Eligibility and Enrollment
This enrollment period begins three months before a beneficiary turns 65, includes their birthday month, and continues for three months after
What is the Initial Enrollment Period (IEP)?
This is required before discussing plan-specific details
What is a Scope of Appointment (SOA)
A client prefers lower costs and is comfortable with network restrictions is looking for what type of plan.
What is an HMO?
This list determines which drugs are covered by a plan.
What is a formulary?
AEP
Annual Enrollment Period
This enrollment period allows MA member to switch plans or return to Original Medicare from Jan 1st to March 31st
What is OEP (Open Enrollment Period)
During an inbound telesales call, a beneficiary is not on the line, but a spouse calls requesting plan information and says they “always handle their Medicare decisions.” What is the compliant response before sharing any details?
What is decline to disclose information and require the beneficiary’s participation or verified authorization (such as a valid POA or documented consent)?
A client wants Nationwide flexibility and is willing to pay more would be looking or this type of plan.
What is a PPO
Drugs are placed into levels that determine cost. These are called this.
What are tiers?
MOOP
What is Maximum Out-of-Pocket?
This Type of enrolment period is triggered by life events like moving or losing coverage.
What is a Special Enrollment Period (SEP)
"This plan is best for you." Why is this non-compliant?
What is because it could be considered misleading or not based on the beneficiary's needs?
A beneficiary has both Medicare and Medicaid and needs coordinated care is looking for this type of plan.
What is D-SNP
This restriction may require approval before a drug is is covered.
What is prior authorization?
LIS
What is Low-Income Subsidy?
A beneficiary moves to a new county where their current MA plan is not offered. When does their SEP typically begin?
During a recorded call an agent downplay potential out-of-pocket costs to secure an enrollment. What compliance issue does this create?
What is misleading or incomplete disclosure of plan information?
During a phone call, a beneficiary agrees to enroll but seems confused about provider networks. What must you do before completing the enrollment?
What is ensure understanding by reviewing provider networks details and confirming comprehension?
A beneficiary's drug is not on the formulary. What is one possible solution to explore?
What is formulary exception or alternative medication?
SOA
A beneficiary delays Part B due to employer coverage and later retires. What must they avoid to prevent lifelong penalty.
What is enrolling during their Part B Special Enrollment Period (within 8 months of losing employer coverage)?
A beneficiary asks you to skip required disclosures because they are "in a hurry" and not willing to do a quick quote. What is the compliant action even if it risks losing the sale?
What is completing all required disclosures and ensuring understanding before proceeding?
When conducting a needs analysis you discover the beneficiary has multiple chronic conditions and frequently sees specialists but does not qualify for SNP. What is most appropriate to consider when helping choose a plan for the beneficiary.
What is review total cost of care, specialist copay and provider networks.
A beneficiary wants to enroll immediately, but their medication is subject to step therapy. What must you clearly explain before proceeding?
What is that they may be required to try alternative medications before the plan covers their current drug
PA
What is Prior Authorization?