Medicare
What are the 4 parts of Medicare?
Part A covers for Hospital related services while Part B covers for medical services. The two combined are known as Original Medicare.
Part C is a Medicare Advantage Plan; HF has a total of 6 plans to offer under this LOB.
Finally, Part D covers for prescription drugs, and it will either be covered by a chosen (Prescription Drug Plan) PDP or by the chosen Part C.
Which plan is ideal for mbrs who will only use their insurance for emergencies?
The Green Leaf (a.k.a. Catastrophic) Plan
Which Essential Plans are family plans?
None! All EPs are individual plans.
Which CHPs have no OOP costs?
All CHPs have $0 copay/coinsurance/deductible. They are only responsible to come out of pocket for their premium payment.
If a member wants to speak to a CM (Care Manager), how should we proceed?
Check on TrueCare to see who the CM is, and send that CM a task. Advise mbr he/she should receive a call back within 24 hours.
If the mbr does not have a CM assigned as of yet, please follow the Clinical Inquiries Reference Guide to direct the task or message to the appropriate team/dept.
What are the MAPs that HF offers?
IBP, LIP, CC, 65+, CBP, and Signature
What is the difference between the Standard and Non-Standard/Premier plans?
Standard Plans do not include adult dental and vision benefits while Premier Plans do.
Standard Plans will only include Dental and Vision for mbrs under 19 years old.
What is the minimum age requirement for each EP?
EP 1 & 2 mbrs must be at least 19.
EP 3 & 4 mbrs must be at least 21.
What are the new vendors, specific to CHP?
There are no new vendors. The vendors are the same as Medicaid, excluding MAS/ModivCare.
What is the ME1088 screen useful for and where can it be located?
The ME1088 screen, found in MHS, is used to review the OOP costs and deductible that mbr has paid and has been applied on account.
That being said, the claims need to be processed first in order to have the corresponding OOP and deductible added to those ME1088 screen amounts.
For Part D, what are the two plans provided by HF?
And which of those two plans do each of our MAP follow?
Standard Drug Plan and Enhance Plan
LIP, IBP, and CC follow the Standard Drug Plan while the 65+ and Signature Plan follow the Enhanced Plan.
CBP will have Part D covered by their respective creditable coverage.
What is CSR and what plan includes this accommodation?
CSR is Cost Sharing Reduction and is only embedded into the Silver Leaf plans.
Which EPs are eligible for transportation?
EP 3 & 4
When is the Open Enrollment Period for CHP?
There is no OEP for CHP. Individuals may enroll and/or switch to a different CHP as needed.
Where do we go to verify HOH for on-exchange mbrs?
BizTalk !!
Find name listed next to/under Responsible Party.
What is the difference between LIP and Complete Care?
Although both Complete Care and LIP are both dual-eligible plans, CC actually manages both Medicaid and Medicare while LIP mbrs may have straight Medicaid or MA managed through a different MCO.
Another main difference is that Complete Care also includes LTC (Long Term Care) benefits in its plan.
What is the renewal process for QHP mbrs?
QHP mbr must renew during Open Enrollment Period (OEP) Nov 1st – Jan 31st or within 60 days of a Qualifying Life Event (QLE).
On-Exchange mbrs will do so through NYSOH.
For off-exchange mbrs, they must do so internally with Retention dept. Note off-exchange mbrs are passively renewed to the following year if they do not contact CCO during their renewal window to request a plan change as long as they are up to date in their payments.
List all EP mbrs eligible for APTC.
None of the EP mbrs are eligible for APTC (because the premiums are either very low or $0).
What are acceptable reasons for Involuntary Disenrollment?
The member will be disenrolled involuntarily if they:
– Aged out (19th Birthday Month),
– Moved out of coverage area,
– Failed to recertify,
– Deceased, or
– Failed to pay premium
What system(s) can we use to find if a mbr has an LIS on the account?
You can find whether a mbr has a LIS (Low Income Subsidy) applied to plan by checking in OnContact and/or in Marx.
Explain MyAdvocate to us as if we were an interested member.
My Advocate is a tool, provided by our contractor Change Healthcare, who offers services including: Medicare Savings Complete, Recert Complete, Part D Complete, Community Link.
MyAdvocate helps our members stay enrolled in the best plan that meets their needs, and they assist by connecting members to other assistance programs such as EPIC. And it's FREE!
Explain APTC to us as if we were the member.
APTC (Advanced Premium Tax Credit) is an assistance to cover premium costs for those making under 400% of Federal Poverty Level. The eligibility for this subsidy is determined by the NYSOH. On-exchange mbrs are the only ones eligible for an APTC.
When can an EP member change plans?
At any time since there is no Open Enrollment Period (OEP) for EP mbrs.
Explain the premium to the HOH/RP of a new CHP mbr.
If the HOH/RP of a CHP member calls in to see how much their premium payment is, give them the general response based off the plan determination of said premium and how many children there are in family. Please also offer to transfer to CHP Payment Dept. to speak to a specialist on further details or to make a payment.
Where do you go to find an on-exchange mbr's premium?
On BizTalk, the "TotalRespAmt" column will show the member’s actual monthly premium responsibility (after APTC or Other Subsidy is applied).