Client Scenarios
Betty Enrolled in an MA-only plan last month when she received her Medicare A and B, not realizing she needed prescription coverage to avoid a penalty, even if she doesn't take any medications right now. She can use this SEP to change to an MAPD plan.
What is OEP-New?
This SEP is only good for the 3 months prior to the client's part B effective date.
What is ICEP? Good for 3 months BEFORE a delayed part B effective date.
Jonathan moved to Las Vegas six months ago, but has not updated his address in Marx. However, he did enroll in a new plan last month at his local Wal-Mart. Jonathan has an SEP to make a change.
What is False? He no longer qualifies for a moving SEP since he enrolled in a plan in his new area.
When searching for a FEMA SEP, this is the best place to look.
What are Josh's FEMA emails and/or carrier specific FEMA event lists?
Marx is down and we cannot confirm LIS. This question is ideal to help determine if someone has LIS without using marx or a medicaid checker.
What is: "How much do you pay for your prescriptions?"
This SEP can only be used if a client has a drug plan in addition to government issued drug coverage, such as VA or Tricare.
What is OCC SEP?
This SEP can be used if a client had level 4 LIS in 2023, but was changed to Level 1 LIS in 2024.
NLS SEP (Gain, loss, or change in LIS status)
Marie was recently diagnosed with a heart condition after she had a stent placed, however she is already on a C-SNP for her diabetes. Marie does not have an SEP and will have to wait until AEP.
What is False? Marie can use another C-SNP SEP for her newly diagnosed heart condition.
This is best practice any time you submit a C-SNP application, especially with Humana.
What is setting proper expectations with your client? Inform them that the health verification form must be filled out by their doctor and returned to you asap. Email the form to the client, and if possible, fax it to the doctor's office too.
Gregory is 68 and has not elected Medicare Part B. He has had Cobra since he was let go of his job in July of last year. It is now April 1. This is his next enrollment period available to him.
What is GEP?
Gregory had 8 months to elect his Part B after losing employer coverage. Since he missed that window, the next opportunity he will have to get Part B will be during GEP (Jan 1-March 31) of next year. Then he will have an ICEP to enroll in an MAPD.
Janice requested braille copies of her plan documents since she is blind, but never received the appropriately formatted plan materials in time to make a decision on her plan. She can use this SEP to make a change to a plan that better fits her needs.
What is ACC SEP?
You can use this SEP if someone had an increase in their medicaid level.
What is MCD? (Gain, lose, or change in medicaid status)
Merriam has had A and B since she turned 65 three years ago, as well as coverage through her employer. She was laid off from her job six months ago, and elected COBRA coverage. Her COBRA coverage will end this coming April 30th. Unfortunately since she did not select a plan when she lost her employer-sponsored coverage, she will have to wait until AEP to enroll in an MAPD.
What is False? LEC SEP is applicable to the loss of COBRA coverage as well as employer or union-sponsored health insurance.
This is best practice for someone who is a serial switcher and has comparable plans from Humana, UHC and Aetna in their area.
What is transferring to Aetna? Put the client in a better position, and protect your business and placement rate at the same time! Win win!
Carl received a letter from Medicare that his MAPD was identified as a poor performing plan. What SEP may he have and how should his agent use it appropriately?
SEP-OTH, enter "Low Rated Plan [h-code]" in the text field.
Agents must make a concerted effort to validate the plan is identified as a poor performer (Medicare.gov) and include the plan’s contract number in the SEP-OTH field with the words Low Rated Plan.
Robert was auto-enrolled in a state MAPD (passive enrollment) starting this month and wants to make a change. He can use this SEP to do so.
What is DIF SEP?
It is April. James has been on a UHC plan for 3 years, has diabetes, LIS level 2, and is a veteran. Name at least SEPs he has available to him, in order of easiest to use. (There are more than 3 possible)
Bonus points if you can name more potential SEPs he might have if available in his area.
LIS, Five Star, OCC, FEMA, C-SNP
Buck has an MAPD, but gets most of his care through the VA, with the exception of one prescription he fills at Walgreens since it's just down the street from his house. Buck has an SEP he can use to make a change.
What is True? Buck has an OCC SEP available to him, but his agent should do their due diligence to ensure he understands he will want to get ALL of his medications filled through the VA.
Joe and his wife Karen won big in the Mega Millions six months ago, and as a result lost their medicaid. They are still on their D-SNP plans, and were surprised by a big bill from when Karen went to the hospital last month. This is what you should advise the client.
What is switch to a standard MAPD? Since they lost their medicaid, they are generally responsible for cost sharing (sometimes as much as 20%) as long as they keep their old D-SNP. A regular MAPD would be a much better option to lower their cost sharing responsibility.
The medicaid checkers are back up! Hooray! You look up Meridith's information in ThinkAgent and notice she has a medicaid waiver. This is what you should do.
What is pivot to ancillary? Agents should not swtich clients with a medicaid waiver.
Clients on PACE should generally remain on PACE. However, if a client openly suggests they want to disenroll, we can help them with this SEP.
What is PAC SEP?
It is May 15th. Dolly has been on her plan for 2 years. She mentions had to evacuate due to hurricanes in Florida in February. She likely has this SEP available to her.
What is FEMA SEP. (She missed MA-OEP during this disaster. Check the FEMA lists to confirm.)
Bonnie and Clyde just got out of jail on January 15th. They both have A and B. It is now April 1st. They have an SEP to get onto an MAPD.
You are speaking to Anna, sister and caretaker for Elsa. She wants to get Elsa switched over on to a better plan, but states she does not have POA over Elsa. This is best practice in this situation.
What is ensure Elsa is on the phone call with Anna? Anna is not POA so she cannot make healthcare decisions without Elsa's consent. However, since it seems she is the decision maker in this situation, you can talk to both of them at the same time, as long as Elsa is the one to complete the application herself.
Patty used her LIS Q2 SEP on April 1st. Her new UHC policy was issued a week later. It is now April 20th, and she just learned UHC doesn't cover implants! An agent can do this to help. (2 accepted answers)
What is use her LIS Q2 to get her on a better plan; since the UHC plan is not in force yet, you can still use this SEP.
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What is pitch her a SmartComplete Dental plan?