RANDOMNESS
A federal health insurance program for low-income families and children, eligible pregnant women, people with disabilities, and other adults
Medicaid
The federal government pays for part of Medicaid and sets guidelines for the program. States pay for part of Medicaid and have choices in how they design their program.
Medicaid varies by state and may have a different name in your state.
What system do we use to quote Medicaid Benefits in? (There are 2 Answers)
Maestro, because we have all Wrap plans, the Medicaid benefits will be in Maestro
EOC can also be used to Quote benefits for Medicaid as a back up.
What are the 3 Medicaid Eligibility Levels
Full Medicaid-No Copay Full Medicaid Benefits, Member responsible for Part D copay, Provider must bill Medicaid, Provider cannot "Balance Bill" member
QMB only- No Copay, NO MEDICAID BENEFITS, Member responsible for Part D copays, Provider must bill Medicaid, Provider cannot "Balance Bill" member
Partial Medicaid- Has Copay, Has NO MEDICAID BENEFITS, Member Responsible for Part D Copay , Member will get Bills from provider
What is an NBA (Next Best Action)?
NBAs are a member-specific interaction to help close gaps in care during inbound and outbound calls with members.
If a member wants us to schedule an appointment with a Dr, where would we document that?
Schedule An Appointment Intent
When scheduling a HouseCalls visit, how will members be notified? (2 answers)
A phone call
A postcard or in the mail
What systems do we use to change a PCP for a member? (2 Answers)
Maestro and Rally Connect (either through website or Florida Health plans site )
*Rally Connect can be found in your DSNP Toolbox or find a provider on Florida Plans Website
If I need to find what level Medicaid a member has, where am I going to look?
Summary page on Maestro under Medicaid History
Under plan tab Medicaid history
Name 3 possible NBAs that you might see in Maestro
If a member needs to change their address, what intent would I use in Maestro?
Update Member Address
An option Medicare beneficiaries can choose to receive most or all of their Medicare benefits through a private insurance company
Medicare Advantage Plan or Medicare part C
Plans contract with the federal government and are required to offer at least the same benefits as original Medicare, but may follow different rules and may offer additional benefits.
Unlike original Medicare, enrollees may not be covered at any health care provider that accepts Medicare, and may be required to pay higher costs if they choose an out-of-network provider or one outside of the plan's service area.
What system do we use to complete an HRA (Health Risk Assessment)
ICUE
*will come up as an NBA if there is one that needs to be done
When I'm quoting a benefit, what am I going to tell the member?
All relevant information including any copay, any limitations, and stipulations that are listed with the benefit.
When looking at NBAs, which one do you present first?
What Intent in Maestro would I use if the member lost their ID Card?
Send Member Materials
Who are the best trainers in the world........No just kidding...What system do we use to make sure a house call Rep. is in the area the member resides in and to also see any existing appointments with house calls?
HouseCalls Member Status .....It's in the Advocate OneNote
What system do we do Demographic Changes ?
Maestro
Member needs to schedule a pick up to go to the Dr. How are we going to help? (List all steps please)
1 Find Member in Maestro (fully HIPAA; Verify NEVER FORGET HIPAA)
2. Check member Medicaid level
3. Check members Benefits to see if they have the benefit
4. Look in wellness grid to get telephone number and hours to call transportation vendor
5. Use Probing questions to find out if they need a ride home (all trips are one way)
6. Contact transportation give information and warm transfer member to Transportation
How will I recognize a Gap in Care and how do I close the Gap in Care
1. Look at the members record in Maestro see if there is an NBA
2. Follow the scripting and go through all the NBA on the account
What intent would I use if a member wants us to be able to talk to her daughter about her medical insurance?
Manage Auxiliary Persons
What type of caller can be treated as if they are the member calling?
POA/Guardian/Conservator
Must have proper paperwork on file and listed on their account.
Can update everything and discuss everything as if they are the member.
If we are not sure what system we use to make a change where can we find this information?
DSNP Toolbox
*SME is not an acceptable answer but is available to you as well. Need to try to look up first
Member calling in to see if a MRI is covered and what their copay is.....Tell me the steps to give them the correct information....
1. Find member in maestro (fully Hipaa; Verify NEVER FORGET HIPAA)
2. Look at Medicaid History to see what level of Medicaid member is (if full or QMB only NO COPAY)
3. Review Medical Benefit to give all stipulations and limitations
What is the Difference between a health assessment and a HouseCalls?
HRA The Health Assessment (HA) is a Medicare requirement that provides the plan with health-related information about members. Answers are confidential and the information provided may be used to help connect the member with additional health care services. Completed in ICUE
HouseCall In-home health visits for MA/MAPD UnitedHealthcare members. The service is designed to educate and help our members. There is no additional cost for this service to our members.
Where would I go if a member wants to know if a test is covered and what their copay would be?
Review Medical Benefits