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AHIP MODULE 5
Enrollment Guidance (MA/Part D)
| Question | Answer |
|---|---|
| Memory Check: Who is eligible to enroll in MA or Part D plans? | MA - eligible if person is entitled to Part A AND enrolled in Part B Part D - eligible if person is entitled to Part A AND/OR enrolled in Part B |
| What is the plan called where employer obtains approval from Medicare to enroll Part B only retirees, even if the retirees are not entitled to Part A? | EGWP |
| What is the medical condition that previously made the person with it ineligible to receive MA benefits? When does that restriction end? | ESRD - ends 01/01/21 |
| What extra benefit should a bene look out for when selecting/changing their MA plan if they think they might be spending 6 months or more outside their service area? | "visitor/traveler benefit" - Temporary Exception to Involuntary Disenrollment When an Enrollee Moves from the Service Area |
| True or False: there is no scenario where CMS will allow an abbreviated enrollment form because nothing can be missed no matter what. | False - in certain cases CMS will allow abbreviated enrollment forms (usually its a form to switch a plan, not a new account app) |
| True or False: a persons eligibility to enroll in a stand alone PDP depends on how they receive their medical benefits? | True |
| In order to be enrolled in a stand-alone PDP, the person must be enrolled in one of the following: | 1) Original (FFS) Medicare 2) PFFS (does not include Part D coverage) 3) MSA 4) 1876 Cost Plan 5) MA EGWPS (if PDP is also an EGWPS) |
| True or False: there is a MA PFFS exception (at plan level) where a person enrolled in a MA PFFS that does not cover Part D may enroll in a stand alone PDP, even if the same MA org offers a PFFS | True, its more of a clarification of the rule that says if a person is eligible to enroll in a PDP if they are enrolled in a "PFFS plan that does not include Rx coverage" |
| For benes enrolled in a "coordinated care plan", what is the rule about where the bene holds their Rx coverage? | bene must receive their medicare Rx benefit through the "coordinated care plan" (some exceptions for Employer/Union retiree group plans) |
| What option(s) do benes in a "1876 Cost Plan" have for receiving their Rx coverage? | through the 1876 cost plan or from a "freestanding Rx plan" |
| Memory Check: The period between October 15 - December 7 is called? | AEP |
| Memory Check: The period between January 1 - March 31 is called? | MA-OEP (OEP) |
| What are the four periods of enrollment varied by individual circumstances? | IEP (bene first eligible for Medicare) MA New Benes (starts month of entitlement) SEPs Continual OE for institutional individuals |
| True or False: as long as the rep is confident that the caller is eligible, they can submit the app and adjust down the road if need be. | False - if the app does not include attestation of eligibility to enroll, it is denied |
| What are the six enrollment periods for MA and Part D? | ICEP, IEP, AEP, SEP, OEPI, MA-OEP |
| What are the two enrollment periods that MA plan sponsors hold and not immediately accept? | MA-OEP and OEPI (sponsors can "close" for enrollments during MA-OEP and OEPI) |
| What options do benes have during AEP when it comes to MA and PDP plans? | Enroll, Disenroll, Change Plans |
| What options do benes have during ICEP/IEP when it comes to MA and PDP plans? | Enroll |
| True or False: during OEP persons choosing an MA plan during their ICEP may do so. | True |
| What options do MA benes have during OEP when it comes to MA and PDP plans? | MA options - Disenroll, Change Plans, Change Part D option under MA plan (change from MA to MA-PD or MA-PD to MA) PDP options - Enroll (if disenrolling from MA or MA-PD) |
| Memory Check: What is the period called where people newly eligible for MA make their first enrollment request to an MA plan? | MA ICEP (different from ICEP) |
| Memory Check: What is the period that begins 3 months before a persons first entitlement to Original Medicare? | ICEP (either the last day of month preceding entitlement or last day of their Part B initial enrollment period*) *IEP-Part B (3-1-3) |
| True or False: a person can make one enrollment choice under ICEP, when effective, it is used up and the decision is locked | False - a person choosing an MA plan during ICEP have an MA-OEP through last day of 3rd month of entitlement |
| The Part D IEP begins and ends when? What options does someone in that period have? | 3-1-3 - bene gets 1 Part D plan choice (including MA-PD ) |
| The MA ICEP and Part D IEP will occur together during what occurrence? | when a newly eligible person enrolled in BOTH Part A and B at FIRST eligibility |
| True or False: an agent can solicit and accept enrollments forms for AEP starting October 1st | False - no forms can be solicited or accepted for AEP before October 15 |
| When can marketing reps start marketing their AEP plans for current/prospective years? | October 1 |
| During MA OEP - MA and MA-PD enrollees have these 3 options: | 1) Change (MA or MA-PD), Disenroll (back to original medicare), 2) Change (Part D under their MA plan), 3) Enroll in a PDP (only if disenrolling to Original Medicare) |
| True or False: MSA enrollees can use the MA OEP to disenroll from their MSA | False - they can not disenroll from their MSA during MA OEP |
| During an SEP, benes who disenroll from a MA and enroll in Original Medicare may have guaranteed Medigap issue rights. What does the bene have to do? | Nothing, MA plans notify the bene if this applys |
| Some situations that result in an SEP include: | MOV, involuntary loss of creditable drug coverage, gaining or losing medicaid, gaining or losing EH/LIS, changing employer/union sponsored plans, becoming a US citizen, dropped Medigap (trial period) and those applying for a C-SNP |
| Memory Check: What is a C-SNP? How does enrollment work? | Chronic Care SNP, serve individuals with their specific condition, if the bene has that condition and is not enrolled in one, they have an SEP to get that done |
| True or False: there is an SEP for people in a SNP but no longer are eligible for that SNP | True |
| Memory Check: bene loses Part D creditable rx coverage, what can they do? | if it was involuntary, they have an SEP to get in a PDP or MA-PD - timeline is 0-1-2 * ends 2 months after the loss or the date the bene gets the notice (whichever is later) |
| When does the SEP take place for those who are dual eligible or eligible for LIS? What are their options? | first 9 months of year, benes entitled to A+B can enroll or disenroll from a MA or Part D plan. benes only entitled to Part B can do that same but only for PDPs |
| Memory Check: for SEPs... who is considered an "at risk" or "potential at risk" bene? Can they challenge that decision? | benes who have been determined as at risk and benes who its thought to have the potential to be at risk - they can appeal it |
| When do the "at risk" SEP limitations not apply? | other part D enrollment periods, including AEP or other SEPs |
| If a bene has an SEP because they are entitled to A and.or B and had a change in their Medicaid/EH status, when does that take place? | Whichever is later, the change or notification of change and continues for 3 months (does not count toward the 1 per calendar year limit for benes who are Medicaid/LIS eligible |
| When is the SEP for Medicare benes who drop a Medigap policy after enrolling for the first time in a MA plan? What would be their options during this period? | first 12 months of enrollment in MA plan (during this time they can disenroll back to original medicare or rejoin a medigap plan) |
| When is the SEP for employer/union benes who elect/drop a employer MA? What would be their options during this period? | begins when employer plan allows it and ends 2 months after the month coverage ends |
| What is the SEP for benes who realize there is a 5-star plan in their service area? | they can go to a 5-star MA plan, PDP, or Cost plan and it takes place each year on 12/8-11/30 (of the following year) |
| What are some examples of places someone in a OEPI plan would reside? | skilled nursing facility, nursing facility, rehab, ICF/MR, psychiatric hospital/unit, or LTC hospital |
| If a OEPI bene is moving out of a qualified facility, how long until the OEPI ends? | 2 - months * they can apply for MA, Part D or Original Medicare |
| True or False: All MA organization MUST accept ALL OEPI requests | False, but if they elect to work with them, they must accept ALL in that case |
| When is the Cost Plan enrollment period generally and in many cases? What if the Cost plan offers an optional Part D benefit? | generally its an annual-OEP of at least 30 days, but many do allow it year round BUT if the plan offers the optional Part D benefit, the bene has to sign up for that portion during the Part D standard enrollment periods |
| True or False: a MA bene who leaves can move to a Cost plan at any time because Cost plans are treated different. | False - they must have a valid MA disenrollment period first |
| In some cases an enrollment mechanism is used that takes data from non-Medicare sides of business to fill in applications for enrollment. What is that process called and who does it help? | "Opt In" mechanism - for those in their ICEP based on initial enrollment into Medicare, those enrolled in a non-medicare plan with the same/parent org, those that do not have a break in coverage between non-medicare and MA plan |
| In which cases would CMS allow a bene to be auto-enrolled in a Medicare plan? | -certain duel eligible benes -bene eligible for LIS (that doesn't have Part D covered) enrollment into a MA-PD or PDP |
| What are two websites where people can apply for these plans? | medicare.gov and ssa.gov/medicare |
| What are some requirements for electronic enrollment mechanisms? | enrollee must be given all required pre-enrollment info, mechanism must comply with CMS data policies, and mechanism must advise each enrollee at beginning of process they are actually applying |
| If someone other than the enrollee is applying for the enrollee, what must happen? | 1) attest to having authority under state to do so 2) confirm proof of authorization (depending on state) 3) provide contact info |
| True or False: a marketing rep can NEVER assist with the completion of an enrollment form | False - but the form must clearly indicate the reps name if so and there are some exceptions (app mailed by rep, "office use only", simple correction (w/ rep initials |
| True or False: all enrollment mechanisms must clearly explain whether part A or B must be kept when moving to an MA or Part D plan | True - must keep medicare part A and B if enrolling into a MA plan and must keep A OR B if enrolling in a Part D plan |
| What is the only case when a rep can ask health screening questions during enrollment? | to determine eligibility to enroll in a SNP |
| During the post-enrollment phase what is the sponsor required to provide the new bene? | receipt (within 10 days), copy (if req), confirmation # (apps sent via phone/web), and proof of coverage |
| What if the enrollee has multiple elections? | must explain to enrollee which elections they have and get their choice for when the effective date will be |
| What are the two types of disenrollment (for MA, Part D and Cost plans)? | Voluntary and Involuntary |
| True or False: if a bene is leaving a plan voluntarily, the plan can contact the bene to find the reason and attempt to discourage them from leaving | False, they can get the reason but may not discourage from leaving |
| How does an MSA holder/Cost plan bene disenroll from that product? | "write to the plan" they cannot call |
| What are the 4 scenarios where plan sponsors are required to disenroll a bene? | 1) MOV (including incarceration, excluding V/T 2) Bene drops the required A or B for their plan 3) SNP bene loses eligibility (gets complicated) 4) PDP bene who materially misrepresents themself |
| Go into more detail on when a SNP bene loses eligibility... | Can keep on file if bene is expected to be eligible again within 6 months, enrollee dies, plan contract ended, bene fails to pay their Part D-IRMAA (3-month grace), not lawfully in US |
| True or False: for MA and Part D orgs, they are generally required to disenroll benes who changed residence without notification to Plan after 6 months (MA) and 12 months (Part D) | True, unless they have a V/T benefit (MA) or are in LIS (Part D) |
| MSA plans also have to disenroll benes who no longer meet eligibility requirements except for: | 1)those with ESRD (effective dates before 01/01/21) 2) those who elected hospice benefit |
| There are many reasons why a Cost plan must disenroll benes, name some: | not continuously enrolled in Part B, MOV, temporary (90+ days) absence from service area, deceased, contract terminated/removed, bene not in USA, failed to pay Part D IRMAA (only plans offering Part D) |
| What are some involuntary reasons a plan may disenroll a bene? | does not pay premiums, disruptive behavior, provided fraudulent info, allowed others to use his/her benefits |
| What rights do the enrollee have when being involuntarily disenrolled? | notify in writing, grace period > 2 months, right to make a complaint |
Created by:
cmazzariti
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