Product Basics-Building a Foundation

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Product BasicsBuilding a Foundation

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This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

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Introduction

Welcome to the Product Basics—Building a Foundation course.

The overall goal of this course is to help you learn and retain basic information regarding Medicare Advantage and Prescription Drug plans.

A course is considered completed with a passing score of 90% or higher on the test for this module.

You will be required to re-take this module, and possibly other modules, if a complaint is received regarding your sales practices.

Additional modules may be assigned as a method of retraining depending upon the nature of the inquiry, if one should be received by the plan.

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This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

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Learning Objectives

• Election Periods and Star Ratings

• Scope of Appointment (SOA)

• Completing an Application

• Enrollment and Disenrollment Process

• Grievances and Appeals

This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes. 3

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Medicare Advantage Election Periods


An Election Period is a defined time when Medicare beneficiaries may enroll or make changes to their plan.

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Initial Coverage Election Period (ICEP)

ICEP eligibility begins three months immediately before the beneficiary’s first entitlement to both Medicare Part A and Part B and ends on the later of:

1. The last day of the individual’s Part B initial enrollment period, or;

2. The last day of the month preceding entitlement to both Part A and Part B.

Once an ICEP enrollment request is made and enrollment takes effect, the ICEP election has been used.

In most cases, if the Medicare beneficiary does not enroll during this time period, he or she will have to wait until their next qualifying election period.


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ICEP - Examples

Example 1: Mrs. Kim’s 65th birthday is June 8, 2021. She is eligible for Medicare Part A and Part B beginning June 1, 2021 and has decided to enroll in Part B beginning on June 1. Her ICEP begins on March 1, 2021 and ends on September 30, 2021.

Example 2: Mr. Johnson’s 65th birthday is April 17, 2020. He is eligible for Medicare Part A and Part B beginning April 1, 2020. Because he is still working and has health insurance provided by his employer, he has decided not to enroll in Part B during his initial enrollment period for Part B.

Upon retiring, he will have the opportunity to enroll in Part B (through a Part B Special Election Period). He has enrolled in Part B effective May 1, 2021. His ICEP is February 1 through April 30, 2021.


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Special Election Period (SEP)

A SEP is a set time, outside of other election periods (for example, IEP and AEP), when a beneficiary can enroll or change his/her current plan enrollment.

During a SEP, a beneficiary may discontinue enrollment in a MA plan, change to a different MA plan or change to Original Medicare coverage (except for MSA plan enrollees).

Once a beneficiary has elected the new MA plan, the SEP ends for that individual – even if the time frame for the SEP is still in effect.


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Special Election Period (SEP) Example

Mr. Garcia, a current MA plan member, currently lives in Ohio. He plans to move to California on June 18. A SEP is available to this beneficiary starting May 1 and lasts through August 31.

He may choose a plan effective date of up to three months after the application date for his new California MA plan.


Application Receipt Date Possible Effective Date

Month of May-OR-Month of June

July 1

August 1

September 1

Month of July

August 1

September 1

October 1

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Dual/LIS Special Election Period (SEP)

This SEP begins the month the beneficiary becomes eligible for Low Income Subsidy (LIS) or receives any type of assistance from Medicaid. It is available one time per-calendar-quarter during the first nine months of the year; or:

• January – March

• April – June

• July – September

The SEP is considered “used” based on the month the beneficiary makes the election (application date). The effective date of an enrollment request made using this SEP is the first of the month following receipt of an enrollment request.


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Annual Election Period (AEP)

During the Annual Election Period (AEP) Medicare beneficiaries can make a change (enroll or disenroll) regarding their coverage choices. They may add or drop MA and/or drug coverage or return to Original Medicare.

No action is required if the Medicare beneficiaries choose to keep their current plan. Beneficiaries should check with the plan sponsor for any changes to their plan benefits for the coming year.

• AEP occurs from October 15 – December 7 each year

• Changes in coverage are effective January 1


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Open Election Period (OEP)

OEP occurs annually from January 1 – March 31. Beneficiaries, enrolled in a MA-only or MA-PD plan, may use the OEP to switch to:

1. Another MA-PD plan;

2. A MA-only plan; or

3. Original Medicare with or without a PDP.

NOTE: This enrollment period does not allow for Part D changes for beneficiaries enrolled in Original Medicare, including those enrolled in stand-alone PDPs.


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Open Enrollment Period for Institutionalized Individuals (OEPI)

The OEPI is continuous for beneficiaries who move into, reside in, or move out of an institution. The OEPI ends two months after the month the beneficiary moves out of the institution.

A MA eligible institutionalized individual can make an unlimited number of MA elections during OEPI.


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Part D Late Enrollment Penalty (LEP)

The LEP is an amount added to the MA-PD/PDP plan premium of a beneficiary who did not obtain creditable prescription drug coverage (i.e., prescription drug coverage that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage) when they were first eligible for Part D or who had a break in creditable prescription drug coverage of at least 63 consecutive days.

The agent or broker must inform the beneficiary of this penalty.


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Star Ratings Program

The Medicare Part C & D Star Ratings program is designed to rate the quality and performance of MA and PDP plans. Note the following:• Plans are ranked annually at the contract level on a scale of 1 to 5 Stars

(5 is the highest)

• Ratings are comprised of measures that cover both Part C and Part D

• One time each plan year, beneficiaries can use a SEP to enroll into a 5-Star plan


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Scope of Appointment (SOA)

SOA guidelines were established to ensure Medicare Advantage and Part D plan sponsors do not market any health care related product, beyond the scope agreed upon by the beneficiary, and documented by the plan, prior to a face-to-face or telephonic marketing appointment.


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Scope of Appointment (cont.)

• The documentation must be in writing, in the form of a signed and dated agreement by the beneficiary, or a recorded oral agreement

• Use the most current SOA form provided by the plan associated with the enrollment

• Another carrier’s SOA form may be used, if it is CMS approved

ALL agents and brokers are responsible to complete the SOA per CMS guidelines.


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Pre-Enrollment Checklist


Prior to making an enrollment decision, beneficiaries must review and complete the pre-enrollment checklist.

This is where the beneficiary acknowledges their full understanding of plan benefits and rules prior to enrollment.

This document is included in the Summary of Benefits.

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Completing an Application

Prior to signing the enrollment application, the agent should review plan information to ensure the prospective member is making an informed choice.

The agent should:

• Verify the beneficiary is eligible to enroll and has a qualifying election period

• Review and confirm the beneficiary’s existing coverage (including existing Medicare Advantage plan type) to ensure proper plan selection

• Verify the application is signed and dated

• Inform the beneficiary they will receive an Outbound Enrollment Verification (OEV) letter


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Completing an Application (cont.)

• The agent must submit the application immediately via fax, overnight mail or online

• The “application date” is the date the agent or broker receives the enrollment request

• If a beneficiary wants you to hold an application, you must explain that you can either submit or cancel the application following established procedures

Be sure to transmit all pages of the application, including any necessary supporting documentation.


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Common Application Errors

Missing or incorrect information may delay processing of the enrollment form and subsequently the effective date. Examples include:

• Missing signature and/or date

• Missing or invalid Medicare Beneficiary Identification Number

• Selection of an invalid or incorrect election or enrollment period; selecting the incorrect election period may impact the effective date allowed for the beneficiary


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Common Application Errors (cont.)

Make certain that the applicant’s permanent address is in the service area of the plan that the beneficiary has selected. An application for a beneficiary who does not live in the plan’s service area will be denied.

Review critical personal data with the applicant to ensure accuracy:• Full Name as it appears on the Medicare card• Date of Birth• Gender• Phone number• Address (a Post Office Box may be used as a mailing address but

NOT as a permanent address)


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Solicited vs. Unsolicited Applications

CMS has strict rules about when agents and brokers can begin to 1) market, and 2) submit enrollments for 2022 plans.

1) MARKETING PLANS: You can start to market 2022 MA, MA-PD, or PDP plans on October 1.

2) SUBMITTING APPLICATIONS: 2022 Plan enrollment applications cannot be accepted until October 15. Agent-assisted applications dated as received prior to October 15 will be rejected and denied.

The submission of a 2022 enrollment application prior to October 15, 2021 will result in a sales allegation.


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Effective Date

Except for some SEPs and other circumstances, a beneficiary cannot request an enrollment effective date. The plan will use the selected election period to determine the effective date.

In general, except for AEP, most of the applications received in the current month will be effective the first of the following month. Remember:

• No retroactive effective dates will be issued

• The plan effective date cannot be prior to Medicare Part A and Part B entitlement


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Enrollment Reminder

Remind the applicant that:

They can only be enrolled into one MA, MA-PD, or PDP at a time

Enrollment into a different MA, MA-PD, or PDP will cause automatic disenrollment from their existing MA, MA-PD, or PDP

Enrollment into a Medicare Supplement (Medigap) plan will not cause an automatic disenrollment from a MA or MA-PD and vice versa

Once enrollment into the new plan has been confirmed, the old plan should be sent a request to disenroll


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Enrollment Process

• An outbound verification letter is sent by the plan to the applicant to verify understanding of their intent to enroll into the health plan he or she selected

• The applicant’s plan will be effective the first day of the following month (or January 1 for AEP election) after the application is received by the plan (pending CMS approval)

• A health plan identification (ID) card and Evidence of Coverage are issued approximately 14 days after the application has been received by the plan

NOTE: ID cards may take longer than 14 days to arrive during AEP. If the new enrollee has not yet received their ID card and needs access to benefits, he or she can use the plan acknowledgement letter.


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Incomplete Applications

If the enrollment application is incomplete, the beneficiary will be notified that additional information is required before the plan can process the request.

See the list below for guidelines on when missing information must be received by the plan.


Missing information on non-AEP submission

Missing info must be received by the plan within 21 calendar days of last day or the month prior to member’s effective date, whichever is later.

Missing information on AEP submission

Missing info must be received by the plan within 21 calendar days or December 7th, whichever is later.

Election period is only missing piece

Missing election period must be obtained within 7 calendar days of receipt of application, or it must be denied.

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What is Disenrollment vs. Cancellation?

A disenrollment applies if coverage ends after a member’s effective date. Disenrollment can be voluntary or involuntary.

• Voluntary disenrollments are initiated by the member and can generally only occur during specific periods such as AEP or OEP (MA or MA-PD plans only)

• Eligible members can disenroll voluntarily by submitting a written request to the plan. Disenrollment requests cannot be taken verbally

A cancellation applies if a request is received prior to a member’s effective date or by the date on their OEV letter.• Cancellation requests are initiated by the member and can be received either

verbally or in writing • OEV letters will also advise the last day a member may cancel their plan;

applications received at the end of the month do get 7 days to be cancelled after they are processed allowing for some cancellations to be accepted after the first


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Involuntary Disenrollment

Involuntary disenrollment may automatically occur for the following reasons:

• Incarceration

• Moving out of plan service area

• Loss of entitlement to either Medicare Part A or Part B

• Loss of special needs status, or

• Death


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Grievances and Appeals

The Grievances and Appeals process has been established so members have a way to contact us regarding dissatisfaction with their plan or benefit determinations.

A complete explanation of the process for filing Grievances or Appeals is provided in the member’s Evidence of Coverage.


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Grievances

A member may express dissatisfaction with any aspect of the operations, activities, or behavior of a plan sponsor.

• The member may call or submit a grievance in writing to the plan.

• The member will receive notification of the outcome in writing


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Appeals

An appeal is a complaint or notification of a problem regarding decisions about the member’s medical bills or health care.

• The member must request an appeal in writing within sixty (60) calendar days of the denial

• The plan must process Part D appeals no later than seven (7) calendar days of receipt


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Foundation / Basics Assessment

Now it is time to put together all of the elements covered throughout this course.

An assessment will be given to test your knowledge on the information presented. A score of 90% or above on the assessment is required to successfully pass this module. If a score of 90% is not obtained, the assessment can be attempted again immediately.

Please click the link to access the assessment.

After completing the assessment for this course, refer to your online training summary for your certification progress.


CLICK HERE FOR ASSESSMENT

https://anthem.uat.coursestage.com/course/view.php?id=39&pageid=43

Product Basics-Building a Foundation

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Transcript of Product Basics-Building a Foundation