Medicare Advantage Organizations Disclosure Requirements

Questions and Answers

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?

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?

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?

To establish a system for confirming beneficiary understanding of the plan Signup and view all the answers

What information must agents review with beneficiaries regarding their prescriptions?

Whether prescriptions are in or out of formulary Signup and view all the answers

What is the primary purpose of the Humana Care Highlight program?

To recognize physician practices that meet quality and cost-efficiency guidelines Signup and view all the answers

What is a benefit of enrolling in Centerwell Pharmacy?

Improved member experience and potential savings Signup and view all the answers

What should agents discuss with beneficiaries regarding Care Highlight?

Clinical quality and cost efficiencies of contracted providers Signup and view all the answers

What is a resource available to agents for promoting top-tier providers?

Job Aid: TRN REF 1306 7 steps to promote top-tier providers in Find a Doctor tool Signup and view all the answers

What should agents avoid doing when discussing physician practices with beneficiaries?

Attempting to steer beneficiaries to specific providers Signup and view all the answers

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?

Specific details about the plan's formulary, including covered medications and drug tiers Signup and view all the answers

What is the primary purpose of the requirement for agents to confirm beneficiaries understand the plan's rules?

To allow beneficiaries to make informed decisions about their coverage and access to care. Signup and view all the answers

During a telephonic enrollment, which of the following is NOT a required component of the information that must be reviewed with the beneficiary?

The procedures for appealing a denied claim or a change in coverage. Signup and view all the answers

Which of the following is TRUE regarding coverage for out-of-network providers and services?

MA plans may have limited coverage for out-of-network services, but must cover emergency and urgent care regardless of provider network. Signup and view all the answers

Which of the following is the primary reason for requiring MA organizations to disclose information in a "clear, accurate, and standardized form"?

To help beneficiaries compare different MA plans and make informed choices based on their needs. Signup and view all the answers

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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Description

Quiz on the disclosure requirements for Medicare Advantage organizations, including clear and accurate information on benefits and refraining from misleading activities.