Disclaimers
What is supposed to be read verbatim in the completed new plan details
ssbci statement
pecl and evidence of coverage
IF a client is new to an area we do not have to inquire about doctors
False
What must be compared
1. premium
2. Primary copay
3. Specialist copay
True or False
The IVR must be played and read
true
What is the total points for this section
15
In addition to saying whether a doctor is in or out of network , what must we confirm about the doctor
Location
Network participation must include what
Effect on emergency and urgent situations
What is the pecl statement?
: “Before making an enrollment decision, it is important that you fully
understand our benefits and rules. If you have any questions, you can call and speak to a
Customer Service representativ
When using Milliman :
What statement is required after going over drugs ( not verbatim)
Are there any other drugs ?
For Dental : What is required for you to go over
For Vision: What is required for you to go over
For hearing: What is required for you to go over
• Dental: Routine exam copay, number of routine exams per year, annual allowance, and member
reimbursement
• Vision: Routine exam and glasses coverage
• Hearing: Routine exam coverage
In addition to the pecl statement- what another statement must be read
Evidence of Coverage: Review that EOC provides complete list of covered services,
limitations, and exclusions; reference obtaining copy at [carrier URL] or calling for copy
If a customer adds a drug after you do a milliman search, what must you do (include)
manually input drug
type
dosage
quantity
If the client has LIS what must you go over
Original Premium
original Drug cost and deductible
If the customer has LIS. what must we go over
original cost and lis cost
premium
drug deductible and cost
True or False
the 30 day standard rx is required to go over for each customer
False - its the 30 day preferred ( standard if preferred is not available)
What is considered baseline benefits
(14)
Carrier name
Plan Name
Plan type
Network Participation
premium
ssbci-
medical / drug deductible
copays ( compare)
hospital
moop
drugs tiers (30 day preferred)
dvh
pecl
Evidence of coverage statement