Questions and Answers
What actions should agents avoid when communicating with beneficiaries? (Select all that apply)
It is appropriate to place the beneficiary on mute to discuss matters with other parties during the call.
False
What can periods of unexplained silence during a call negatively impact?
Consumer's experience
Agents should be prepared to handle the call at any time to avoid ______.
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Match the following negative communication behaviors with their 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 points for Needs Analysis Technique?
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What is the minimum requirement points for presenting a solution?
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What is the minimum requirement points for Call to Action?
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What is the minimum requirement points for understanding and addressing gaps/barriers/concerns?
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What is the minimum requirement points for expanding AOR relationship through Humana support/initatives?
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What is the minimum requirement points for demonstrating active listening skills throughout the call?
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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 to determine eligibility on their behalf?
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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 with a focus on experiences with current coverage?
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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 the provider network status, current prescriptions, preferred hospital, and 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?
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Did the agent accurately complete the consumer's application including 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 to target specific members?
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Did the agent engage in high-pressure sales tactics?
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Did the agent disclose health information to the wrong party?
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Did the agent cross-sell non-health plans during a Medicare plan call?
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Did the agent cold call for MA/MAPD/PDP interest without permission?
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Did the agent provide compliant call closing including carrier name and confirmation number?
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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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Study Notes
Call Quality Guidance for DMS Agents
- Focuses on MarketPoint Call Quality requirements for inbound and outbound calls related to MA, MAPD, or PDP products.
- Intended for DMS agents, helping them maintain compliance and enhance consumer experience during calls.
Document Overview
- Primary resource for evaluators during call evaluations.
- Evaluators include Call Quality Managers, Sales Leadership, and Compliance Professionals.
- Does not provide exhaustive examples due to the diverse nature of telephonic calls.
- Designed for 'Situational Sales' to adapt to varying sales styles and beneficiary interactions.
Compliance/Business Process
- Requires adherence to detailed call opening protocols and compliance guidelines.
- Evaluator checks compliance based on "Yes," "No," or "Not Applicable" responses.
- Scoring ranges from 85% to 100% indicates agents are on target; below 85% highlights a need for coaching or remediation.
Scoring Dynamics
- Compliance section: Key elements include required call opening, identifying beneficiaries, and reviewing current coverage.
- Consumer experience section focuses on effectiveness and proficiency in call behaviors.
Key Compliance Questions
- Mandatory call opening and proper handling of Scope of Appointment before telephonic marketing.
- Documentation of beneficiary information, including names and permissions prior to accessing MARx system.
- Identify and communicate election period, priority benefits, and provide summaries of benefits during the call.
Consumer Experience
- Evaluates active listening and addressing gaps or concerns expressed by the beneficiary.
- Techniques used: Needs Analysis, Presenting Solutions, and Expanding Relationships through Humana support.
Important Call Elements
- Agents must document compliance elements, including gathering email addresses and discussing care provider options.
- Training focus on avoiding high-pressure sales tactics and ensuring PHI is not disclosed incorrectly.
Summary of Components
- Compliance questions (C1-C23) with specific weights outline the evaluation criteria.
- Business process questions (BP1-BP9) focus on procedural adherence.
- Consumer experience questions (CE1-CE6) assess engagement and effectiveness in communication.
Conclusion
- This document serves as a comprehensive guide to ensure DMS agents meet compliance standards, enhance consumer experience, and improve overall call quality in handling Medicare-related inquiries.### Call Guidelines and Permissions
- Begin discussions by confirming the caller's interest in specific options to tailor the presentation.
- Inform that the conversation does not affect current or future health coverage unless a plan is enrolled today.
- Enrollment through the agent requires the beneficiary or authorized representative's direct involvement.
Beneficiary Identification
- Collect the full name of the primary beneficiary and ascertain the caller's relationship if different.
- Confirm the beneficiary's ability to make health care decisions; evaluate if a Power of Attorney (POA) is involved.
Accessing Information
- Agents must obtain permission from the beneficiary before accessing MARx for eligibility checks.
- Provide a disclosure about eligibility checking, emphasizing that it is optional and based on current information.
Election Period Verification
- Determine valid election period eligibility based on Medicare Advantage (MA) plan requirements.
- Clarify which election period is relevant for the enrollment request, as it dictates the effective coverage date.
Qualification of Interested Parties
- Fully qualify each party by confirming Medicare eligibility, assessing existing coverage types, and determining if Low-Income Subsidy (LIS) benefits apply.
- Additional health-related inquiries may be needed for those interested in Chronic Condition Special Needs Plans (CC-SNP).
Understanding Beneficiary Needs
- Assess the reasons for inquiries about different plans, focusing on current coverage experiences and unmet needs.
- Identify the benefits deemed most important by the beneficiary, considering health care needs, medications, and financial concerns.
Summary of Benefits Review
- Review a detailed Summary of Benefits (SOB) prior to enrollment confirmation, ensuring clarity on plan specifics.
- Key elements include premiums, deductibles, maximum out-of-pocket expenses, and covered services, including both in-network and out-of-network situations.
Provider and Prescription Coverage
- Offer to review the status of provider networks (PCP, specialists) and ensure beneficiaries understand prescription coverage under new plans.
- Confirm understanding of how using out-of-network providers impacts their benefits.
Coverage Impact Explanation
- Explain how enrolling in a new plan can affect current coverage, including the possibility of disenrollment from existing plans.
- Distinguish new plans from supplemental insurance products, providing clarity on overall coverage changes.
Required Disclosures
- Ensure that all mandated disclosures for the chosen plan are communicated effectively to the beneficiary.
- Disclosures are critical in maintaining accurate, clear, and standardized information delivery.### Compliance Requirements for MA Organizations
- MA organizations must avoid providing inaccurate or misleading information to beneficiaries.
- Agents must disclose whether they represent every plan in the area within the first minute of a sales call.
- Organizations need to confirm beneficiaries' understanding of products, including rules applicable under the plan.
- Detailed disclosure requirements outlined in various CMS guidelines ensure transparency in telephonic enrollments.
Enrollment Confirmation Procedures
- Agents must confirm beneficiaries are ready to enroll by stating the plan name and effective date.
- A verbal attestation of intent to enroll is mandatory during enrollment requests.
- Agents must ensure the plan name includes the appropriate plan type as per regulation.
- The effective date of coverage must be communicated to beneficiaries prior to the coverage start.
Personal Information Documentation
- Agents must accurately complete applications, capturing essential data: contact information, payment options, language preference, and alternate format election.
- A toll-free customer service number, including TTY services, must be provided to beneficiaries.
Signature Compliance
- Agents are required to follow specific protocols for obtaining compliant electronic or verbal signatures during enrollment.
Ethical Sales Practices
- Agents must represent themselves as licensed agents and cannot mislead beneficiaries regarding their relationship with Medicare.
- Health-related questions must be limited to what is necessary for enrolling rather than for targeting enrollment based on health status.
- High-pressure sales tactics are prohibited; agents should focus on beneficiary needs without intimidation.
Confidentiality Regulations
- Agents must not disclose protected health information to unauthorized individuals.
- Cross-selling non-health products during Medicare calls is prohibited, and agents should redirect inquiries to appropriate channels.
Contact Regulations
- Cold calling for Medicare-related products without prior established business relationships is not allowed. Agents may only contact beneficiaries who have requested contact or who have an existing relationship.
Call Closing Compliance
- At the end of calls, agents must confirm the carrier's name, provide a customer service number, and issue an application confirmation number.
Business Processes for Engagement
- Collecting email addresses is crucial for enhancing digital engagement and retention post-enrollment.
- Agents should discuss the Humana Care Highlight Program to assist beneficiaries in selecting a primary care provider without steering them toward specific options.
- It's necessary for agents to gather permission for Centerwell Pharmacy outreach to ensure member benefits post-enrollment.
- Agents should involve authorized parties when completing Health Risk Assessments (HRA) to better identify and address beneficiaries' needs.
- Accurate documentation in CRM databases is essential for compliance and effective communication with beneficiaries.
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Description
Guidance for DMS agents on MarketPoint Call Quality requirements for inbound and outbound calls focusing on MA, MAPD, or PDP products.
