Intro Consent/Pre-eligibility
Agents must read the following verbatim as part of what step of the Intro- "For your protection, I do need to inform you that this call may be monitored and recorded and may be shared with insurance companies who administer the plans we sell/offer."
Read Medicare disclaimer
When an agent is Inquiring about providers the will receive only 6 points if they only verify these.
Agent only asks about providers
An will be given full credit for this section if they do the following: Agent gives correct tier information or co-pay/coinsurance for each of the Member’s prescription *Give full points as long as the Agent offers to look up prescription even if the Member does not want to volunteer that information or does not take prescription. • Agent Provided any drug restrictions (quantity limits, prior-authorization, step therapy etc.) if applicable
Prescription formulary information was accurately presented
• Agent asks, do you have a POA (power of attorney) • Agent reads the following: For you to start receiving these benefits we will need to switch you out of your current plan. That means your new coverage will replace your current coverage on [INSERT DATE]. Prior to continuing, do you understand you will be enrolling in a new plan? - verbatim language not required *If it is not clear that the Member is enrolling into a plan by completing the application also score as failure under ‘Red flag indicator / Cause for concern’ is criteria for this section of Application/Enroll Process
Verifies Member's understanding of the plan and receives agreement to begin application
In the Post Enrollment section of a call you must give the following information to get full credit for "Agent provides their direct number and Telecare number"
• Agent provides their phone number and extension • Agent provides Telecare number • If Agent states this information at any point of the call prior to post-enrollment, Agent must restate this information again during the close of the call
The Agent states that GoHealth/GoMedicare (we) offers Medicare Advantage plans, Medicare Supplement Insurance plans, and Stand-Alone Prescription Drug Plans (PDP), and receives permission to continue the call as part of this stage of the Intro.
You will receive full points for asking about prescriptions for VA if you do this.
Confirm customer receives all Rx through VA.
For this section an agent will be marked down in two areas if they do the following agent presents any benefit incorrectly also remove points under, ‘Gave inaccurate information’ name the section this is under.
Discuss all needs mentioned by Member (additional benefits)
If Agent read/played all enrollment disclosures and received an affirmative response, give total points and mark down in compliance section under "Agent Received "Yes" instead of "I agree" is part of which section of Application/Enroll Process
Read or play application signatures and receives consent to enroll
An agents states the application is being completed in order to send the Member information in the mail causes this level of mark down for Compliance section.
Red flag indictor / cause for concern
Points are automatically awarded for enrollments in October 15-December 7 (AEP)
Determined eligibility to enroll (election)
*Full points if the Agent identifies at least 1 additional benefit the Member is interested in or if the Member declines to answer in this section of the Needs Analysis.
Inquire about additional benefits
Name at least 4 elements required to go over in Completed QA required plan benefit review
• Carrier Name • Premium and describes the difference between the current plan to the new plan, if applicable • PCP co-pay and describes the difference between the current plan to the new plan, if applicable • Specialists co-pay and describes the difference between the current plan to the new plan, if applicable • Medical and prescription deductible (if applicable) • Hospital co-pay (number of days with a co-pay and co-pay amount) Ex: $125 for days 1-5" • Preferred prescription tiers as they appear in Marketplace. If the Member has LIS Agent may give LIS prescription co-pay range (0-9.20 for 2021) ($0-9.85 for 2022) • Agent can provide premium, prescription deductible, and prescription cost with or without LIS • Agent states out of network benefits if the Member sees out of network providers *QA required plan benefits must be completed before the application starts *If any benefit presented incorrectly also mark down under, ‘Gave inaccurate information’
In order to compliantly assign an in-network provider in the application the agent must have completed these steps.
• Agents asks the Member for their primary care provider • Agent assigns an in-network PCP • If assigning a new PCP for the Member the Agent gives the provider's last name and phone number • If the Agent is not assigning a new PCP Agent asks if the Member is a current patient of the PCP
These two words will get you marked down in compliance section for sure.
Free, Best
QA will Mark as 'Red Flag Indicator / Cause for Concern' if Agent verified consumer information in this database without consent
MARx (CMS)
In order to get full points on QA for "Inquire about providers" you must do these three things.
• Agent asks the Member if there are any primary providers they see that should be taken into account when looking for a new plan • Agent asks the Member if there are any specialist providers they see that should be taken into account when looking for a new plan • Agent asks if there are any hospitals they go to
*If the provider is not in-network for a PPO plan, the Agent explains that the provider is not in-network but may accept at a higher co-pay (and give co-pay) is part of which section of Plan Presentation
Network participation was presented for the Member's providers
As part of "Read or play application signatures and receives consent to enroll" to get full credit here you must read verbatim paragraph about plans that previously was only in the UHC application.
• ALL CARRIERS: Agent reads verbatim, "HMO-POS/PPO ONLY: To get the lowest costs, you must use in-network providers, with the exception of emergency or urgently needed care. With this plan, you have access to providers outside of the network. If you go to a provider in the network, the costs may be lower. If you choose to go outside the network, it's important to check the provider is Medicare-approved and will accept the plan otherwise your services may not be covered and you may have to pay the total price. HMO ONLY: If your plan does NOT have out-of-network coverage, you can only use in-network providers. "
All plan benefits that were presented were presented accurately will get you credit for this section.
Agent gives inaccurate information
When Branding the phone call Agent states they are a "Licensed Sales Agent," a "Licensed Insurance Agent," a "Licensed Medicare Sales Agent," or a "Licensed Medicare Insurance Agent" required on the first call with a consumer within this amount of time.
The First 5 Minutes
Agent asks the Member if there are any prescriptions they would like to check on the formulary and must verify dosage and quantity (if the Member has that information) as part of this step in Needs Analysis
Inquire about prescriptions
In order to receive full points for Completed QA required plan benefit review an agent must compare these different areas from the old plan to the new one.
• Carrier Name • Premium and describes the difference between the current plan to the new plan, if applicable • PCP co-pay and describes the difference between the current plan to the new plan, if applicable • Specialists co-pay and describes the difference between the current plan to the new plan, if applicable
Agent receives full credit for "Agent receives responses from the Member to application questions" when they state the following.
• Agent reads each question that is not marked "optional" on the Marketplace application • Agent asks, "Are you a current/established patient of the provider" even when marked optional on the application when assigning a current in-network provider • Agent can state the answers to the questions themselves and receive confirmation from the Member or have the Member provide answers to the questions
All enrollments must be completed on this type of call.
Inbound Call.