Questions and Answers
Which of the following actions should be avoided during a call with a beneficiary? (Select all that apply)
It is appropriate to place a beneficiary on mute for personal discussions?
False
What should an agent do if the consumer's communication is difficult to understand?
Exercise empathy and provide necessary assistance.
Periods of unexplained ______ negatively impact the consumer’s experience.
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Match the following issues with their corresponding descriptions:
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Did the agent ask to save prescription data for enrollment?
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Did the agent ask for Digital Onboarding permission?
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Did the agent ask and properly document the PTE question?
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What is the minimum requirement for Needs Analysis Technique?
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What is the minimum requirement for Presenting a Solution?
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What is the minimum requirement for Call to Action?
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What is the minimum requirement for understanding and addressing the gaps/barriers/concerns?
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What is the minimum requirement for expanding AOR relationship through Humana support/initiatives?
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What is the minimum requirement for demonstrating active listening skills throughout the call?
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Did the agent review the Summary of Benefits prior to completion of the enrollment?
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Did the agent offer to review provider network status, current prescriptions for plan coverage, preferred hospital network status, and preferred facility network status?
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Did the agent explain how enrolling will affect current coverage including being disenrolled from their current plan?
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Did the agent read all required disclosures for the determined plan of interest?
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Did the agent confirm the beneficiary was ready to complete his/her enrollment including stating the plan name and effective date?
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Did the agent accurately complete the consumer's application and review contact information, payment options, language preference, and alternate format election?
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Did the agent follow the appropriate steps to obtain a compliant signature?
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Did the agent claim to be endorsed or work for Medicare?
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Did the agent ask health-related questions that can be used for targeting a subset of members?
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Did the agent engage in high-pressure sales tactics?
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Did the agent disclose health PI information to the wrong party?
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Did the agent cross-sell non-health plans on a Medicare plan call?
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Did the agent conduct cold calling for MA/MAPD/PDP interest without established EBR or permission?
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Did the agent provide compliant call closing?
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Did the agent collect the applicant’s email address?
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Did the agent discuss Humana Care Highlight Program to help the applicant select a primary care provider?
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Did the agent ask permission for Centerwell Pharmacy outreach?
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Did the agent complete the HRA with an authorized party?
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Did the agent accurately document their CRM database?
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Did the agent ask if additional parties are seeking assistance?
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Did the agent use the required call opening?
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Did the agent follow guidance from CMS as it relates to the Scope of Appointment (Telephonic)?
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Did the agent identify the name of the primary beneficiary?
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Did the agent determine if the beneficiary is able to make their own healthcare decision?
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Did the agent obtain and document permission from the beneficiary prior to accessing MARx?
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Did the agent determine valid election period eligibility?
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Did the agent fully qualify each interested party?
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Did the agent determine the reason the beneficiary is inquiring about a different plan?
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Did the agent determine which benefits are a priority for the beneficiary?
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Did the agent review the Summary of Benefits prior to completion of the enrollment?
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Did the agent offer to review provider network status, current prescriptions, and hospital network status?
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Did the agent explain how enrolling will affect current coverage?
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Did the agent read all required disclosures for the determined plan of interest?
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Did the agent confirm the beneficiary was ready to complete their enrollment?
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Did the agent accurately complete the consumer's application?
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Did the agent follow the appropriate steps to obtain a compliant signature?
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Did the agent refrain from claiming to be endorsed or work for Medicare?
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Did the agent refrain from asking health-related questions that could be viewed as cherry-picking?
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Did the agent refrain from engaging in high-pressure sales tactics?
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Did the agent avoid disclosing health PI information to the wrong party?
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Did the agent refrain from cross-selling non-health plans on a Medicare plan call?
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Did the agent refrain from cold calling for MA/MAPD/PDP interest without established EBR?
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Did the agent provide compliant call closing?
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Study Notes
Document Overview
- Focuses on MarketPoint Call Quality requirements for DMS agents managing calls about Medicare Advantage (MA), Medicare Advantage Prescription Drug (MAPD), or Prescription Drug Plans (PDP)
- Intended for DMS agents conducting inbound and outbound sales calls
Compliance and Business Process
- Developed as a resource for evaluators to provide feedback to Licensed Sales agents
- Evaluators include Call Quality Managers, Sales Leadership, and Compliance Professionals
- Document highlights necessary actions but does not cover all call scenarios due to diversity in interactions
Scoring and Evaluation Mechanics
- Compliance and business process components evaluated using Yes, No, or Not Applicable
- Scoring for compliance:
- 85%-100% indicates agents are on target; review and coaching recommended for any missed elements
- Below 85% signifies need for immediate attention, with discussions on violations and remediation
Consumer Experience Evaluation
- Consumer experience scored by effectiveness on specific call behaviors, with a range of 0-3 points for scored components
- Exceptional (3 points), Full (2 points), Inconsistent (1 point), and Did Not Demonstrate (0 points) ratings
- Scores categorize agents as either requiring attention or demonstrating acceptable behavior
Compliance Definitions and Questions
- Key compliance questions addressed include:
- C1: Required call opening procedures
- C2: Adherence to Scope of Appointment mandates
- C5: MARx disclosure requirements
- C17: Refraining from claiming Medicare endorsement
- C19: Avoiding high-pressure sales tactics
Business Process Questions
- Key questions include:
- BP1: Collecting applicant’s email address for communication
- BP2: Discussing Humana Care Highlight Program for primary care provider selection
- BP4: Completing member care assessments with authorized parties
Consumer Experience Focus
- Focuses on enhancing customer interactions through techniques such as:
- CE1: Needs Analysis Technique
- CE3: Call to Action emphasis
- CE6: Active listening as a critical component
Key Elements Summary
- Compliance section includes 23 questions, each weighted differently based on importance
- Business process section includes 9 questions, also tailored to ensure thorough engagement
- Consumer experience section presents 6 questions aimed at refining agent-customer interaction dynamics
Important Regulations
- Compliance with 42 CFR requirements is essential for agents conducting telephonic enrollments
- Scopes of Appointment must be secured and documented before engaging prospective enrollees
Conclusion
- Continuous monitoring and feedback are crucial for improving DMS agents' call handling and ensuring compliance with Medicare guidelines
- Emphasis on understanding the consumer experience is critical and contributes to successful sales interactions.### Enrollment Process Guidelines
- Agents must affirmatively inquire about caller's interest in plan options and tailor presentations accordingly.
- Conversations regarding enrollment do not affect current or future health coverage unless an enrollment occurs on that call.
Beneficiary Identification
- Agents must obtain the full name of the primary beneficiary and the caller.
- If the caller differs from the beneficiary, the agent should establish the relationship to the beneficiary.
Decision-Making Capability
- Agents must determine if the beneficiary can make their own healthcare decisions and identify if a Power of Attorney (POA) or authorized representative is necessary.
Consent for Information Access
- Prior to accessing beneficiary information, agents must obtain explicit consent and explain the purpose of the access.
- Required eligibility information includes Medicare ID, name, birth date, and social security number, alongside a disclaimer regarding CMS’s final eligibility determination.
Valid Election Period Verification
- Agents are responsible for confirming valid election periods for enrollment, per established guidelines to ensure effective dates of coverage are accurate.
Qualifying Interested Parties
- Full qualification of all interested parties is required; agents must verify Medicare eligibility, current coverage, and assess additional health-related inquiries for specific needs.
Understanding Beneficiary's Needs
- Agents must identify the reasons beneficiaries seek new plans and assess their current plan's benefits to understand unmet needs.
Prioritized Benefits Discussion
- Fundamental to the conversation is determining which benefits the beneficiary prioritizes in their desired plan.
Review of Summary of Benefits
- Agents must review the Summary of Benefits (SOB) prior to enrollment, including monthly premiums, deductibles, copayments, emergency services, and coverage limitations.
Provider Network Status Review
- Agents should evaluate the network status of Primary Care Providers, specialists, pharmacies, and hospitals to help beneficiaries understand their options and any impacts of out-of-network services.
Explanation of Enrollment Impact
- Assess the implications of enrolling in a new plan, particularly how it may lead to disenrollment from existing coverage. This includes discussing the nature of IDV/OSB products compared to supplemental plans.
Required Disclosures
- Agents are obligated to read all necessary disclosures relevant to the plan of interest, ensuring beneficiaries fully understand the product being offered.
Resource References
- A variety of resources are referenced for training and compliance, including Medicare presentations, disclosures, job aids for sales integrity, and specific documentation related to enrollment practices and eligibility verification.### Intent/Purpose Overview
- Regulations require MA organizations to provide accurate and clear information to beneficiaries.
- Agents must disclose their representation status clearly within the first minute of a sales call.
- MA organizations need a system to confirm beneficiaries understand their plan.
Enrollment Requirements
- Agents must confirm beneficiaries' readiness to complete enrollment including stating the plan name and effective date.
- Accurate completion of consumer applications requires reviewing: contact information, payment options, language preference, and alternate format election.
- Telephonic signatures must comply with outlined standards and procedures.
Compliance and Agent Representation
- Agents cannot misrepresent their affiliation with Medicare or CMS.
- Refraining from health-related inquiries is essential to avoid targeting specific subsets of potential members, referred to as "cherry-picking."
- High-pressure sales tactics are prohibited; agents should provide information based solely on beneficiaries’ needs.
Privacy and Disclosure
- Agents must safeguard protected health information, disclosing it only to authorized individuals.
- Cross-selling non-health plans during Medicare discussions is prohibited.
- Cold calling without prior established business relationships or documented permissions is not allowed.
Communication and Documentation
- Agents must provide beneficiaries with carrier information and application confirmation after enrollment.
- Collecting email addresses is critical to engage beneficiaries and support retention through digital communications.
- The Humana Care Highlight Program aids in selecting primary care providers, emphasizing quality and efficiency without steering beneficiaries.
Outreach and Assessments
- Permission must be obtained for outreach by Centerwell Pharmacy, enhancing member experience through additional benefits.
- Completion of Health Risk Assessments (HRAs) with authorized parties is part of addressing community health needs.
Documentation Practices
- Accurate documentation in CRM databases is vital for compliance and maintaining effective communication with beneficiaries.
- Providing incorrect beneficiary details can lead to privacy risks and issues in marketing strategies.
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Description
This quiz assesses the knowledge of customer service representatives on appropriate behaviors during calls with beneficiaries, including communication strategies and etiquette.
