the physician will just send us the bill and we'll pay it directly 99.9 percent of the time our data shows we're serving roughly a third of the numbers we're able to educate the provider open their financial benefit of the speed of payment and it takes the member out of the middle. >> they just bill medicare and medicare reimburses them the reason they don't take hmos you set the fee not medicare who is setting the fee you or medicare. >> we'll arrested on 0 rate based if we don't we pate them one hundred percent medicare. >> you'll pay medicare's fee. >> absolutely that's why they

accept 2 we're not proposing 9.99 percent we're paying the few rates that's why 99 percent of the time the providers accept the plan and agree to a. >> what happens if they don't accept it. >> we'll get the bill and pay it directly. >> i don't know what the out of benefits from the network our worse case scenario you have a contracted situation they don't have willing provider for the medicare providers on the other hand, we found this is a dramatic you are the primary with the benefit plan being wrapped up around the determination of when a with

whether the preparation of the claim is a contractual one so in a medicare advantage plan in our national p pox o plan their dramatically kind of differences of before mentioned from a local hmo or p po because we include a medicare provider let's just slide back a little bit let's see to slide 5 nicole if you don't mind this slide highlights some of the further vandals of the national medicare advantage p po as i mentioned anywhere the folks live in their covered in the u.s. materials we build a kilogram design that has the same or better benefits than the members have today and the non differential network i've mentioned you don't need to

identify a primary care provider and we have a number of benefits those include the chiropractic and gym membership health and wellness that seniors find toxic you're hearing aids benefit a really terrific program that enables members to get discounted hearing aids the example is that a $2,000 hearing aid by a member offered for $600 on a hearing aid base that's the substantial savings and the solution for caregivers that provides support typically for the adult of retiree member you know family members or what have you providing take care care to their parents typically or other

relatives and gives us a network of services to do that more effectively and less stress and burden. >> so you don't need a primary care physician. >> yeah. it's not an hmo plan. >> you need a doctor to prescribe prescriptions and prescriptions for physical therapy and referrals to prediabetic classes. >> i still have a primary care physician but not forced to select one from our network is the point. >> they can be anyone. >> that's right as long as they serve medicare what is great we never seek to disrupt an existing relationship between the retiree and the physician. >> the point is we don't force if there were a local hmo plan

you'll be forced to select a primary care physician in the network no one else name will appear on the card you'll go to the physician first, this is a real open access architecture that allows you to maintain any current care physician and you're not forced to pick from our list if we could i guess one final note this is group based business just the way i become used to having a dictated service model with 2k5k9d people on the phone answering you know questions about their benefits or where to go for care i've heard the concern of urgent care we have a 2k5k9d client service model that's built for clients

in the city and county of san francisco that is kri7b8 high touch we're in the midst of rolling out a new service model that is available on the a s o plan you have today called the advocate for me it is really a revolutionary service model when a person caudal calls a number so it will be available everywhere in january first of 2016 you call into the service center you provide our service number there's an intelligent routinely process that matches our number against our claims history if you're a.d. admitted to the hospital or recently had a series of set of the your call will be routed to a nurse who will see your medical record

that leap frogs the - it will have the inability to adjust a claim with a well trained consumer rep that explains coverage and access and eligibility questions each the levels has a third party calling u calling capacity the nurse can call the provider with the member on the line to call a pharmacy with a prescription renewed or filled for a member or call the primary care physician or identify an urgent care center it's a transitional level of services to get out the thorn i didn't aspects i know

you've been struggling with on the urgent care issue i think you appreciate the providers to provide us on a will realtime basis oftentimes you'll have a clinic that offers walk in hours they want the physician it build up his are her practices or a clinic my consolidated or open a new one capturing the demographic on a realtime basis is a challenge we face but this level of customer service with this third party calling combablt with realtime the patient north's needs care that evening we'll have someone on the phone to have a call provider do you have evening hours and handle that kind of

interface we're excited about that and if this is something of interest i'll bring some of our operation overlook disburse rows reduce to show you. >> i'll be curious how this is going to work at the present how will you guarantee the system is going to work. >> we'll empower our customer service reps to pick up the phone they have access on their computer terminals to get the information to make the calls with the member on the line as opposed to everything a directory is provided it is usually not continued. >> through the chair i was at

the harvard kindergarten school with leadership from the white house and h h s and all sorts of folks that was called how to get the data to flow there the system there were the smart it people in the room, i was shocked at the problem was asz as real as soon as one person changed one thing you don't know until it is known it is changed a gigantic problem it is a project so a bunch of people working out the district of columbia and harvard that are taking the initiatives to solve this problem i didn't royals the magnitude until i was with the leaders a fukdz san francisco is a unique place real estate is expensive i'll tell you i used

to run a urgent care clinic from 998 to 2005 or 4 unless your totally staffed you can't add the urgent care into a practice urgent care a set of skills and tools and challenges you can't draw urgent care into this you can but not really urgent care it is not sown up if you cut yours the primary care is not going to do it they've got the skills and know how in new york there's a chain of urgent cares and city care their rapidly opening up the patients acknowledge they have to pay you something i don't know if it is

extra san francisco is tough real estate is expensive and decreases don't get that much anymore they're charging ridiculous amazes amounts of money to have an office across the street from the hospital outside of star ratings decreases are not getting salary increases but reductions every year they don't expect reductions in this business we can august that on the merits of broken system but when your rent goes up and your staff increases and everything goes up your heading for a major problem so urgent care is a separate animal is my main point i know a lot of

the urgent care decreases in san francisco whether you contract with you or not i don't know, you, do a google search and find those centers most decreases would like to get paid more after 5 o'clock but i'm sure your code they don't get paid more for a tloushgs visit or whatever my employees get paid more but the extra time or after hours is any different than any other times there's a multitude of reasons there's a bunch of data points of my observation over the last decade. >> we're running out of 7, 8, 9 we're going to move through the deck. >> let's do that so slide 6

really covers the critical kind of performance that has helped to us deliver sustainable performances year after year you'll see the star ratings i'll speak about those on a future slide we have a program called house calls nurses go into the members homes and do a unique environmental access and coordinate with their care provider we work hard at the network initiative contracting i've mentioned the medicare 2k5k9d service model if we jump to slide 7 this is the long tunnel way we manage patient from healthy to end of life care and everything in between i'm not a physician i stayed at a

holiday in i'd like walk you through this i'll bring bay back my colleague but i've got a couple of slides that shows you the work slide 8 is how the national network works a great history of acceptance and the next slide 9 shows our experience we're able to have the 9.9 percent of the providers accept our plan after we do the appropriate outreach and pay them only a fee per service level the next slide houses calls this is - >> can you interrupt you on slide 9. >> of course arrest i wanted to point out 612 percent of our claims are in network and others out of network this is our actual.

>> those are your town hall claims nicole do you want to come up? and it's on >> go ahead. >> so what we did is take a look at 12 months of claims by medicare ab members on our curiosity city plan and take a look at to see how many of the claims were simpleminded by the decreased they're the decreases in the that is p po network 38 percent were outside of network and again, a member can go to any medicare participating it is not va but anyone that participate in medicare basically one-tenth of one percent members decreases submitted claims no united health care that will not submit

claims to medicare health care under the p po plan. >> the punch line 36 percent out of network those providers represented they'll accept the plan and will file the claims directly with us so having no disruption whatsoever i mentioned the house calls program which we think is a high impact program we identify the members that maybe have two or three chronic disease states the participation goes into the home and literally goes through the medication cabinet with an ipad of questions to ask this is closing gaps in care and providing a coordination of care and in between the providers that a member sees and ran

corporation did a research and presented their finding as a result, the advance meows notice highlighting those in home nursing segment will continue but establish best practices along the lines so we're rather pleased with that outcome if we jump to the next slide. >> just interrupt this part of house calls there's a request for that. >> they don't have so request or pay we call them and say we would like to have a nurse come to our home most of the nurses will come back and see the same patients year after year and establish a personal relationship. >> it's like home care. >> but more of a primary care than a specific kind of disease

care nurse so let's see slide 11 question have a pharmacy safer program that is popper with the part d plan that will continue it offers $2 genetic drugs at the retail pharmacies highlighted there if we move to the next slide in railroadss we're getting the member from 3 id cards medicare part ab card a separate part d card and the city plan a s o card down to a simple card tease to understand we want to highlight the next slide c.m.s. requires us to review the m ap d for high-risk medications and focuses on drugs that cause confusion and

sedition or other things for example, a sleeping aid or certain muscle relaxants they cause injury risk of if you will, and other things in a post 360 population there are 9 hundred plus individuals that are taking one of the drugs today so we'll develop a detailed outreach campaign to contact their physician and understand why they're on the drug and what alternate therapies to mitigate this risk and make sure there notice disruption in their care or therapy this is something we want to highlight but it is for the protection and benefit of the member. >> 9 hundred and 5 that's a lot of members. >> it is. >> those drugs may not be good for someone what are they people

doing they'll not be able to get them. >> they can if there's a medical reap to stay on them but typically commissioner breslin there's an alternate drug with no side effects it is not about denying care therapy it is about creating the right alters to create and mitigate so the member is safe. >> there will be a lot of confusion and disruption. >> we've got a long experience of handholding numbers at the end of the day the doctors recognize it is for their walgreens and safety everyone like the status quo but we do a good job of walking them through the process. >> this is a reflective of what

we see view as a positive outcome you'll see a substantial reductions in emergency room visit and the in patient admissions a very large increase in the number of remoigsdz we're able to evaluated and a spike in primary care visit we want our retirees to get care frequently and regularly not in an e.r. setting or hospital but to drive that primary care engagement that's a big part of our driving to the hyatt high quality levels in the performance of our platoon the next slide shows you us driving the drive to 5 plan to the 5 star threshold in the c m s star ratings i've mentioned over 99 percent of our group and p po members are on a 5 star

we've got high performance invest this make sure we're delivering for our members that translates into better reimbursement and better plan so i think with that if we jump to 17 i mentioned that the risk adjustment factors is a big part of the program having a sick person is not a problem as long as we have the coordinating reimbursement we've set the standard our house care nurses help us in the business and if we jump to the next slide i'll ask nicole to come up and share a bit of the benefit design work that enhances the benefits for

the members cardboard to what they currently have nicole. >> thank you so what we did he take a look at the end new york times network benefits an 85 percent plan basically the way the plan coordinates with after medicare the plan plays states in place of medicare we've designed the equivalent of the current design it is largely co-pay based there are a lot of benefits to co-pay based basically, the co-pay base plan provides sharing expenses regardless of the costs of the care we find that co-pays have a higher satisfaction rate less guesswork in the percentage

they'll have to pay basically, the way we set up our design the members on average spend the same amount in out-of-pocket prices for each plan top box shows the number of experiences they go to a doctor's office visit in the first example the member pays $3 medicare pays 85 percent and the member pace $3 and the second example in the decrease charges nor o more for the doctors office and medicare pays 80 percent the member is responsibility for the 85 so on average $57 we take out the guesswork and the member p will

pay $5 when they go to the doctors office so on the average it's the same as you have today any questions on the view the plan design if you look at the next slide. >> i have one question you made a couple of recommendations that retirees like the peculiarity of co-pays so usually there's a co-pay or co-insurance or i mean there are generally other things. >> correct. >> i want to be clear when you say co-pay that's all you pay and you're done or other things going coming down they're always unpredictable that didn't rove the reality of unpredictable things later i feel like this is not a real stated because that

is fixed and that's not fixed people don't like uncertainty. >> i agree in our experience they like the predictability of co-pays. >> in the absences of other charges. >> d this goes before the doctor's visit. >> absolutely within the quote that the member - the deductible has been removed no longer a $250 deduct when a member goes to a doctor they'll pay a co-pie as opposed to the 15 percent the united health care pays after medicare pays that's the $6 amount when they look at their evidence of coverage their see the actual flat co-pay. >> okay. >> so that would be like $57.

>> correct. >> like $20 at kaiser for an office visit. >> correct. >> too good to be true usually is too good to be true. >> the next slide is the consideration that have been talked about earlier in the presentation there are a number of advantages to group medicare advantage plan there's pa number of advantages inform a coordination plan and the flexibility is more in terms of the benefit design and the medicare side we have to comply with the c.m.s. regulations there's that impact but because we're able to provide equality benefits there are savings i want to mention work the members will receive one set of communication for the plan one

package of dmungsz for medical as well as 0 that pharmacy one id card things of that nature definitely things to keep in mind as you look at different options there are a couple of slides at the end that talk about the retiree experience if you look at moving to a p po plan for 2016 the first slide walks us through the retiree experience and kind of rolling out the plan and after the plan goes into fleet week we're here to help the retiree when wet roll out a plan the retirees will get a letter for a new option and provide support to the residencies and the plan sponsor in a number of ways we hold educational meetings that

supplement you have a couple of weeks of vendors coming in and being in bone krefrn program from 8 to 5 for two weeks we can splult that with strategy open enrollment meetings for retirees to come and ask questions and later than learn about the option we'll fund the materials we'll send out information on tips for educating our decrease as well as using out of network physicians it was mentioned one of the things we do to help prevent drufks so reach out to all current providers that have submitted claims to the members and let them know they have members e members on a p