CQ-JA037 - Condensed MarketPoint Call Quality Scorecard - DMS (1).pdf

2024 Definitions and Insights - DMS 2024 Revised 2/1/2024 The following job aid will provide guidance on the MarketPoint Call Quality requirements for DMS agents handling inbound and outbound calls where the primary product of interest is MA, MAPD, or PDP products....

2024 Definitions and Insights - DMS 2024 Revised 2/1/2024 The following job aid will provide guidance on the MarketPoint Call Quality requirements for DMS agents handling inbound and outbound calls where the primary product of interest is MA, MAPD, or PDP products. MarketPOINT Call Quality Team Humana Inc. 2/1/2024 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Table of Contents Document Description…………..………………………….……………………………………………………………………….. 3 Compliance/Business Process (format/scoring mechanics) ………………………………………………………... 3 Consumer Experience (format/scoring mechanics) ……………..……………………………………….…….. 5 Elements at a Glance Form Elements Summaries ………………………………………………………………………………………………………. 7 Compliance Definitions and Insights Question C1: Required Call Opening …………………...……………………………………………………………………... 9 Question C2: Telephonic SOA ………………………………………………...…………………………………........................ 10 Question C3: Applicant Name ………………………….………………...………………………………………………………... 10 Question C4: Decision Maker ……………………………………………………………….………………………….………. 11 Question C5: MARX Disclosure ………………………………………………………………………….……………………... 12 Question C6: Election Period ……………………...………………………...………………………………………………...…... 13 Question C7: Qualifying ……………………………………………………….…………………………………………………... 13 Question C8: Current Coverage …………………………………………………………………………………………………. 14 Question C9: Priority Benefits …………………………………………………………………………………………………. 15 Question C10: Summary of Benefits …………………………………………………………………………………………. 16 Question C11: Provider/Prescription Review …………………………………………………………………………. 17 Question C12: Enrollment Impacts ……………………………………………………………………………………………. 18 Question C13: Plan Disclosures …………………………………………………………………………………………………. 18 Question C14: Consent to Enroll …………………………………………………………………………………………………. 19 Question C15: Application Completion ………………………………………………………………………………………. 20 Question C16: Application Signature …………………………………………………………………………………………. 21 Question C17: Endorsed by Medicare …………………………………………………………………………………………. 22 Question C18: Cherry Picking …...………………………………………………………………………………………………. 22 Question C19: High Pressure Sales ……………………………………………………………………………………………. 23 Question C20: PHI Disclosure …...……………………………………...………………………………………………………. 23 Question C21: Cross Selling Life …………………………………………………………………………………………………. 24 Question C22: Cold Calling MA …………………………………………………………………………………………………. 24 Question C23: Compliant Call Close ……………………………………………………………………………………………. 25 Page 1 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Business Process Definitions and Insights Question BP1: Email Address …….…………………...………………………………………………………………………….. 27 Question BP2: Humana Care Highlights (TPP)...……………………...…………………………………...................... 27 Question BP3: Centerwell Pharmacy Consent (MAF) ………...………………………………………………………. 28 Question BP4: Member Care Assessment (MCA) ……………………………………………….……………………... 28 Question BP5: CRM Database …………………………………………………………………………………………………….. 29 Question BP6: Additional Parties …………………………………………………………………………………….………….. 30 Question BP7: Presciption Data…………………………………………………………………………………………………… 30 Question BP8: Digital Onboarding……………………………………………………………………………………………… 31 Question BP9: PTE Question ………………………………………………………………………………………………………. 32 Consumer Experience Definitions and Insights Question CE1: NEADS Analysis Technique...……... …………………………………………..…………………………… 33 Question CE2: Presenting Solution …………………………………………...……………………………………….………… 35 Question CE3: Call to Action …………………………………………….…………………………………………………………. 37 Question CE4: Gaps/Barriers/Concerns/Objections.……………...…………………………………………………..… 38 Question CE5: Expanding AOR Relationship through Humana Support/Initiatives……………………. 40 Question CE6: Active Listening ………………………...…………………………………………………………………………. 42 Page 2 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 DOCUMENT DESCRIPTION: This document will serve as the primary resource for the evaluator during the call evaluation process. o An evaluator is defined as a certified associate authorized to provide feedback to Licensed Sales agents. ▪ Examples include: Call Quality Managers and Professionals Sales Leadership Team Sales Integrity Senior Compliance Professionals It will be important to note that the document will provide an essence of what agents can do on the call(s) but will not provide every example due to the varying nature of telephonic call types. This document is designed to adapt to ‘Situational Sales’ meaning it will provide examples on various agent sales styles and beneficiary dynamics. o Agents are not required to display every example type. The evaluator must consider the individual situation and beneficiary interactions throughout the evaluation process. COMPLIANCE/BUSINESS PROCESS (FORMAT AND SCORING DYNAMICS) Format: The description below provides details on the formatting of the definitions and insights for the compliance section of the form. 1st Section: o Question: States the question as it would appear on the form including weighted points. ▪ If you click on the blue text, it will take you back to the Table of Contents. nd 2 Section: o Intent/Purpose: ▪ Compliance: This is an explanation provided by our Sales Integrity partners that outlines the reason an element is required along with the value. It will explain the WHY behind the WHAT. Specific elements from key compliance documents are sited as a reference. ▪ Business Process: This is an explanation provided by Humana Strategic Initiatives that outline the reason an element is required along with the value. It will explain the WHY behind the WHAT. 3rd Section: o Required Components: The chart will provide insight into what the specific requirements are for each question. This is a minimum expectation and does not mirror best practices or operational guidance. ▪ If there are different requirements on Production/Non-Production calls, it will be outlined in this area. Page 3 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Scoring Dynamics: The compliance and business process sections are scored using Yes, No, or Not Applicable relating to minimally required actions. After all questions are answered, the agent will receive the following range of scores: Scoring Opportunity Level Description Range This is the goal and expectation for all Telephonic Sales Agents relating to their Compliance score. 85% - 100% Agent’s Leader recommended course of action: On Target Review form for details on any missed elements. Discuss sales presentation feedback with agent. Scores in this range indicate a significant coaching opportunity Scores Below and highlight an immediate need to review findings with the 85% agent. or Agent’s Leader recommended course of action: Attention Needed Review form for details on any missed elements. Violations of Sales Discuss sales presentation feedback with agent. Conduct Document coaching discussion including any remediation Policy steps and expectations moving forward. Page 4 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 CONSUMER EXPERIENCE (FORMAT AND SCORING DYNAMICS) Format: The description below provides detail on the formatting of the definitions and insights for the sales/beneficiary experience section of the form. This section will be measuring the effectiveness and proficiency of specific call behaviors. This section is not measuring if minimum expectations were met. 1st Section: o Question: States the question as it would appear on the form including weighted points. ▪ If you click on the blue text, it will take you back to the Table of Contents nd 2 Section: o Intent/Purpose: This is an explanation provided by our Sales Integrity Compliance and Call Quality team that outlines the reason this is a required element, along with the value. It will explain the WHY behind the WHAT. rd 3 Section: o Possible Examples: This section provides details on how to demonstrate the specific element along with suggested verbiage. By providing several examples, this allows the agent to customize their approach based on the situation and the consumer’s need. ▪ It will be important to note that not ALL examples are required, nor should these examples be used as a checklist towards accomplishing a demonstrating score. o Avoid/Limit: A listing of different behaviors that an agent needs to avoid. This behavior does not automatically mean the agent does not receive credit. The evaluator will need to determine if the presence of behavior caused a negative beneficiary experience or business outcome. Page 5 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Scoring Dynamics: All scored components in the Sales section include a range between 0-3 points. Point Rating Name Description/Definition 3 Points Exceptional/Modeling Exceeded expectations on established behaviors within component by displaying Humana values. No actionable feedback can be provided on an element. Call element could be flagged as a training resource for new hires and agents seeking additional guidance/examples in each component. 2 Points Full/Demonstrating Agent exhibited most of the expected behaviors outlined in ‘Demonstrating Examples’ but some coaching is needed. Agent tried to complete expected behavior and when faced with a challenge/barrier, made attempts to overcome/address; however, their technique needs enhancements to increase success. 1 Point Inconsistent/Learning Agent may have exhibited some expected behaviors outlined in ‘Demonstrating Examples;’ however, there were more opportunities than successes in the specific component. The missed behavior has a larger scope of impact compared to the successful behaviors Agent tried to complete expected behavior and when faced with a challenge/barrier, the agent did not attempt to address or overcome. 0 Point Did Not Demonstrate Agent did not attempt to exhibit any of the expected behaviors After all beneficiary experience questions are answered; the agent will receive the following range of scores: Scoring Range Outcome 15 – 18 Points Exceptional/Modeling Rating 11 – 14 Points Full/Demonstrating Rating 6 – 10 Points Inconsistent/Learning Rating Below 6 Points Immediate Attention Required Page 6 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 FORM ELEMENTS SUMMARY (COMPLIANCE): Question Weight C1 Did the agent use the required call opening? 1 C2 Did the agent follow guidance from CMS as it relates to the Scope of Appointment 4 (Telephonic)? C3 Did the agent identify the name of the primary beneficiary? 1 C4 Did the agent determine if beneficiary is able to make their own healthcare decision? 4 C5 Did the agent obtain and document permission from the beneficiary prior to accessing 4 MARx to determine eligibility on their behalf? C6 Did the agent determine valid election period eligibility? 3 C7 Did the agent fully qualify each interested party? 3 C8 Did the agent determine the reason the beneficiary is inquiring about a different plan with 2 focus on experiences with current coverage? C9 Did the agent determine which benefits are a priority for the beneficiary? 2 C10 Did the agent review the Summary of Benefits prior to completion of the enrollment? 4 C11 Did the agent offer to review (1) provider (PCP and Specialist) network status (2) current 4 prescriptions for plan coverage and pharmacy network status (3) preferred hospital network status and (4) preferred facility network status. C12 Did the agent explain how enrolling will effect current coverage including being disenrolled 3 from their current plan? C13 Did the agent read all required disclosures for the determined plan of interest? 2 C14 Did the agent confirm the beneficiary was ready to complete his/her enrollment which 3 includes stating plan name and effective date? C15 Did the agent accurately complete the consumer's application and review the following: 1) 2 contact information; 2) payment options, 3) language preference, and 4) alternate format election? C16 Did our agent follow the appropriate steps to obtain a compliant signature? 3 C17 Did the agent refrain from claiming to be endorsed or work for Medicare? 8 C18 Did the agent refrain from asking health related questions that can be used for or could be 2 viewed as being used to target a subset of members (cherry-picking)? C19 Did the agent refrain from engaging in high pressure sales tactics? 8 C20 Did the agent avoid disclosing health PI information to the wrong party? 4 C21 Did the agent refrain from cross selling non-Health plans (i.e., Life insurance) on a Medicare 4 plan call? C22 Did the agent refrain from cold calling for MA/MAPD/PDP interest without established EBR 8 or permission space? C23 Did the agent provide compliant call closing? 2 Page 7 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 FORM ELEMENTS SUMMARY (BUSINESS PROCESS): Question Weight BP1 Did the agent collect the applicant’s email address? 2 Did the agent discuss Humana Care Highlight Program to help the applicant select a primary BP2 4 care provider (TPP)? BP3 Did the agent ask permission for Centerwell Pharmacy outreach (MAF)? 4 BP4 Did the agent complete the MCA with an authorized party? 4 BP5 Did the agent accurately document their CRM database? 2 BP6 Did the agent ask if additional parties are seeking assistance? 2 BP7 Did the agent ask to save prescription data for enrollment? 2 BP8 Did the agent ask for Digital Onboarding permission? 2 BP9 Did the agent ask and properly document PTE question? 2 FORM ELEMENTS SUMMARY (CONSUMER EXPERIENCE): Question Weight CE1 Needs Analysis Technique Scale of 0-3 CE2 Presenting a solution Scale of 0-3 CE3 Call to Action Scale of 0-3 CE4 Understanding and addressing the gaps/barriers/concerns Scale of 0-3 CE5 Expanding AOR Relationship through Humana Support/Initiatives? Scale of 0-3 CE6 Demonstrating active listening skills throughout the call? Scale of 0-3 Page 8 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 COMPLIANCE: Question C1: Did the agent use the required call opening? (1 Point) Intent/Purpose: 42 CFR § 422.2274(b) requires that agent be licensed and trained, which necessitates agent identification. MMCM CH 2: 40.1.3 (Enrollment via Telephone) states that "MA organizations may accept requests for enrollment into their MA plans via an incoming (in-bound) telephone call to a plan representative or agent." It also requires that telephonic enrollment requests be "recorded (audio)" and include a statement of the individual's agreement to be recorded. MMCM CH 2: 40.2 (Processing the Enrollment Request) requires that agent information be included in application submissions. Production Non-Production Inbound Provide first and last name Advise licensed agent Outbound Follow DMS-033 Outbound Call Requirements job-aid Resources: o All Scripts and Voicelogs Internal Resource Guide (DMS-044a) o Go/BOLD Question C2: Did the agent follow guidance from CMS as it relates to the Scope of Appointment (Telephonic)? (4 Points) Intent/Purpose: 42 CFR § 422.2264(c)(3)(i),(iii) requires that MA organizations and their agents secure and record a Scope of Appointment agreement prior to marketing, and that marketing remain within that scope. 42 CFR § 422.2274(b)(3) requires that agents "secure and document a Scope of Appointment prior to meeting with potential enrollees." 42 CFR § 422.2274(c)(9)(ii) requires that MA organizations "establish and maintain a system for confirming that agents/brokers appropriately complete Scope of Appointment records for all marketing appointments (including telephonic.)" Required Components For Outbound Calls Only “In your area, we have a wide variety of plans such as [Medicare Advantage plans, Medicare Advantage Prescription Drug plans, Stand-alone Prescription Drug plans, Medicare Supplement Insurance Plans, Optional Supplemental Benefits, Stand-alone Vision, Stand-alone Dental]” List out all product types available in the caller’s area. “Would you like to discuss all these options or are you only interested in certain ones?” Obtain affirmative response or specific plans identified and tailor presentation based upon caller’s selection. {verbatim} ”This conversation has no effect on your current or future health coverage, unless you enroll in a plan today. Talking to me does not obligate you to enroll or automatically enroll you in a plan.” Page 9 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  Resources: o Policy: DMS Medicare Communications and Marketing Reference Guide (DMS-029) o Policy: CPL-119: Final Rule and 48-hour Rule FAQ o Policy: CPL-119a: Final Rule Policy o Policy: CPL-ISO-127: Compliant Marketing Discussion Prior to Securing the SOA o Training Document: Medicare Plans disclosure grid TRN-REF-245a o HMU Training: Sales Integrity Education Series - Scope of Appointment Question C3: Did the agent identify the name of the primary beneficiary? (1 Points) Intent/Purpose: MMCM CH 2: 40.1.3 (Enrollment via Telephone) states that "for all telephonic enrollment requests, the MA organization must ensure that the telephonic enrollment request is effectuated entirely by the beneficiary or his or her authorized representative. MMCM CH 2: 40.2 (Processing the Enrollment Request) states that "for telephonic enrollment requests, all required elements listed in Appendix 2 must be included," which includes "beneficiary name." MMCM CH 2: 40.2.1 (Who May Complete an Enrollment Request) states that only a beneficiary or legal representative may complete an enrollment request. Required Components Collect the first and last name of the primary beneficiary and/or caller as applicable o If the beneficiary is different from the caller, the agent should at minimum obtain/establish name/relationship of who is calling Question C4: Did the agent determine if beneficiary is able to make their own healthcare decision? (4 Points) Intent/Purpose: MMCM CH 2: 40.2.1 (Who May Complete an Enrollment Request) states that only a beneficiary or authorized representative may complete an enrollment request, and outlines scenarios where, e.g., a POA (Power of Attorney) necessitates the involvement of an authorized representative. MMCM CH 2: 10 defines Authorized/Legal Representative. MMCM CH 2: 40.1.3 (Enrollment via Telephone) states that "for all telephonic enrollment requests, the MA organization must ensure that the telephonic enrollment request is effectuated entirely by the beneficiary or his or her authorized representative." Required Components Agent must inquire as to whether the beneficiary makes his/her own healthcare decisions and confirm if a POA, or authorized representative, is required prior to review of the presentation of benefits per job aid, disclosures, and application. Resources o Mentor Document: POA Types and Allowed Actions (humana.com) o HMU Training: Sales Integrity Education Series - Power Of Attorney Page 10 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question C5: Did the agent obtain and document permission from the beneficiary prior to accessing MARx to determine eligibility on their behalf? (4 Points) Intent/Purpose: HHS Rules of Behavior - D. Privacy provides that, amongst other requirements, users will "not access information about individuals unless specifically authorized and required as part of assigned duties." Required Components If agent access Marx, the following disclosure is read PRIOR to accessing: "Before we explore your plan choices, I’d like to check your eligibility status. This is optional, and not required before we discuss plans, but this will help determine what plans you may be eligible to enroll into. Please note that this is based on current information available and does not guarantee eligibility. CMS will make the final determination of eligibility If you submit an application." "To look up your eligibility, you would need to provide me your Medicare ID OR First and Last Name, Date of Birth and Social Security Number." "If you provide consent, I will be able to see your personal and health information within your profile with Medicare. "Do I have your consent to check your eligibility status?" Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Job Aid: Medicare Plans Required Disclosures Grid - ENGLISH & SPANISH (DMS-245) o Job Aid: MARx Access and Disclosure/Permission in Canvas (RC-800) o Job Aid: Medicaid Eligibility Tool in Vantage - Required (RX-801) o Rep communication: MARx and Medicaid Eligibility Tool Use Expectations... (sharepoint.com) o HMU Training: Compliant Use of the MARx System o Job Aid: DMS-011 AEP Playbook (humana.com) Question C6: Did the agent determine valid election period eligibility? (3 Points) Intent/Purpose: MMCM CH 2: 20 (Eligibility for Enrollment in MA Plans) outlines MA plan eligibility requirements. MMCM CH 2: 30 (Election Periods and Effective Dates) states that "in order for an MA organization to accept an election, a valid request must be made during an election period. It is the responsibility of the organization to determine the election period of each enrollment or disenrollment request." The section goes on to outline additional election period guidance and details. MMCM CH 2: 30.6 (Effective Date of Coverage) states that "to determine the proper effective date, the MA organization must determine which election period applies to each individual before the enrollment may be transmitted to CMS." MMCM CH 2: 40.2 (Processing the Enrollment Request) requires that in "processing all enrollment requests, the MA organization must verify Medicare entitlement" and the "MA organization must determine the effective date of coverage for all enrollment requests." Page 11 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  Required Components Agent must either ask questions or make clear statements that advise which election period is being used to include the plan’s effective date. Agent must use a valid election period following guidelines established by CMS Resources ▪ Policy: DMS 024 – Medicare Enrollment Options ▪ Job Aid: CQ_JA014 Call of Concern Email Template.docx (sharepoint.com) Question C7: Did the agent fully qualify each interested party? (3 Points) Intent/Purpose: MMCM CH 2: 20 (Eligibility for Enrollment in MA Plans) outlines MA plan eligibility requirements. MMCM CH 2: 40.1.3 (Enrollment via Telephone) states that "the MA organization must ensure that all MA eligibility and enrollment requirements provided in this chapter are met. MMCM CH 2: 40.2 (Processing the Enrollment Request) requires that in "processing all enrollment requests, the MA organization must verify Medicare entitlement." Required Components Agent must establish the following 1. Determine Medicare eligibility, 2. Understand current medical/rx coverage including EGHP (Employer Group Health Plan) and Veteran benefits (including TRICARE and CHAMPVA) to determine if there is an impact to what plan options would best suits their needs, and 3. If eligible for LIS/DE benefits. 4. If applicable, agent must ensure to fully qualify caller by asking additional health-related questions in the event of a CC-SNP enrollment Resources: ▪ Rep communication: MA/MAPD/PDP IMpact on TRICARE for Life and CHAMPVA Question C8: Did the agent determine the reason the beneficiary is inquiring about a different plan with focus on experiences with current coverage? (2 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii) and 42 CFR § 422.2268 (a)(1), (2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2264(c)(3)(ii)(D) permits MA organizations to "review the individual needs of the beneficiary including, but not limited to, health care needs and history, commonly used medications, and financial concerns." Required Components Agent must gain understanding of what benefits their current plan meets or does not meet their needs. Resources: ▪ HMU Training: Sales Integrity Education Series - Conducting a NEADS Analysis Page 12 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  ▪ HMU Training: NEADS Analysis ▪ JOB AID: TRN-REF-1323a Consultative Sales Job Aid ▪ Job Aid: DMS 214 Medicare Presentation of Benefits ▪ Job Aid: DMS-011 AEP Playbook (humana.com) Question C9: Did the agent determine which benefits are a priority for the beneficiary? (2 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii) and 42 CFR § 422.2268 (a)(1), (2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2264(c)(3)(ii)(D) permits MA organizations to "review the individual needs of the beneficiary including, but not limited to, health care needs and history, commonly used medications, and financial concerns." Required Components Agent must gain an understanding of what benefits a priority would be or are important in the new plan of interest. Resources: ▪ HMU Training: Sales Integrity Education Series - Conducting a NEADS Analysis ▪ HMU Training: NEADS Analysis ▪ Job Aid: TRN-REF-1323a Consultative Sales Job Aid ▪ Job Aid: DMS 214 Medicare Presentation of Benefits ▪ Job Aid: DMS-011 AEP Playbook (humana.com) Question C10: Did the agent review the Summary of Benefits prior to completion of the enrollment? (4 Points) Intent/Purpose: 42 CFR § 422.111(a),(b) requires that MA organizations disclose information, to include the benefits offered under a plan, in "clear, accurate, and standardized form." 42 CFR § 422.2262(a)(1)(i),(iii) and 422.2268 (a)(1),(2) require that MA organizations refrain from providing inaccurate or misleading information, or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2264(c)(3)(ii)(D) permits MA organizations to "review the individual needs of the beneficiary including, but not limited to, health care needs and history, commonly used medications, and financial concerns." 42 CFR § 422.2267(e)(4) requires the contents of the PECL be reviewed during telephonic enrollments, to include EOC, providers, medications, premiums/copayments/coinsurance, emergency/urgent, plan-type rules, and effect on current coverage. 42 CFR § 422.2274(c)(9)(i) requires that MA organizations "establish and maintain a system for confirming that beneficiaries enrolled by agents or brokers understand the product, including the rules applicable under the plan." Page 13 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  Required Components Agent provides accurate information on plan details described in the SOB (Summary of Benefits) per approved script requirement (list below): Monthly Plan Premium (standard amount or subsidized amount if the beneficiary has LIS) Part B premium reduction (If applicable) Medical deductible (If applicable) Pharmacy (Part D) deductible and applicable tiers (can provide subsidized amount if beneficiary has LIS) Maximum Out of Pocket (MOOP) responsibility and explain this is for medical services only In Network Benefits (and out of network if PPO/PFFS plans) copays and coinsurances for: o Inpatient/Outpatient Hospital Care o Doctors Visits (Both PCP and Specialist) and of any referral and/or prior authoirization requrirements o Inpatient and outpatient Mental Health services o Preventive care (provide 2-3 examples) o Emergency room o Urgently needed services Review coverage for out-of-network providers and services (e.g., except in emergency or urgent situations, plan does not cover services by out-of-network providers (i.e., doctors who are not listed in the provider directory)). Coverage outside the United States Additional benefits should be reviewed, including costs and limitations on: o Dental Benefits o Vision Benefits o Hearing Benefits Review the right to cancel this enrollment and the specific date through which cancellation may occur. The Agent should then inquire as to whether the beneficiary is interested in reviewing any other benefits included in the EOC or SOB. Agent would review any additional benefits requested by the beneficiary. Agent accurately answers all additional questions asked by applicant or their legal representative. Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits Page 14 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question C11: Did the agent offer to review (1) provider (PCP and Specialist) network status (2) current prescriptions for plan coverage and pharmacy network status (3) preferred hospital network status and (4) preferred facility network status? (4 Points) Intent/Purpose: 42 CFR § 422.111(a), (b) requires that MA organizations disclose information, to include the benefits offered under a plan, in "clear, accurate, and standardized form." 42 CFR § 422.2262(a)(1)(i),(iii) and 422.2268 (a)(1), (2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2264(c)(3)(ii)(D) permits MA organizations to "review the individual needs of the beneficiary including, but not limited to, health care needs and history, commonly used medications, and financial concerns." 42 CFR § 422.2267(e)(4) requires the contents of the PECL be reviewed during telephonic enrollments, to include EOC, providers, medications, premiums/copayments/coinsurance, emergency/urgent, plan-type rules, and effect on current coverage. 42 CFR § 422.2274(c)(9)(i) requires that MA organizations "Establish and maintain a system for confirming that beneficiaries enrolled by agents or brokers understand the product, including the rules applicable under the plan." Required Components Agent needs to review/disclose provider network status for selected plan for all plan types. The evaluator will be assessing if the following providers are reviewed: o Primary Care Provider (even for non-HMO plans o Specialists (as applicable) o Pharmacy o Hospital o Any other provider of importance to the beneficiary If out-of-network, confirm beneficiary's understanding of some impacts to using OON (Out of Network) provider. If the network requires referrals within specified provider affiliation, the agent must discuss this requirement. Agent offered to review prescriptions to determine if in/out of formulary. o If the plan requires a prescription to obtain Prior Authorization, Step Therapy, etc., the agent must advise the applicant of this requirement. Agent provides accurate information on plan details described Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Job Aid: AEP Playbook (DMS-011) o Job Aid: Care Highlight™ – 7 steps to promote top-tier providers in Find a Doctor tool ( TRN-REF- 1306coTTP) o Job Aid: Find A Dcotor - Care Highlight FAQ o Rep Communication: Physician Care Highlighting and Value-Based Providers Page 15 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question C12: Did the agent explain how enrolling will effect current coverage including being disenrolled from their current plan? (3 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii) and 422.2268 (a)(1),(2) require that MA organizations refrain from providing inaccurate or misleading information, or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2262(a)(1)(xiv) prohibits MA organizations from implying that an MA plan operates as a supplement to Medicare. 42 CFR § 422.2267(e)(4) requires the contents of the PECL be reviewed during telephonic enrollments, to include effect on current coverage. 42 CFR § 422.2274(c)(9)(i) requires that MA organizations "establish and maintain a system for confirming that beneficiaries enrolled by agents or brokers understand the product, including the rules applicable under the plan." Required Components The agent must explain the potential effect that enrolling in this plan will have on other, current coverage, which may in some cases mean that the individual is disenrolled from the beneficiary’s current health coverage (e.g., another MA plan, Medigap, TFL/ChampVA). If call initiates with interest in an IDV/OSB product, the agent must explain that this is not a hearing/dental/vision “rider” but a full plan. Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Job Aid: TRN-REF-245a : Medicare Plan Disclosure Grid o Training Document: TRN-REF 1400b How Tricare, ChampVA, VA, and Group plans work with Medicare Advantage Question C13: Did the agent read all required disclosures for the determined plan of interest? (2 Points) Intent/Purpose: 2 CFR § 422.2262(a)(1)(i), (iii) and 42 CFR § 422.2268 (a)(1), (2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2267(e)(41) requires, within the first minute of a sales call, that a TPMO states whether they do or do not represent every plan in the area. 42 CFR § 422.111 contains numerous disclosure requirements. 42 CFR § 422.2274(c)(9)(i) requires that MA organizations "establish and maintain a system for confirming that beneficiaries enrolled by agents or brokers understand the product, including the rules applicable under the plan." MMCM CH 2: 40.1.3 (Enrollment via Telephone), 40.2 (Processing the Enrollment Request), 40.4.1 (Prior to the Effective Date of Coverage), Appx 2 (Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests), and Exhibits 1, 3 provide numerous disclosure requirements. Required Components All relevant disclosures as outlined in CMS/Humana approved script were completed (i.e., verbally or via IVR (INTERACTIVE VOICE RESPONSE)) and collecting agreement/understanding. This will include disclosures listed in the application (i.e.: pop up, required statements) Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Job Aid: TRN-REF-245a Medicare Plan Disclosure Grid o Training Document: TRN-REF-1345 Path for Agents Page 16 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question C14: Did the agent confirm the beneficiary was ready to complete his/her enrollment which includes stating plan name and effective date? (3 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii) and 42 CFR § 422.2268 (a)(1),(2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. PLAN NAME 42 CFR § 422.2262(a)(1)(x) and 42 CFR § 422.2268(a)(6) prohibit MA organizations from using "a plan name that does not include the plan type." 42 CFR § 422.2274(c)(9)(i) requires that MA organizations "establish and maintain a system for confirming that beneficiaries enrolled by agents or brokers understand the product." MMCM CH 2: 40.1.3 (Enrollment via Telephone), 40.4.1 (Prior to the Effective Date of Coverage), and Appx 2 (Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests) together require that plan information, to include plan name, be provided. EFFECTIVE DATE MMCM CH 2: 30 (Election Periods and Effective Dates) states that "once the election period is identified by the MA organization, the MA organization must determine the effective date." MMCM CH 2: 40.2 (Processing the Enrollment Request) states that the "MA organization must determine the effective date of coverage for all enrollment requests," and that "the MA organization must notify the member of the effective date of coverage prior to the effective date." BENEFICIARYREADY TO ENROLL MMCM CH 2: 40.1.3 (Enrollment via Telephone) states that "individuals must be advised that they are completing an enrollment request." Additionally, it states that "each telephonic enrollment request must include a verbal attestation of the intent to enroll." MMCM CH 2: 40.2 (Processing the Enrollment Request) references "verbal attestation of intent to enroll." Required Components Agent completed the following: o 1) provided the plan name; o 2) advised of the plan's effective date; o 3) confirmed the beneficiary was ready to complete his/her enrollment. Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Job Aid: TRN REF 851a Fast App: How to complete MA/MAPD enrollment o Job Aid: TRN REF 1345 Path for DMS Agents Question C15: Did the agent accurately complete the consumer's application and review the following: 1) contact information; 2) payment options, 3) language preference, and 4) alternate format election? (2 Points) Intent/Purpose: Page 17 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 CONTACT INFORMATION: MMCM CH 2: 40.1.3 (Enrollment via Telephone), Appx 2 (Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests), and Exhibits 1, 3 together pertain to agent collection of beneficiary contact information. MMCM CH 2: 40.2.1 (Who May Complete an Enrollment or Disenrollment Request) requires contact information for authorized representatives. 2022 MCMG (Required Materials and Content - Scope of Appointment) requires that beneficiary contact information be obtained on the recorded call. PAYMENT OPTIONS: MMCM CH 2: 40.1.3 (Enrollment via Telephone), 40.2 (Processing the Enrollment Request), and Appx 2 (Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests) together provide guidance as to the presentation of payment options and collection of payment information. LANGUAGE PREFERENCES/ALTERNATIVE FORMATS: 42 CFR § 422.111(h)(1) requires that an MA organization have a toll-free customer service number that includes interpretation and adaptive/TTY services. MMCM CH 2: Introduction states that "organizations are required to provide information to individuals in accessible/alternate formats (for example, Large Print, Braille), upon request and thereafter, as outlined in Section 504 of the Rehabilitation Act of 1973 (and subsequent revisions)." See also Appx 2 (Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests). Required Components Agent must complete application in its entirety, with special attention to the following: o 1) Capture all application contact information; o 2) Ask and capture selected payment option. o 3) Ask and capture language preference o 4) Ask and capture alternate format election. Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Training Document: FastApp - How to Complete an OSB Plan Enrollment (TRN-REF-851e) o Training Document: TRN-REF-851a: Fast App: How to Complete an MA/MAPD Enrollment o Training Document: TRN-REF-1345 Path for Agents Question C16: Did our agent follow the appropriate steps to obtain a compliant signature? (3 Points) Intent/Purpose: MMCM CH 2: 40.1.3 (Enrollment via Telephone), 40.2 (Processing the Enrollment Request) and Appx 2 (Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests) together address and require telephonic signatures. Required Components Agent completed appropriate steps to sign the enrollment electronically/verbally. Resources: o Job Aid: OSB Add on Enrollment - DMS-213a – Optional Supplemental Benefits T-Signature Steps o Job Aid: DMS 214 Medicare Presentation of Benefits Page 18 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question C17: Did the agent refrain from claiming to be endorsed or work for Medicare? (8 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii),(xi) and 42 CFR § 422.2268 (a)(1),(2),(3) require that MA organizations refrain from providing inaccurate or misleading information, engage in activities that could mislead or confuse beneficiaries, or misstate the organization's relationship/status regarding CMS or Medicare. Required Components Agent represented themselves as a licensed agent from their company and made no indication that they are employed by Medicare to provide enrollment services. Question C18: Did the agent refrain from asking health related questions that can be used for or could be viewed as being used to target a subset of members (cherry-picking)? (2 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(vi) prohibits targeting potential enrollees based on health status. 42 CFR § 422.2264(c)(2)(iii) states that "MA organizations holding or participating in marketing events may not conduct activities, including health screenings, health surveys, or other activities that are used for or could be viewed as being used to target a subset of members (that is, 'cherry-picking')." MMCM CH 2: 40.2 (Processing the Enrollment Request) states that "MA organizations may not ask health screening questions during completion of the enrollment request. MA organizations are only permitted to send health assessment forms after enrollment. However, MA organizations may ask very limited health status questions related to a beneficiary’s eligibility to join an MA plan, such as whether the individual is enrolled in Medicaid, or is currently admitted to a certified Medicare/Medicaid institution." Required Components Agent did not ask any health-related questions unless it was part of their suitability/neads assessment or was required for enrollment in the plan (i.e., CC-SNP) Resources: o Policy: DMS-213a – Optional Supplemental Benefits T-Signature Steps o Job Aid: DMS 214 Medicare Presentation of Benefits Question C19: Did the agent refrain from engaging in high pressure sales tactics? (8 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii) and 42 CFR § 422.2268 (a)(1),(2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. Required Components Agent presented and enrolled beneficiary in a plan based on the needs of the beneficiary without overwhelming the applicant’s resistance with fear, doubt, confusion, or intimidation. Page 19 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question C20: Did the agent avoid disclosing health PI information to the wrong party? (4 Points) Intent/Purpose: 45 § CFR 164.502 prohibits disclosure of protected health information except as specifically permitted. Required Components Agent did not disclose any information Humana deems as Protected and Confidential as it relates to the applicant to any non-authorized individual. Resources: o Job Aid – Humana’s Privacy – Guide for Disclosure of Information Question C21: Did the agent refrain from cross selling Non-Health plans (i.e., Life insurance) on a Medicare plan call? (4 Points) Intent/Purpose: 42 CFR § 422.2262(a)(1)(i),(iii) and 42 CFR § 422.2268 (a)(1),(2) require that MA organizations refrain from providing inaccurate or misleading information or engage in activities that could mislead or confuse beneficiaries. 42 CFR § 422.2264(c)(3)(iii) states that "MA organizations holding a personal marketing appointment may not market non-health related products, such as annuities." 42 CFR § 422.2268(b)(3) states that "MA organizations may not market non-health care related products to prospective enrollees during any MA or Part D sales activity or presentation. This is considered cross-selling and is prohibited." Required Components Agent did not discuss non-health products to prospective enrollees during an MA or Part D sales activity. If a non-health inquiry is made by the consumer, the agent will provide the beneficiary with the inbound toll-free number for non-health related information. Question C22: Did the agent refrain from cold calling for MA/MAPD/PDP interest without established EBR or permission space? (8 Points) Intent/Purpose: 42 CFR § 422.2264(a)(2) prohibits MA organizations from, without prior request, "telephone solicitation (that is, cold calling), robocalls, text messages, or voicemail messages." This includes "calls based on referrals, calls to former enrollees who have disenrolled or those in the process of disenrolling, except to conduct disenrollment surveys for quality improvement purposes, calls to beneficiaries who attended a sales event, unless the beneficiary gave express permission to be contacted, and calls to prospective enrollees to confirm receipt of mailed information." However, "calls are not considered unsolicited if the beneficiary provides consent or initiates contact with the plan." In addition, 42 CFR § 422.2264(b) outlines permissible contact for plan business. 42 CFR § 422.2268(b)(13) prohibits MA organizations from soliciting "Medicare beneficiaries through unsolicited means of direct contact, including calling a beneficiary without the beneficiary initiating the contact." Page 20 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  Required Components Agent did not conduct unsolicited contact which is defined as discussing CMS regulated products on an outbound call with a non-Humana member that does not have a documented/recorded permission to contact or have an established business relationship. Resources o Policy: CPL 073 Outbound Telephonic Enrollment Question C23: Did the agent provide compliant call closing? (2 Points) Intent/Purpose: CARRIER NAME AND PHONE: 42 CFR § 422.111(h)(1) requires that an MA organization have a toll-free customer service number that includes a TTY service. 42 CFR § 422.2274(c)(9)(i) requires that MA organizations "establish and maintain a system for confirming that beneficiaries enrolled by agents or brokers understand the product." CONFIRMATION NUMBER: MMCM CH 2: 40.1.3 (Enrollment via Telephone) requires the inclusion of "a tracking mechanism to provide the individual with evidence that the telephonic enrollment request was received (e.g., a confirmation number)." See also MMCM CH 2: 40.4.1 (Prior to the Effective Date of Coverage). Required Components Agent must provide the following: o 1) carrier name and customer service phone number and o 2) Application confirmation number. Resources: o Policy: DMS-213a – Optional Supplemental Benefits T-Signature Steps o Job Aid: DMS 214 Medicare Presentation of Benefits Page 21 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 BUSINESS PROCESS: Question BP1: Did the agent collect the applicant’s email address? (2 Points) Intent/Purpose: As consumers pivot to completing more activities online, it will be important as an organization to help members do business within a variety of channels. Collecting email address will help retention as digital onboard will engage a member early, and even through enrollment submission confirmation emails. Required Components Agent asks the beneficiary for their email address. Question BP2: Did the agent discuss Humana Care Highlight Program to help the applicant select a primary care provider (TPP)? (4 Points) Intent/Purpose: To help our members make more informed choices about their healthcare, Humana Care Highlight program recognizes physician practices that meet quality and cost-efficiency guidelines. This program aims to provide Humana-covered beneficiaries with information on physician effectiveness and efficiency of contracted providers for consideration when making their healthcare decisions. Required Components Agents follow the process of discussing care highlight provides (focused on clinical quality and cost efficiencies) as appropriate. Agent did not attempt to "steer" beneficiary to any specific provider. Resources: o Job Aid: TRN REF 614a AEP Playbook o Job Aid: TRN REF 880v Humana Care Highlights Program o Job Aid: TRN REF 880w Care Highlights FAQ o Humana website: Care Highlight (humana.com) o Job Aid: TRN REF 1306 7 steps to promote top-tier providers in Find a Doctor tool o Operational Communication: Rep Communications - Physician Care Highlighting and Value-Based... (sharepoint.com) Page 22 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question BP3: Did the agent ask permission for Centerwell Pharmacy outreach (MAF)? (4 Points) Intent/Purpose: During all Humana MA, MAPD, and PDP Sales presentations, agents should present the benefits of Centerwell Pharmacy. Enrollment in Centerwell Pharmacy benefits members with an improved member experience, additional health, and well-being benefits, as well as potential savings with preferred cost-sharing on covered prescription medication. Members who receive prescriptions by mail order tend to have better adherence to the prescriptions which can improve their health outcomes. Required Components Agents reviewed the value of Centerwell Pharmacy and attempted to gain permission for Centerwell Pharmacy to make outreach after enrollment. Resources: o Job Aid: TRN-REF-1306gm-ja DMS ROY Group Medicare - Job Aid (humana.com) Question BP4: Did the agent complete the HRA with an authorized party? (4 Points) Intent/Purpose: When agents complete the HRA, they are contributing to Humana's Bold Goal which is to improve health outcomes and health equity by addressing the needs of the whole person, co-creating solutions to address social determinates of health-related social needs for our members and communities. Required Components Agent asks for permission to complete the HRA and followed process as outlined Resources: o 2022 Member Care Assessment - Whole Health Toolkit (NA-78) o Job Aid: NA 79 Survey Questions and Talking Points Page 23 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question BP5: Did the agent accurately document their CRM database? (2 Points) Intent/Purpose: Our documentation is critical when providing a world-class experience and remaining compliant. If the beneficiary’s information is incorrect, important communications may be sent to the wrong party which can result in HIPAA concerns. The information we document is also critical in our marketing strategy such as our mailing lists and outbound campaigns. Required Components If no CRM/CANVAS record exists, an agent should try to obtain and document demographic information which includes: o Residence including county o Phone number o Veteran status o Email Address o Retirement/Group status o Preferred Language (if alternate languate used on call) If CRM/CANVAS record exists, an agent should try to verify and update demographics o Residence including county o Phone number o Veteran status o Email Address o Retirement/Group status o Preferred Language (if alternate languate used on call) Information must be valid and/or verified cannot be inaccurate o EX: “test” or “XXX” Resources: o Rep Comm: Safeguarding Caller Information Page 24 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question BP6: Did the agent ask if additional parties are seeking assistance? (2 Points) Intent/Purpose: Humana has an expansive portfolio of products to meet the needs of different consumers. As part of providing the Perfect Telesales Experience, agents should take the time to understand the various ways that Humana can help a caller as well as any other potential beneficiaries. Required Components Understanding the caller’s household needs by determining if others may benefit from the plan(s) being discussed. Examples include: o Example: Dental: If there are dependents that should be added to the application o Example: Medicare in Home Appointment: If other Medicare or soon to be Medicare eligible recipients will attend Asking for referrals o "If you have any family members or friends that would benefit by speaking with me, please give them my number and I would be happy to assist them too.” Question BP7: Did the agent ask to save prescription data for enrollment? (2 Points) Intent/Purpose: Our Humana Clinical partners work hard to deliver the Perfect Experience to our Humana members. In an effort to improve the new member experience, agents should ask to save the caller’s prescription information at the time of sale. By providing consent to save this information when initially provided, Centerwell Pharmacy will have the information needed to potentially call the member to discuss their prescriptions. These efforts to assist members with their prescriptions will help retain members and grow our business. Required Components Agent asks for consent to save medication data and followed process as outlined o The Pharmacy Calculator includes verbiage which asks permission for Humana to save the prescription information the caller is about to provide. If the caller responds “Yes” to the consent question and does enroll with the agent on that call, the information will be sent to Centerwell Pharmacy. Resources: o Job Aid: TRN-REF-1312a Pharmacy Calculator - Asking for Consent to Save Rx Job Aid o Job Aid: TRN-REF-1312b Pharmacy Calculator - Asking for Consent to Save Rx Video o Communication: Rep Comm - Reminder to Offer to Look Up Rx and Asking Consent to Save Rx Data Question BP8: Did the agent ask for Digital Onboarding permission? (2 Points) Intent/Purpose: Agents who utilize Digital Onboarding are Pioneering Simplicity for their members while also contributing to growth, retention, and the Perfect Telesales Experience. Humana has created a digital onboarding experience that makes it easy for new Medicare members to engage with Humana digitally. At time of enrollment, new Page 25 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 members have a choice to receive important communications and plan materials digitally. Shortly after enrollment, new members who opt-in to receiving digital materials receive a welcome email from Humana. The email reminds them that they successfully enrolled in a new plan and invites them to set up their personal MyHumana account by following the online link within the email. Required Components Agent explains value of providing email address for digital onboarding o Example: Immediate enrollment confirmation o Example: Fast and easy access to plan documents, all in one secure location o Example: MyHumana Self-Service for members If applicant opted-in to receiving materials online: o “You will receive an email with a link that will take you to the MyHumana registration page. It is important that you follow this link and complete the registration process. Once you register, you will be able to access plan materials like your member guide. You will also be able to tailor the specific items you would like to receive online or by paper.” If applicant chose not to receive materials online: o “If you decide later that you would prefer to receive your communications online, you can make these changes at any time by logging on to Humana.com or by calling Customer Service.” Resources: o Job Aid: DMS-261: Digital Onboarding Job Aid Question BP9: Did the agent ask and properly document PTE question? (2 Point) Intent/Purpose: Providing our callers with a Perfect Telesales Experience is at the core of everything we do. Asking the PTE question will allow us to take real time personal accountability to the service we provide. Accurate documentation will allow DMS to understand the results of our pursuit of a Perfect Experience. Required Components Agent must ask the appropriate PTE question based on the call direction, receive a quantified response, and accurately record the response on every call regardless of outcome. If a caller provides a response of 3 or lower the agent must follow up to understand how we could have provided a better experience during the call. Resources: o DMS-050: PTE Guidance Page 26 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 CONSUMER EXPERIENCE: Question CE1: Needs Analysis Technique (Minimum Requirement: 2 Points) Intent/Purpose: Humana highly encourages the use of a consultative selling approach in helping consumers. We do not start with our products. Instead, we first invite prospects to describe their situation. This dialogue is key to identifying the plat type that may be suitable. It also enables us to envision the plan benefits or extras that will be the most helpful to the consumers. Our first objective on a call is to build a relationship which creates value and trust with the consumer. Agents have a limited amount of time to engage our consumers and understand how Humana may help make a positive impact on their lives. Our ability to provide consumers with the right solution is based on understanding their needs/wants. Agents need to ask the right questions to help focus on the consumer’s area(s) of interest. Possible Gather enough information from the beneficiary so the agent can present a specific Examples/ plan; however, consideration will be provided when the beneficiary provides all information necessary to understand their initial healthcare needs. Methods: o Example: The agent presented a PPO option because the beneficiary advised that they routinely receive care in 2 different states (snowbird). Keep questions simple by asking questions that uncover one need at a time. Examples include but are not limited to: o Example: “What benefits are important to you as you consider your healthcare options?” Engage the beneficiary through conversation which allows the beneficiary to openly discuss their healthcare needs. An example can include but is not limited to: o Example: “Is it ok to ask a few questions so that I can understand what you are looking for in a plan?” Uses of different question techniques (open-ended/target options) to have the beneficiary explain their current gaps/likes/dislikes. Examples include but are not limited to: o Example: “Do you prefer a plan with low out-of-pocket cost which allows you to stay in network or do you prefer a plan that allows you to go in and out of network but may have a higher premium?” Ask questions based on previous information provided by the beneficiary to gain clarity and acceptance. An example can include but not limited to: o Example: “You said that you wanted a plan that had transportation benefits, is that correct?” Understanding the consumer’s household needs by determining if others may benefit from the plan(s) being discussed. Examples include: o Example: Dental: If there are dependents that should be added to the application o Example: Medicare In Home Appointment: If other Medicare or soon to be Medicare eligible recipients will attend Incorporating healthcare needs portfolio in discovery and presentation phases of discussions. o Example: Uncovering dental/vision needs or gaps in coverage when discussing medical plans o Example: Review of prescription needs and wants when presenting Medicare Supplement options Page 27 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Avoid/Limit: Presenting a plan prior to understanding the primary healthcare needs of the beneficiary o Example: Beneficiary is seeking to understand prescription plan options and the agent discusses lowest costing PDP plan in area without reviewing options such as MAPD. Asking multiple questions at a time does not provide the beneficiary with an opportunity to answer questions Asking yes or no questions limits the agent’s ability to understand the consumer’s specific needs. o Example: “Are you happy with your supplement?” o Example: “Are you looking for a better plan?” Resources: o Job Aid: DMS 214 Medicare Presentation of Benefits o Job Aid: DMS-011 AEP Playbook (humana.com) o HMU Training: Sales Integrity Education Series - Conducting a NEADS Analysis o HMU Training: NEADS Analysis o JOB AID: TRN-REF-1323a Consultative Sales Job Aid Page 28 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question CE2: Presenting a solution (Minimum Requirement: 2 Points) Intent/Purpose: When an agent presents a solution, it needs to be focused on addressing the consumer’s needs/wants and how the solution will meet those needs. We are looking for agents to display value rather than the price. This involves a balance of confidence, trust, and knowledge. Presenting an appropriate solution aligns the needs expressed by the beneficiary and not working on one plan fits all mentality. Possible Present a Humana plan option with specific examples on how it will meet the Examples/ needs/wants expressed in the call. o Example: “The Humana Gold Plus plan will help meet the needs you expressed Methods: such as low out of pocket costs. It has a $0 monthly premium, and your PCP (Primary Care Physician) copayment is just $5.” o Example: “While this plan costs a few dollars more than what you are currently paying, it provides you with embedded dental and vision that you don’t have now.” Help the beneficiary become aware of the need for the Humana option and how it will make a positive impact in their lives. o Example: Reminding the member about the part b giveback they are now getting, or the OTC (Over the Counter) card benefit that they were asking about at the end as a positive way to leave the call. Recapping the important benefits, the beneficiary mentioned at the end to reiterate why it was a good idea for the prospect to change their coverage to Humana. o Example: Asking the beneficiary to recap the reasons they selected Humana and having them jot it down for reference. Use techniques to help engage the beneficiary throughout the plan presentations such as: o Speaking clearly o Routinely pausing to gauge the consumer’s understanding/approval of plan being presented (tie-back) o Adjusting the pace to meet the consumer’s needs Portray Humana and its partners in a positive light Provide accurate information on the plan options that are being discussed Being mindful of your pace and tone If Humana is not the appropriate plan that can meet the consumer’s needs, explain the reasoning and additional options the beneficiary may have. Avoid/Limit: Presenting a plan, the beneficiary does not qualify for or is not in the service area Automatically offering the lowest cost plan, without having uncovered the consumer’s needs and preferences Presenting any plan without providing personalized examples of how your recommendation fits the consumer’s needs Providing too much information in a short period of time confuses the consumer. o Examples or indications given by the beneficiary that they did not understand include: ▪ “Can you repeat that?” ▪ “I’m confused and not sure how this plan will help.” Discussing benefits in a checklist manner without engagement from the consumer. Using acronyms or internal Humana jargon that the beneficiary is not familiar with that creates confusion. Use statements or word choices that do not convey confidence in product, plan, or service such as “I’m not sure,” “I do not know,” “I’m pretty, sure,” or “I think” unless followed up with a statement indicating what can be done (i.e., “I’m not sure, but I will research that for you”) Page 29 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  Focusing on the value of the call to action instead of the plan option (i.e., explaining the value of an in-home appointment instead of the Humana PPO) Page 30 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question CE3: Call to Action (Minimum Requirement: 2 Points) Intent/Purpose: A call to action refers to the direction the agent provides that leads the beneficiary to take immediate action. Because agents handle a variety of call types, the call to action can vary based on the business needs and circumstances of the call. Agents should continue to refer to the respective AEP/ROY Playbooks, Rep Communications, and Leadership directives to ensure they are aligned with the business models/strategy. Agents must always provide a beneficiary with a call to action, even if the action is not to consider Humana. Possible Setting the stage of the business model option as the call progresses. Examples/ o Example: “I will be happy to review those options with you and if we find a plan that meets your needs, we can discuss what options you have available from there.” Methods: Explaining the value of the call to action and how it will benefit the consumer Addressing questions as it relates to how the call to action will benefit the consumer’s needs If Humana is unable to meet their needs (i.e., the beneficiary does not have an election period and our do not pass underwriting for our supplement options), the agent must provide next steps such as the dates of the next annual enrollment period or how to qualify for extra help. Avoid/Limit: Providing multiple options as a call to action unless directed by DMS Leadership o Example: “I will be more than happy to complete the enrollment over the phone, or I can have an agent come out and discuss this with you. Which would you prefer?” Providing inaccurate information as it relates to the call to action o Example: Avoiding sending an application via wet signature disguised as a detailed kit Page 31 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question CE4: Understanding and addressing the gaps/barriers/concerns (Minimum Requirement: 2 Points) Intent/Purpose: From time to time, a beneficiary may have either a gap in understanding, a barrier that prevents them from purchasing, or concern about how the plan will meet their needs. A proactive agent will ensure that these gaps, barriers, and/or concerns are addressed as they progress through their plan presentation. If the agent is unaware of these concerns during the presentation, the beneficiary will provide another opportunity once the call to action is provided by the agent. Remember that these gaps, barriers, and concerns are not necessarily a sign that the beneficiary is not interested. Overall, as a buyer, people want to make sure they made the right decision. Agents should consider this an opportunity to solidify the reason for selecting Humana. Examples Gap Barrier Concern Is this a supplement? Spouse not available and How do I use it when I go Why is this $0? helps make decisions out of town? I do not have any money until Are my doctors in the next week network? Possible Throughout the conversation, the agent proactively addresses potential gaps, barriers, Examples/ and/or concerns. Use a combination of techniques to help address their gaps, barriers, and/or concerns Methods: such as: o Give the beneficiary the opportunity/chance to explain o Ask questions to determine what is causing the beneficiary to not see the value of the Humana option presented o Summarize their concerns and explain how Humana may be able to meet their needs ▪ Examples can include: Doing the Math: Explaining the cost savings between a $200 a month Supplement plan ($2400/year) compared to the $75 a month LPPO (Local Preferred Provider Organization) plan ($900) in their area. Added Benefits: Consider the quadrant the beneficiary may fit into, and review benefits based on their needs/wants o Take a moment to confirm that you have answered the consumer’s concerns through simple check-in statements ▪ Example: “Does that make more sense?” ▪ Example: “Have I answered all of your concerns?” o Redirect the beneficiary back to the flow of the sales process and then review the value of the call to action. Avoid/Limit: Addressing the concern by over-talking or interrupting the beneficiary during their explanation Shifting ownership of the concern or question by advising the beneficiary to have the local agent answer the questions during the in-home appointment. o An agent should try to address a few concerns and should not send all inquiries to the field. Page 32 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  ▪ This would assist in highlighting the value of the plan and demonstrating that Humana agents are here to provide support and guidance. Not acknowledging gap, barrier, or concern and proceeding with call to action Advising the beneficiary to locate their answers via the Humana website or materials that are being mailed for their review. Resources o Job Aid: TRN-REF-1323a Consultative Sales Job Aid Page 33 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question CE5: Expanding AOR Relationship through Humana Support/Initiatives? (Minimum Requirement: 2 Points) Intent/Purpose: Enhancing Humana’s relationship with the beneficiary is important in establishing trust. When trust is established, this can lead to increased beneficiary satisfactions, quality scores, and retention. Possible When promoting or faced with concern for completing specific initiatives, the agent is Examples/ effectively communicating on how initiatives enhance the relationship between Humana and the beneficiary which can include: Methods: o Example: Obtaining MAF (Centerwell consent) ▪ “Centerwell may be able to save you time and money by delivering medications directly to your home. This has helped members stay up to date on their medications which are important for healthcare needs.” o Example: Discussing benefits of TPP (Top Performing Providers) ▪ “This provider focuses on care highlights and receives top scores for quality of care and cost efficiency. These doctors may proactively reach out to you to remind you of wellness visits, follow up on previous appointments, and more!” o Example: Completing MCA (Member Care Assessment) ▪ “Humana cares about your overall well-being beyond just medical and prescription care. By completing the member care assessment, Humana can co-create solutions to address social determinates of health-related social needs for our members and communities.” o Example: Explaining value of providing email address with immediate enrollment confirmation and digital onboarding ▪ “By obtaining your email address, Humana can send helpful communication which can include enrollment confirmation, enrollment status, and contact information.” o Example: Differentiating experience with AOR relationship ▪ “Please take down my name and number. As your agent, it is my responsibility to ensure that I help connect the dots between Humana and your best health. While customer service can help with many things, if you find yourself with questions about your plan, wanting to understand how it compares to other plans you have seen, or are not sure who to turn to with questions, please call me.” Avoid/Limit: Not implementing key enrollment opportunities that may benefit the beneficiary referenced in the demonstrating examples section. Actively discouraging participation o Example: “Giving me your email address is optional, so we don’t need to do that?” o Example: “I do not feel comfortable asking you questions on the MCA so let us skip it. Page 34 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024 Question CE6: Demonstrating active listening skills throughout the call? (Minimum Requirement: 2 Points) Intent/Purpose: There are numerous ways to tell whether someone is not paying attention during face-to-face contact; however, it is not as easy during a phone interaction. The main indicators that can impact a consumer’s experience while on the phone are based on the effectiveness and/or quality of the verbal exchanges. In this environment, it is critical to minimize the impacts of external influences to prevent them from negatively impacting the consumer’s experience. By directing your attention to the current call, this ensures the beneficiary knows their call is our top priority. Possible Ask/clarify the issue/concern at the start of the call, if not already communicated by Examples/ the consumer. Use of the consumer’s name throughout the conversation Methods: o Trying to address a beneficiary by their title if provided ▪ Example: “Good afternoon, Dr. Smith, thank you for calling Humana to review your options.” Personalize the conversation based on specific information learned about the beneficiary and their unique situation. o Example: Discussing the weather, pets, or children/grandchildren Utilize clarifying questions to ensure that the correct message has been received to help gain control of the call. Repeat or paraphrase what the beneficiary has said to show comprehension Display a willingness to assist the beneficiary to find a solution to their concern Acknowledge and/or provide empathy as appropriate Display appreciation for membership, Veteran Service, and/or considering Humana for their healthcare needs. Provide a summary of what has been conveyed back to the consumer Provide periodic updates to maintain engagement with the beneficiary while researching the consumer's issue. Acknowledging hardship through use of empathy and tone Avoid/Limit: Agent repeatedly requested information that the beneficiary has already provided. Consideration will be given when a consumer’s communication is difficult to understand, etc. It is not appropriate to place the beneficiary on hold/mute for purposes other than assisting with the current call o Example: Answering a secondary call that has come into the agent’s extension o Example: Placing a beneficiary on mute to engage in discussion with other parties Interrupting the beneficiary to obtain information needed to document records without reasoning or explanation Distractions that interfere with and impact the ability to address the needs of the consumer o Example: Not being prepared to handle the call at any time o Example: Engaging in conversation with coworkers, web browsing, e-mails, IMs, etc. Periods of unexplained silence negatively impact the consumer’s experience. Examples or indications given by the beneficiary that they were negatively impacted by dead air: o Example: Are you still there? o Example: Hello? Page 35 CQ_JA037: DEFINITIONS AND INSIGHTS DMS 2023 _ AGENTS | Revised 2/1/2024  Summary of Changes Date Changes 2/14/2023 New Document 6/14/2023 C2. TSOA only applicable for outbound calls C7. Added CCSNP requirements BP1. Removal of document