Stage 2 Limit (Initial Coverage Period) $3700 $3750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% Generics-56% / Brands 65% Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $

61 Klamath County Silver & Silver Rx Plan Changes Description Silver & Silver Rx Premiums Silver - $59 Silver Rx - $113 Silver - $65 Silver Rx - $122 Ambulance Silver Silver - $200 Silver - $150 Emergency $65 $100 Durable Medical Equipment 15% 20% Dialysis 15% 20% Outpatient Surgery Hospital Silver - $200 / $325 Silver Rx - $225 / $325 20% / 30% Outpatient Surgery ASC 20% / 30% $225 / $325 Silver Rx Prescription Drugs Deductible (Tiers 3, 4, 5 only) $0 $75 Stage 2 Limit (Initial Coverage Period) $3,700 $3,750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% True Out of Pocket - $4,950 Generics-56% / Brands 65% True Out of Pocket - $5,000 Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $

62 Klamath County Bronze & Bronze Rx Plan Changes Description Bronze & Bronze Rx Premiums Bronze - $0 Bronze Rx - $21 Bronze - $0 Bronze Rx - $31 Emergency $65 $100 Outpatient Surgery Hospital Bronze Rx - 20% / 30% Bronze Rx 25% / 40% Outpatient Surgery ASC Bronze Rx - 20% / 30% Bronze Rx - $225 / $325 Bronze Rx Prescription Drugs Deductible (Tiers 3, 4, 5 only) $0 $100 Specialty Medications (Tier 5) 33% 31% Stage 2 Limit (Initial Coverage Period) $3,700 $3,750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% True Out of Pocket - $4,950 Generics-56% / Brands 65% True Out of Pocket - $5,000 Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $

63 Klamath County 2018 Plans Plans Premium ATRIO Bronze (PPO) $0.00 ATRIO Bronze Rx (Basin) (PPO) $31.00 ATRIO Silver (PPO) $65.00 ATRIO Silver Rx (PPO) $ ATRIO Gold Rx (PPO) $ ATRIO Special Needs Plan (HMO) (D-SNP) $

64 Preventive Services All 2018 Plans Preventive Care Service Cost Share Annual Physical Exam $0 Bone Mass Measurement $0 Colorectal Screenings $0 Immunizations $0 Mammograms $0 Pap Smears $0 Pelvic Exams $0 Prostate Exams $0 Smoking Cessation $0 (Please see an Evidence of Coverage booklet for a complete list of covered preventive services.)

65 Klamath County 2018 Medical Plans Bronze Bronze Rx Silver & Silver Rx Gold Rx Deductible * $110 $185 $50 $0 In-Network Maximum Out of Pocket Combined Maximum Out of Pocket $3,400 $3,400 $3,200 $3,000 $5,100 $5,100 $4,700 $3,500 * The deductible does not apply to Preventive Services, In-network Office Visits and Diabetic Supplies, Emergency Room, Urgent Care and any Extra Benefits.

66 Klamath County 2018 Medical Plans Benefit Bronze Bronze Rx (In-network / Out-of-network) Silver & Silver Rx Gold Rx PCP Visits $15* / $40 $35* / $40 $15* / $30 $15 / $25 Specialist $25* / $50 $45* / $50 $15* / $40 $15 / $30 Diabetic Supplies $0* / $0 $0* / $0 $0* / $0 $0 / $0 Lab 15% / 25% 15% / 25% $0 / $0 $0 / $0 X-Ray 20% / 30% 20% / 30% 15% / 30% 15% / 20% CT/PET/MRI 20% / 30% 20% / 30% 15% / 30% 15% / 20% DME 20% / 30% 20% / 30% 20% / 30% 15% / 20% Part B Drugs 20% / 30% 20% / 30% 15% / 30% 15% / 20% (* Plan deductible does not apply.)

67 Klamath County 2018 Medical Plans (In-network/Out-of-network) Benefit Bronze Bronze Rx (Basin) Silver & Silver Rx Gold Rx Inpatient Hospital: Acute $275 / $375 Days 1-7 $275 / $375 Days 1-7 $200 / $325 Days 1-8 $200 / $325 Days 1-8 Skilled Nursing (Days 1-100) $20/$100 (1-20) $65/$100 (21-100) $20/$100 (1-20) $65/$100 (21-100) $20/$75 (1-20) $65/$75 (21-100) $20/$75 (1-20) $65 /$75 (21-100) Outpatient Surgery (Hospital) Outpatient Surgery (ASC) 20% / 30% 25% / 40% 20% / 30% $225 / $325 20% / 30% $225 / $325 $225 / $325 $200 / $325

68 Klamath County 2018 Medical Plans Benefit Bronze Bronze Rx (Basin) Silver & Silver Rx Gold Rx Emergency Room $100 * $100 * $100 * $100 Urgent Care $35 * $15 * $15 * $15 Ambulance 20% 20% Silver-$150 Silver Rx-$200 $150 * Deductible does not apply. Worldwide coverage for Emergency/Urgent Care. Emergency Room and Urgent Care cost shares are waived if admitted within 24 hrs.

69 Klamath County 2018 Plans - Extra Covered Services Benefit Routine Eye Exam (every calendar year) Vision Hardware (every two years) Preventive Dental (every calendar year) Health Club Reimbursement Routine Chiropractic Routine Podiatry Routine Hearing Silver & Silver Rx In-network/Out-of-network Gold Rx In-network/Out-of-network $15 / $40 $15 / $30 Silver - $150 Silver Rx - $100 n/a $200 $15 / $15 $500 maximum $500 $500 n/a n/a n/a $15 / $15 $500 maximum $15 / $25 $500 maximum $15 / $25 $300 maximum

70 Klamath County 2018 Prescription Drug Benefits Tier Bronze Rx (Basin) Silver Rx Gold Rx Rx Deductible (Tiers 3,4,5) - $100 $75 $0 Preferred Generic 1 $10 * $6 * $4 Generic 2 $20 * $15 * $10 Preferred Brand 3 $45 $40 $35 Non-Preferred Brand 4 $95 $85 $75 Specialty Meds 5 31% 29% 33% Select Care Drugs 6 $0 * $0 * $0 * - Deductible waived. Our 90-day supply cost share is only 2x the monthly cost share.

71 Klamath County Four Stages of Rx Coverage Plan Deductible Bronze Rx - $100 * / Silver Rx - $ 75 * TRUE Out of Pocket = $5,000 All costs paid by the Member Only 1 2 Initial Coverage Period Copays / Coinsurance * - Deductible waived Tier Desc B Rx S Rx G Rx 1 PG $10 * $6 * $4 2 G $20 * $15 * $10 3 PB $45 $40 $35 4 NPB $95 $85 $75 5 Spec 31% 29% 33% 6 Select $0 * $0* $0 3 COVERAGE GAP Member pays no more than 35% for Brand name drugs and 44% for Generics 4 CATASTROPHIC COVERAGE Cost Share = Greater of: Generics - $3.35, Brand - $8.35, or 5% Once total drug costs reach $3,750 Total Drug Costs = Deductible + Coinsurance + Plan Payments

72 Marion/Polk Counties 72

73 Description Marion/Polk Counties Gold Rx Plan Changes 2017 In-network/Out-of-network 2018 In-network/Out-of-network Gold Rx Premium $185 $209 Ambulance $100 $175 Emergency $65 $100 Dialysis 20% /20% 20% / 30% Outpatient Surgery Hospital $150/$225 $175/$325 Outpatient Surgery ASC $150/$225 $150/$225 Annual Out of Pocket Maximum $2,500 / $5,100 $3,000 / $5,100 Prescription Drug Benefits Stage 2 Limit (Initial Coverage Period) $3700 $3750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% True Out of Pocket - $4,950 Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics-56% / Brands 65% True Out of Pocket - $5,000 Generics $3.35 / Brands $

74 Marion/Polk Counties Silver Rx Medical Plan Changes Description 2017 In-network/Out-of-network 2018 In-network/Out-of-network Silver Rx Premium $67 $88 Ambulance $100 $175 Emergency $65 $100 Dialysis 20% / 20% 20% / 30% Outpatient Surgery Hospital $175/$225 $225/$325 Outpatient Surgery ASC $175/$225 $175/$225 Inpatient Hospital Maximum $1,000 $1,200 74

75 Marion/Polk Counties Silver Rx Prescription Plan Changes Description 2017 In-network/Out-of-network 2018 In-network/Out-of-network Rx Deductible (Tiers 3, 4, 5 only) $0 $100 Specialty Medications (Tier 5) 33% 31% Stage 2 Limit (Initial Coverage Period) $3,700 $3,750 Stage 3 Discounts (Coverage Gap) Generics 49% / Brands 60% True Out of Pocket - $4,950 Generics-56% / Brands 65% True Out of Pocket - $5,000 Stage 4 Copays (Catastrophic Coverage) Generics $3.30 / Brands $8.25 Generics $3.35 / Brands $

76 Marion/Polk Counties 2018 Plans Plan Premium ATRIO Silver Rx (PPO) $88.00 Optional Vision/Dental $27.00 ATRIO Gold Rx (PPO) $209.00

77 Preventive Services All 2018 Plans Preventive Care Service Cost Share Annual Physical Exam $0 Bone Mass Measurement $0 Colorectal Screenings $0 Immunizations $0 Mammograms $0 Pap Smears $0 Pelvic Exams $0 Prostate Exams $0 Smoking Cessation $0 (Please see your Evidence of Coverage booklet for a complete list of covered preventive services.)

78 Marion/Polk Counties 2018 Plans Cost Share Silver Rx Gold Rx Deductible * $50 $0 In-Network Maximum Out of Pocket Combined Maximum Out of Pocket $3,400 $3,000 $5,100 $5,100 *The deductible does not apply to Preventive Services, In-network Office Visits, Diabetic Supplies, Emergency Room, Urgent Care or any Extra or Optional Benefits.

79 Marion/Polk Counties 2018 Plans (In-network/Out-of-network) Benefit Silver Rx Gold Rx PCP Visits $15* / $35 $15 / $30 Specialist $35* / $35 $20 / $30 Diabetic Supplies $0* / $0 $0 / $0 Lab $0 / $0 $0 / $0 X-Ray 15% / 20% 15%/ 20% CT/PET/MRI 20% / 30% 15% / 20% DME 20% / 30% 20% / 20% Part B Drugs 20% / 20% 20% / 20% * Plan deductible does not apply. Copay waived for chronic care management (CPT 99490) offered by your in-network PCP or specialist. There is $0 copay for in-network visits rendered by Family Medicine physicians with a specialization in Obesity Medicine.

80 Marion/Polk Counties 2018 Plans (In-network/Out-of-network) Benefit Silver Rx Gold Rx Inpatient Hospital: Acute $200 / $300 Days 1-6 $200 / $300 Days 1-6 Skilled Nursing $10/$30 (Days 1-10) $20/$50 (Days 11-25) $13.56/$0 (Days ) $10 / $50 (Days 1-100) Outpatient Surgery Hospital $225 / $325 $175 / $325 Outpatient Surgery - ASC $175 / $225 $150 / $225

81 Marion/Polk Counties 2018 Plans Benefit Silver Rx Gold Rx Emergency Room $100 * $100 Urgent Care $15 * $15 Ambulance $175 $175 * Deductible does not apply. Worldwide coverage for Emergency/Urgent Care. Emergency Room and Urgent Care cost shares are waived if admitted within 24 hrs.

82 Marion/Polk Counties 2018 Plans - Extra Covered Services Benefit Silver Rx Gold Rx Routine Eye Exam (one every calendar year) Vision Hardware Allowance (every two years) Preventive Dental (every calendar year) Routine Podiatry (In-network/Out-of-network) n/a * $15 / $30 n/a * $150 n/a * n/a $0 $500 maximum $15 / $25 $500 maximum Health Club Reimbursement $500 $500 * - Available to Silver Rx members as an optional buy-up benefit. See next slide.

83 Silver Rx Members 2018 Optional Buy-up Benefit Package (In-network/Out-of-network) Benefit Routine Eye Exam (one every calendar year) Vision Hardware Allowance (every two years) Preventive Dental (every calendar year) Silver Rx $35 / $35 $100 $35 $500 maximum Monthly Premium $27

84 Marion/Polk Counties Silver Rx Optional Vision/Dental Benefit Please Note: Current Silver Rx members who are not already but who do want to enroll in the Optional Vision/Dental Benefit MUST complete a Plan Change form and pay the $27/month premium to enroll.

85 Marion/Polk Counties 2018 Prescription Drug Benefits Tier Silver Rx Gold Rx Rx Deductible (Tiers 3, 4, 5) - $100 $0 Preferred Generic 1 $6 * $4 Generic 2 $15 * $10 Preferred Brand 3 $40 $35 Non-Preferred Brand 4 $85 $75 Specialty Meds 5 31% 33% Select Care Drugs 6 $0 * $0 * - Deductible waived. Our 90 day supply cost share is only 2x the monthly cost share.

86 Marion/Polk Counties Four Stages of Rx Coverage Plan Deductible Silver Rx - $100 * / Gold Rx - $0 TRUE Out of Pocket = $5,000 All costs paid by the Member Only 1 2 Initial Coverage Period Copay/Coinsurance * - Deductible waived Tier Desc Silver Rx Gold Rx 1 PG $6 * $4 2 G $15 * $10 3 PB $40 $35 4 NPB $85 $75 5 Spec 31% 33% 6 Select $0 * $0 3 COVERAGE GAP Member pays no more than 35% for Brand name drugs and 44% for Generics 4 CATASTROPHIC COVERAGE Cost Share = Greater of: Generics - $3.35, Brand - $8.35, or 5% Once total drug costs reach $3,750 Total Drug Costs = Deductible + Coinsurance + Plan Payments

87 Medicare s Extra Help Program If you have low income You may qualify for extra help with your Medicare Part D drug premium and your drug cost share expenses (deductibles, copays, coinsurance) at the time of service This program is also called the Low Income Subsidy, or LIS Beneficiaries have to apply for this benefit unless they receive notice from Medicare stating they automatically qualify Qualification is determined by the Social Security Administration Contact the SSA: (800) or Visit your local Social Security office at: Douglas Josephine/Jackson Klamath Marion/Polk 1730 NW Hughwood 3501 Excel Dr Ste 101, (Medford) 3501 Excel Dr Ste 101, (Medford) 1750 McGilchrist St SE Suite 110

88 2017 Extra Help (LIS) Income/Asset Thresholds Note: These amounts may change in 2018 Individual Monthly Income less than: $ 1,528* Total Resources less than: $13,820 Married couple living together Monthly Income less than: $ 2,050* Total Resources less than: $27,600 (* Even if your annual income is higher, you may still be able to get some help (e.g., supporting other family members that live with you). Contact the SSA to get assistance.)

89 Douglas County 2018 LIS Subsidized Premiums ATRIO Bronze Rx (Umpqua) (PPO) $ 0.00 ATRIO Silver Rx (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $ ATRIO Gold Rx (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $

90 Josephine/Jackson Counties 2018 LIS Subsidized Premiums ATRIO Bronze Rx (Rogue) (PPO) $ 9.00 with 100% subsidy $ 0.00 with 75% subsidy $ 2.20 with 50% subsidy $ 4.50 with 25% subsidy $ 6.70 ATRIO Silver Rx (Rogue) (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $

91 Klamath County 2018 LIS Subsidized Premiums ATRIO Bronze Rx (Basin) (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $ ATRIO Silver Rx (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $ ATRIO Gold Rx (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $

92 Marion/Polk Counties 2018 LIS Subsidized Premiums ATRIO Silver Rx (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ with 25% subsidy $ ATRIO Gold Rx (PPO) $ with 100% subsidy $ with 75% subsidy $ with 50% subsidy $ 191,70 with 25% subsidy $

93 How to Enroll Reminder: Those with End Stage Renal Disease cannot change plans. Enrolling is as easy as 1-2-3! a. Complete an ATRIO Plan Election (enrollment) form Be sure to properly complete the Medicare ID box in the lower right corner of the form b. Return the form to ATRIO Health Plans Drop off, mail in or fax to: (866) or (541) c. Call our Customer Service team and enroll over the phone: TTY/TDD: (800) Or Go to our website and enroll online at Note: If you qualify for Medicare s Extra Help program, be sure to include a copy of your client s letter from the Social Security Administration.

94 ATRIO s Local Office Address: Office Hours: Douglas County ATRIO Health Plans 2270 NW Aviation Drive, Suite 3 Roseburg, OR a.m. to 5 p.m. (M-F) (Pacific) Customer Service Hours: 8 a.m. to 8 p.m. Daily (Pacific) Toll Free: (877) TTY/TDD: (800) Fax: (866) or (541) Online:

95 ATRIO s Local Office Address: Josephine/Jackson Counties ATRIO Health Plans 1867 Williams Hwy, Suite 226 Grants Pass, OR Office Hours: Customer Service Hours: 8 a.m. to 5 p.m. (M-F) (Pacific) 8 a.m. to 8 p.m. Daily (Pacific) Toll Free: (877) TTY/TDD: (800) Fax: (866) or (541) Online:

96 ATRIO s Local Office Address: Office Hours: Klamath County ATRIO Health Plans 2909 Daggett Ave., Suite 250 Klamath Falls, OR a.m. to 5 p.m. (M-F) (Pacific) Customer Service Hours: 8 a.m. to 8 p.m. Daily (Pacific) Toll Free: (877) TTY/TDD: (800) Fax: (866) or (541) Online:

97 ATRIO s Local Office Address: Office Hours: Marion & Polk Counties ATRIO Health Plans 2965 Ryan Dr SE Salem, OR a.m. to 5 p.m. (M-F) (Pacific) Customer Service Hours: 8 a.m. to 8 p.m. Daily (Pacific) Toll Free: (877) TTY/TDD: (800) Fax: (866) or (541) Online:

98 Where to Get More Help Visit online at: Call Medicare at: Medicare ( ), or TTY/TDD at Medicare staff are available 24 hours a day, 7 days a week Call Social Security at: , or TTY/TDD at Social Security staff are available 7 am to 7 pm, M-F

99 Don t Forget: Compliance is EVERYONE S Responsibility! PREVENT Operate within ATRIO s ethical expectations to PREVENT noncompliance! DETECT & REPORT If you DETECT potential noncompliance, REPORT it! CORRECT CORRECT non-compliance to protect beneficiaries and to save money! 99

100 How Can I Report Potential Non-compliance or FWA? Employees of ATRIO Call the ATRIO Compliance Officer at: (503) Make a report through the Website the Compliance@atriohp.com Agents and Agencies Talk to an ATRIO Sales Manager or Agent Desk Call Your Ethics/Compliance Help Line (If available) Report through ATRIO (website or mail) Beneficiaries Call the ATRIO Compliance Officer Make a report through ATRIO s website Call Medicare 100

101 No Retaliation or Intimidation There can be NO retaliation against you for reporting suspected non-compliance or FWA in good faith. ATRIO will not support tolerate this behavior. There can be NO acts of intimidation toward staff that would prevent them from reporting suspected non-compliance or FWA. Each reported issue will be handled confidentially and respectfully. ATRIO is committed to protecting the job security and promotion opportunities of persons who in good faith, report violations. 101

102 Thank you! ATRIO HEALTH PLANS GET MORE FROM YOUR MEDICARE BENEFITS LOCAL SERVICE WORLDWIDE BENEFITS ENROLL TODAY AND REST ASSURED-WE HAVE YOU COVERED!