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Humana Cert
Certificate Training Aid (1/2)
| Term | Definition |
|---|---|
| Different Sales Violations | sales misrepresentation (section A) + Agent Misconduct Allegations (not Section A) ex. "cherry picking", lie about product, theft, coercion, selling to someone who cannot comprehend the product, implying gov representation, forgery, etc |
| How Sales Violations are Reported | if Section A, must be reviewed/investigated by CMS + if not, company still must review and agent must explain |
| Define Section A Violation | Allegation (by bene) of sales misrepresentation to an MA bene |
| Difference between major and lesser Section A violation | Critical/Major Section A - typically a "willful action" Non Critical/Minor Section A - typically a "negligent action" (ex. non-intentional misrepresentations of network, Rx costs, dates, etc) |
| How to access bene ability to understand | open-ended questions (How long have you lived there?) and active listening for repeating questions/confusion |
| POA/Guardian guidelines | There is no exception to the rule that only the bene or a POA/Legal Guardian are allowed to sign on behalf of bene |
| Role of OIG (Office of Inspector General) | find and eliminate medicare FWA, helps with creating Advisory Bulletins (bene rights), fraud alerts |
| How to conduct a (compliant) NEADS/suitability assessment | Act in benes best interest + verify bene eligibility + ensure they are in service area + NEADS (NOW, ENJOY, ALTER, DECISION, SUMMARIZE) |
| What if the bene wants to keep a non-Humana sup or Rx plan? | you still have opportunity to enroll them in stand-alone PDP, sell additional Humana med sup, and present other humana products (in some cases) |
| When comparing options, make sure to compare the following: | premium, out-of-pocket, coinsurance or copayments, provider participation, Rx coverage, Wellness |
| Important HIPAA Guidelines | Humana Privacy Office manages these guidelines - "protect as if the data was your own" - "minimum necessary" standard when taking info from benes - can be disclosed to "designated personal rep like POA |
| STARS Ratings and what they mean | |
| Role of CMS in Medicaid | established regulations that govern the marketing/sales of MA products |
| Role of DOI in Medicaid | each state maintains regulations for sales/marketing of all insurance products |
| Role of FTC/FCC in Medicaid | maintain regulations regarding telemarketing practices at a federal level |
| Examples of "unacceptable questions" | How often do you see doctor? How many doctors do you have? How is your health? What conditions do you have? When did you last go to hospital? What Rx do you take? Smoke? Exercise? |
| Age-In Enrollees Rule | 1) first day of their birth month or: - born on first of month or - first day of previous month or -if enrolling during or after birth month If ^^ then effective date will be first of next month |
| What to do with multiple enrollments with different proposed effective dates? | must submit enrollment app with the earliest effective date FIRST (ex. IEP) or it will all be screwed up |
| True or False: supplements do not work with MAPD plans | True |
| What to say to a bene who is enrolling in a MAPD and intends to lose their sup plan? | Keep the plan until you receive confirmation from plan that the enrollment was approved - then cancel - it will not be auto-cancelled |
Created by:
cmazzariti
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