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Questions and Answers
According to 42 CFR § 422.2267(e)(4), what information must be reviewed during telephonic enrollments?
According to 42 CFR § 422.2267(e)(4), what information must be reviewed during telephonic enrollments?
- EOC, providers, medications, premiums/copayments/coinsurance, and plan-type rules (correct)
- Provider network status and out-of-pocket costs
- Plan-type rules, emergency/urgent care, and effect on current coverage
- Health care needs, financial concerns, and commonly used medications
What is a requirement for MA organizations when reviewing individual beneficiary needs?
What is a requirement for MA organizations when reviewing individual beneficiary needs?
- To review health care needs, history, commonly used medications, and financial concerns (correct)
- To only review providers and emergency/urgent care
- To refrain from reviewing financial concerns
- To only consider health care needs and history
What must agents discuss with beneficiaries regarding out-of-network providers?
What must agents discuss with beneficiaries regarding out-of-network providers?
- Some impacts of using out-of-network providers (correct)
- The costs associated with using out-of-network providers
- The benefits of using in-network providers
- The process for filing claims for out-of-network services
What is required of MA organizations regarding beneficiary understanding of their plan?
What is required of MA organizations regarding beneficiary understanding of their plan?
What information must agents review with beneficiaries regarding their prescriptions?
What information must agents review with beneficiaries regarding their prescriptions?
What is the primary purpose of the Humana Care Highlight program?
What is the primary purpose of the Humana Care Highlight program?
What is a benefit of enrolling in Centerwell Pharmacy?
What is a benefit of enrolling in Centerwell Pharmacy?
What should agents discuss with beneficiaries regarding Care Highlight?
What should agents discuss with beneficiaries regarding Care Highlight?
What is a resource available to agents for promoting top-tier providers?
What is a resource available to agents for promoting top-tier providers?
What should agents avoid doing when discussing physician practices with beneficiaries?
What should agents avoid doing when discussing physician practices with beneficiaries?
Which of the following is NOT a required component of the information an agent must provide about a plan's benefits, according to the provided content?
Which of the following is NOT a required component of the information an agent must provide about a plan's benefits, according to the provided content?
What is the primary purpose of the requirement for agents to confirm beneficiaries understand the plan's rules?
What is the primary purpose of the requirement for agents to confirm beneficiaries understand the plan's rules?
During a telephonic enrollment, which of the following is NOT a required component of the information that must be reviewed with the beneficiary?
During a telephonic enrollment, which of the following is NOT a required component of the information that must be reviewed with the beneficiary?
Which of the following is TRUE regarding coverage for out-of-network providers and services?
Which of the following is TRUE regarding coverage for out-of-network providers and services?
Which of the following is the primary reason for requiring MA organizations to disclose information in a "clear, accurate, and standardized form"?
Which of the following is the primary reason for requiring MA organizations to disclose information in a "clear, accurate, and standardized form"?
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Study Notes
Regulatory Requirements for MA Organizations
- 42 CFR § 422.111(a), (b) mandates disclosure of benefits in "clear, accurate, and standardized form."
- Organizations must avoid providing inaccurate or misleading information per 42 CFR § 422.2262(a)(1)(i), (iii) and 422.2268(a)(1), (2).
- Individual beneficiaries' needs such as healthcare history and financial concerns must be assessed according to 42 CFR § 422.2264(c)(3)(ii)(D).
- 42 CFR § 422.2267(e)(4) requires reviewing contents of the PECL during telephonic enrollments.
Provider Network Disclosure
- Agents must confirm provider availability in the selected plan, including:
- Primary Care Providers (PCPs) even for non-HMO plans.
- Relevant Specialists, Pharmacies, and Hospitals.
- If out-of-network providers are involved, beneficiaries must understand the implications.
- Referral requirements within specified provider affiliations need to be discussed.
- Prescription formularies must be reviewed to check if medications are included.
Summary of Benefits (SOB) Documentation
- Accurate plan details must be presented according to approved scripts, including:
- Monthly plan premium (standard or subsidized for beneficiaries with LIS).
- Part B premium reduction (if applicable).
- Medical and pharmacy (Part D) deductible information.
- Maximum Out of Pocket (MOOP) responsibility explained for medical services only.
- In-network and out-of-network benefits must be clarified, covering:
- Inpatient/outpatient care, doctor visits, mental health services, preventive care, emergency and urgently needed services.
Humana Care Highlight Program
- Humana promotes healthcare providers that show clinical quality and cost efficiency.
- Agents should discuss care highlight providers without steering beneficiaries to specific ones.
- Resources available for agents include job aids and the Humana website for Care Highlight information.
Centerwell Pharmacy Outreach
- Agents must seek permission for Centerwell Pharmacy outreach during sales presentations.
- Benefits include enhanced member experience, additional health benefits, and potential savings on prescriptions.
- Utilization of mail order prescriptions is linked to better adherence and improved health outcomes for members.
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