Look Up Case Info in CRM
Where do you view documents in CRM received?
OnBase Attachments
Task 6
If a customer is eligible for Medicaid, can they also qualify for APTC?
No they cannot
QHP 2025 tab then click APTC
Are X-Rays included under Medicaid?
Yes but a referral is required from a PCP, OB/GYN or a previously referred specialist.
Under I and look under independent lab or X-ray
What are the plan types/tiers and the percentage of cost that they cover?
Bronze - 60%
Silver - 70%
Gold - 80%
Platinum - 90%
Under the Plan Types/Tiers Tab
Can a customer provide feedback?
Yes, customers can provide feedback
Ref - Submit GAC Task 3
Where would you find the customers QHP Member ID Number?
Under Member Coverages Tab
Task 10
If an individual is ineligible for Medicaid due to the 5 year bar, are they eligible for APTC?
Yes they are eligible for APTC
Under the Eligibility Factors tab
Caller was referred to a dermatologist, will it be covered ?
Covered if medically necessary
Click D and look under Dermatology
Where can you find the QHP plans and subsidies tool?
Under the Plan Designs and Rates Tab
If the customer has been authenticated and they specifically ask what the email is that is linked to the account. (example is when doing password resets) Can we provide the email?
We can provide them with the first letter and the URL. We can ask the customer if they think they know which email it may be and have them tell us, we can confirm with a yes or no to the email they give us
Ref - Confidentiality Matrix under the HIPPA Issues and Resolution Tab
Where can you check customer's income listed?
Under Application Data Tab
Task 7
Household size of 4 and only 1 household member wants to enroll in Dr Dynasaur Pregnant Woman. What is the income limit to qualify?
$5,707.00 monthly
Under the Medicaid 2025 Tab then click Medicaid & Dr. Dynasaur scroll down to the Dr. Dynasaur chart. Then confirm the income under Monthly income for Pregnant Women
True or False
Customer is going out of country for a week. Will inpatient out of country care be covered?
No the only exceptions is if the emergency happened in the US, but a Canadian facility is the closest.
Click O and check under Out of State Health Care Services
True or False
APTC(Advanced Premium Tax Credit) can be applied to a stand-alone dental plan.
False, APTC is applied only to essential benefits, it cannot be applied to a stand-alone dental plan.
Under Plan Types/Tiers Tab
In Access, which screens do you use to verify authorized representative or alternate reporter?
WARN/D first and if nothing is listed then SUBS/D
Ref- Look Up Case info in ACCESS Task 7
Customer called to confirm what he is eligible for, where in CRM would you find that information?
Under Benefit Plans
Task 9
Household size of 3 and only 1 household member wants to enroll into QHP with APTC. What is the income limit to qualify for APTC?
Household of 3 income limit is 180,216
Under the QHP 2025 Tab, click APTC scroll down until you see Inflation Reduction Act Expanded Income Limits for APTC. Click where it says single and you will see a chart with the income limits based on household size.
Customer called to check if Baby Hugger is covered. Is it covered under Medicaid?
Yes it is
Click C and look under Childbirth
What is the difference between Standard and Non-Standard Plans?
All plans cover the same essential health benefits, but non-standard plans may include additional coverage or specialized wellness programs.
Under the Plan Types/Tiers Tab
Vpharm customer is calling to make changes to her income. Can you update the information in access?
No the call is to be transferred to phase 2
Ref- Process Access Change Task 1
What date should you put in for the case access end date after a process is completed?
Yesterday's Date
Task 8
In order to quality for APTC customer must also meet what non-financial requirements?
Meets the eligibility requirements for enrollment in a QHP
Is not eligible for MEC other than individual coverage offered through VHC
If married, must file a joint return for the benefit year
Must not be eligible for Medicaid/Dr. Dynasaur
Under the QHP 2025 Tab then click APTC
How many chiropractor visits is a customer allowed per calendar year before prior authorization is required?
12 visits per calendar year
Under Chiropractic
Caller changed their plan mid-year but remained with the same carrier. Will their deductibles and out of pocket maximum carry over to the new plan?
Yes, Customers who change plans mid-year and remain with the same carrier will have amounts applied towards their deductibles and OOPM carried over to their new plan.
Under the Out of Pocket Costs Tab
Customer called to reenroll into Medicaid but under member coverages you see a lapse/cancelled plan. Can you proceed with the plan selection?
No, the Medicaid plan selection will have to be escalated.
Ref - VHC Plan Selection Task 2