Overview
What's the name of the plan that includes D-SNP H5619-054?
Aligned - Indiana Pathways for Aging
How many ID cards would an IN ALIGNED member have/receive?
TWO: (one for their DSNP H5619-054/MAPD) + (one for their Humana Healthy Horizons of IN/MCD)
What system is used to quote benefits?
Debut
Guidingcare (by Humana Advocates, Members, Mbr reps, etc)
What's the definition of an inquiry?
when a caller needs information such as claim status or Provider Directory.
What is the age requirement for a Pathways Member/Enrollee?
60 years old
True or False: We can email members a copy of their ID cards if they call in & need one sent.
FALSE, per HIPAA guidelines we are not to email any member ID cards (even those for Aligned members)
Why is verifying Cost Share protection important for IN ALIGNED Members?
If the Mbr has CSP they may not have to pay anything out of pocket (deductibles, copays, coinsurance, etc)
All IN Pathways for Aging Members will be automatically assigned a care coordinator upon enrollment to plan-- True or False
TRUE
What's the definition of a grievance?
Written or verbal expression of dissatisfaction with any part of the plan.
Which IN Pathways plan types/issues would we handle?
- Aligned (DSNP H5619-054 + Humana MCD)
- Medicaid only
- Unaligned (Humana MCD + Humana MCR) = for MCD questions only
-Unaligned (Humana MCD + MCR with another carrier) = for MCD Questions only
Member contacts Humana about eligibility & it's been 3+ business days to Enrollment-- Would MET take the call/ is this In Scope for MET?
TRUE/ YES
(Step 2 of Elig. verification & ATC IN Pathways for Aging) &
(IN & Out of Scope transfers to MET)
What system is used to determine what Medicare plan the member has?
MARX or Wipro
If a mbr needs to complete a Medical Health assessment, what will we see in CRM?
ALERTS
What's the definition of an appeal?
A caller/member disagrees with our decision to deny payment for an item or service and can therefore file an appeal. The appeal is a request for us to reconsider our initial decision.
TRUE: A patient or waiver liability, similar to a deductible, is a fixed dollar amount that the member is responsible for paying towards services before normal benefits are applied.
If an IN Pathways member wants to disenroll from their Medicaid plan, who would they need to contact?
*Bonus: Who would mbr need to speak with if they want to disenroll from Humana Medicare DSNP plan?
MAXIMUS - Humana's unable to process disenrollment request.
-Disenrollment/Cancellation team
Whats the Transportation Vendor for Medicare? & Whats the Transporation Vendor for Mediaid?
Carecar
LCP
Humana Advocates can assist mbrs with completing Medicare HRA over the phone.
Where would we find the appeal rights for the caller when filing an appeal for IN mbr?
In the Denial letters that were sent to mbr/mbr rep or in the MET index under Grievance & Appeal heading
What are the Eligibility requirements for the Pathways plan?
Aged 60 years+ for low income, aged, blind & disabled seniors.
---IN Pathways members who may also:
- Have Medicare benefits.
- Qualify for Medicaid, but haven't met the age requirement for Medicare.
- Reside in a nursing facility.
- Receive long-term services and support (LTSS) in a home or community-based setting.
If an Aligned member has LTSS waiver, which plan is the waiver found under in CRM?
**Extra Credit for where indicator's in CRM**
Medicaid plan line
(The Long Term Support Services (LTSS) indicator in the Eligibility section on the Plan Member page in CRM indicates if the member has a PathWays plan waiver, either Yes or No)
An IN Aligned mbr would also be eligible for these 3 benefits compared to the HHH (Medicaid plan only)?
1. Healthy Options Allowance
2. Silver Sneakers Program
3. Spending Account Card
An IN Aligned Mbr needs to complete their MEDICAID Health Needs Screening-- who assists mbrs with completing this HNS?
The mbr's assigned Care Coordinator-- Not Humana Advocates
We can NOT do a verbal appeal. We have to give the caller instructions on how to submit in writing. UNLESS the caller is ill, illiterate, or handicapped to which we need to document that clearly in the case notes.