Scenarios
Today is April 29th, 2021.
Mr. William states he currently has Medicare and Medicaid.
He said he got a letter back in March of this year, stating that he would no longer qualify for QMB+ but, he will still get SLMB benefits.
◦ Based off the information we have; would we be able to help enroll him in an MA plan? Why?
Yes! We can help! Because he recently received a letter indicating change in Medicaid Status
3-1-3 indicates this election
IEP/IEP2
Mrs. Conlon calls in stating she needs help with her doctor and prescription cost. When you ask her if she has Medicare A and B, she says she isn't sure.
What follow up questions can we ask her to validate she does or does not have Medicare A and B?
Do you have a red, white, and blue card?
Are you age 65 or older?
Are you turning 65 soon?
Have you received SS disability for 24+ months?
This Election Code is used for loss, gain, or changed in Medicaid status
MCD
Today is January 7th, 2021.
Mrs. Thomas calls in and tells us that she has Medicare due to disability.
She says she also has an Aetna HMO plan.
She wants to change her plan because her Aetna plan doesn’t offer her the additional benefits she wants/needs.
She tells us she's excited because she's turning 65 on February 22nd, 2021.
◦Does she have an election?
IEP2
3-0-0 is the timeframe for what election
ICEP, delayed Part B
Mr. Jones calls in stating he is looking to get help with some additional benefits. He said he currently has a PDP with Silver Script. He said he pays around $1.00 or $4.00 for his prescriptions. He said he also must see a caseworker once a year.
◦What additional questions should we ask him?
We should ask more digging questions from our SEP Level Job Aid:
◦Level 2: Do you pay $1.30 or $4.00 for your prescriptions?
◦Level 3: What do you pay for your drugs individually?
◦Level 3: Do you have an old receipt or monthly print out from your carrier that would have those cost listed?
◦Level 2: Do you pay your own part B premium or does the state pay that for you? ($148.50)
◦Level 2: Do you have a Medicaid card?
◦Level 3: Does it have the initials QMB on the card?
◦Level 2: Do you have a caseworker you see at least once a year?
◦Level 2: Have you been told you have a spend-down?
◦Level 2: Do you pay anything when you see your doctor now? Or at the hospital?
◦Level 2: Do you get help with your plan premium?
◦Level 3: Have you recently had a loss, gain, or change in your Medicaid? (MCD)
This election code is used if a client has a loss, gain or change in Extra Help Status
NLS
Today is April 4th, 2021.
Mrs. Shaw calls in stating she needs help getting an MAPD plan.
She said her Medicare Part B just started on April 1st, 2021 and she hasn’t chosen any other type of coverage yet.
Her Part A effective date was 10/01/2019.
No! ICEP is only 3 months BEFORE. She gets no month of, and no months after.
0-1-2 is the time frame for this election
OEP New
You are on a call with Mr. Potts and when you ask him what coverage he has now in addition to Medicare, he says he doesn’t have anything. What follow up questions should you ask to validate that he does or does not have additional coverage?
What cards do you show at the doctors?
Do you pay copays at your doctors?
What card do you show at the pharmacy?
Does your plan cover prescriptions?
How much is your monthly plan premium?
Do you have anything like Blue Cross, Humana, Anthem, Aetna, WellCare, etc.?
Can you please go grab any health-related cards you have in your wallet/pocketbook.
This election code is used for clients who have either Medicaid or Extra Help
MDE
Mr. Jones calls in stating he is looking to get help with some additional benefits. He said he currently has a PDP with Silver Script. He said he pays around $1.00 or $4.00 for his prescriptions. He said he also must see a caseworker once a year.
◦Based off this information, would Mr. Jones have a possible SEP?
◦If so, what is the SEP?
He possibly has Medicaid.
One a quarter for the first 3 quarters is the time frame for these clients to make changes
Medicaid/LIS
Mr Jones says he recently moved.
What digging question should we ask about his move?
When did you move?
When did you notify SS?
Did you receive a notification from your plan that you moved out of the plan's coverage area?
1-1-2 is the time frame for this election
MOV