Medigap Agent field guide

Transcription

1 Medigap Agent field guide

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3 Table of contents Introduction Products 5 Eligibility 5 Quoting 6 Submitting application 6 Guaranteed Issue 7 Medical underwriting 9 Common unacceptable medical conditions 10 BMI chart 13 Policy administration Premium payments 14 Cancellation policy 15 Resource guide Contracting 16 Agent center 16 Training 17 Agent servicing 17 Commissions 17 Glossary 18 Medigap Agent Field Guide 3

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5 Introduction This field guide was developed as a tool to assist the agent community in understanding the products, underwriting and administration practices at Priority Health Insurance Company for Medigap (Medicare Supplement) plans. Products Priority Health offers Medigap Plans A, D, F and N. Find summaries and detailed descriptions for each plan at prioritymedicare.com. Click on the plan year at the top of the page, choose the county and then choose Medigap (Medicare Supplement) plans. Eligibility To be eligible for a Priority Health Medigap policy, an applicant: Must be 65 or older Must be currently enrolled in Medicare Part A and Part B Must be a permanent resident of Michigan and physically reside there for at least six months of every year in order to be eligible for coverage and to pay the premium based on the county in which he or she resides. If applicant permanently moves outside the State of Michigan or resides in Michigan for less than 6 months of every year, his or her premiums will change to the applicable Area 2 Premium upon renewal. Coverage will only continue provided all other eligibility requirements continue to be satisfied. If a member moves outside of the United States or its territories, his or her Priority Health Medigap Plan will be terminated. Must not duplicate coverage by having more than one Medicare Supplement plan; or by being enrolled in both a Medicare Supplement plan and a Medicare Advantage plan; or a Medicare Supplement plan and Medicaid at the same time, unless Medicaid covers only the Medigap premium or all or part of the Medicare Part B premium. However, at the time of application, the applicant may have another Medicare Supplement or a Medicare Advantage plan if the applicant intends to cancel the existing coverage. Medigap Agent Field Guide 5

6 Quoting Priority Health provides an on-line quoting tool available on the Agent Center, 1. Log-in to the Agent Center 2. Select Quotes from the menu at the top of the landing page and select "Get a Quote" 3. Select Medicare Advantage & Medigap rates under Agent tools 4. Choose the county 5. Select Medigap (Medicare Supplement) plans 6. Click on Details below each plan for plan details 7. Click on Get instant quote for premiums and a new window will appear Select county (if not already populated) Enter date of birth Enter Part B effective date from the the client s Medicare ID Card (red, white & blue card) Select gender Click Next and select the date for coverage to start Click Next to view premium quotes Submitting an application Online 1. Login to the Agent Center 2. Select Medicare Advantage & Medigap rates under Agent tools 3. Choose the county 4. Select Medigap (Medicare Supplement) plans 5. Scroll down and click on Apply now (Note: Before applying, be sure to read the section directly above called Before you apply ) 6. Follow the directions for completing and submitting the application. 6 prioritymedicare.com

7 Medigap Agent Field Guide Paper applications 1. Fill out the application. 2. After you complete the application; Mail it back to Priority Health in the enclosed self-addressed envelope in the Medigap packet. If you don t have the envelope, you can mail it to: Priority Health Enrollment Department, MS East Beltline NE Grand Rapids, MI Fax to , or E-scan to mypriority@priorityhealth.com Note: Be detailed and complete when completing the application Be sure to answer all questions truthfully and completely. Priority Health may cancel the plan and refuse to pay any claims if pertinent information is not disclosed or if information is falsified. Review the application carefully before your client signs it to be sure that all information has been recorded properly. We will accept an application up to 120 days prior to the requested effective date. Guaranteed issue or medically underwritten? Guaranteed issue In certain situations, an applicant might qualify for Guaranteed Issue. This guarantees their acceptance into a Medigap plan through Priority Health. If you think an applicant qualifies under the following guidelines, please confirm this by checking relevant questions on the application. If you are uncertain, please contact Medicare Sales. 1. If applicant enrolled in Medicare Part B less than 6 months ago and is age 65 or older, application is Guaranteed Issue (also known as Open Enrollment) Medigap Agent Field Guide 7

8 2. If applicant has a Medicare Advantage (MA) plan currently in force or that ended less than 64 days ago, application is Guaranteed Issue up to 60 days before MA coverage ends IF a. the MA plan is leaving Medicare, or b. the MA plan stops giving care in applicant s area, or c. applicant moves out of the MA plan s service area, or d. applicant joined the MA plan when first eligible at age 65 and if that was less than one year ago, or e. applicant replaced a Medigap policy with the MA plan for the first time less than one year ago, or f. applicant is leaving the MA plan because the company misled applicant or failed to follow the rules. 3. If applicant is enrolled in Program of All-inclusive Care for the Elderly (PACE), or if PACE enrollment ended less than 64 days ago, application is Guaranteed Issue up to 60 days before PACE coverage ends IF applicant enrolled in PACE when first eligible at age 65 and if that was less than one year ago. 4. If applicant is enrolled in Original Medicare as well as an employer group or union health plan, or if such a plan ended less than 64 days ago, application is Guaranteed Issue if coverage ends through no fault of applicant. 5. If applicant is enrolled in Original Medicare as well as a Medicare SELECT policy currently in force or that ended less than 64 days ago, application is Guaranteed Issue up to 60 days before coverage ends IF a. applicant moves out of the Medicare SELECT plan s service area, or b. applicant replaced a Medigap policy with the Medicare SELECT plan for the first time and if that was less than one year ago. 6. If applicant is enrolled in Original Medicare as well as another Medigap policy, or if enrollment in the Medigap policy ended less than 64 days ago, the application is Guaranteed Issue IF a. applicant s Medigap insurance company went bankrupt or coverage otherwise ends through no fault of applicant, or b. applicant is leaving the Medigap plan because the insurance company misled applicant or failed to follow the rules. All other situations require underwriting. 8 prioritymedicare.com mypriority.com

9 MyPriority Medigap Agent Field Guide Medical underwriting Underwriting guidelines Application If you have determined that the applicant does not qualify for Guaranteed Issue, you must complete the health information questions on the application. The Priority Health individual underwriting staff will review the application, as well as any available Priority Health claims history. In most cases, we will conduct a recorded telephone interview with the applicant; occasionally we may ask the applicant to obtain medical records. Priority Health claims history We check for Priority Health enrollment and claims history on all applicants in order to verify their medical history. This information should confirm and corroborate the complete medical information already disclosed on the application by the applicant. Pharmacy profile A pharmacy profile may be obtained for each applicant on an application. A prescription drug query provides history for the last 5 years or coverage eligibility dates. This information should confirm and corroborate the complete prescription drug history and information already disclosed on the application by the applicant. Telephone interview Since telephone interviews will be conducted in most cases, please include in Section 1 of the application at least one number where we can reach the applicant Monday Friday, from 8:00 a.m. to 5:00 p.m. Make sure the applicant understands the following: A Priority Health underwriter will contact them for an interview The interview will cover health related questions The interview may last 15 or 20 minutes The call will be recorded. The interview will expand on the application and assess the applicant s eligibility and overall health. The underwriter will also compare the application answers with the applicant s Priority Health claim history (if applicable). Any discrepancies or questions that arise from this will be addressed in the telephone interview. MyPriority Medigap Agent Agent Field Field Guide Guide 9

10 Uninsurable conditions As a general rule, an applicant who has not undergone an age- and gender-appropriate complete physical examination within two years prior to the application date will not be considered for issuance. To reconsider such cases, we may ask that the applicant undergo a complete physical examination with all appropriate testing, at his or her own risk and expense, and forward the results to Priority Health. Applicants who require assistance with the activities of daily living, who use walkers, scooters or other mobility-enabling devices, who take prescription medications to counter the side-effects of other prescription medications, or who are unable to walk moderate distances due to shortness of breath or frailty, will be declined. Following is a list of some (but not all) medical histories which will usually result in an application being declined. Common unacceptable medical conditions Please call Individual Market Underwriting for questionable conditions that may not be on this list, as this list in not considered complete, but a representation of common conditions which are not insurable. Alcohol Abuse Alzheimer s disease Amyotrophic Lateral Sclerosis (ALS) Aneurysm Angina Pectoris Angioplasty Arteriosclerotic Heart Disease Artificial Pacemaker Asthma, Severe Autoimmune Diseases Brain Injury Brain Tumor Cancer, except cutaneous basal cell carcinoma Cardiac Bypass Cardiac Valve Replacement Cardiomyopathy Carotid Artery Occlusion or Stent 10 prioritymedicare.com mypriority.com

11 MyPriority Medigap Agent Field Guide Cerebral Palsy Cerebovascular Accident Chronic Obstructive Pulmonary Disease (COPD) Cirrhosis of Liver Confined to Nursing Home or Hospital Congestive Heart Failure Connective Tissue Diseases Coronary Artery Disease Crohn s Disease Dementia Depression, Major Diabetes, Insulin Dependent (IDDM) Drug Abuse Dwarfism, Gigantism Emphysema Endocarditis Epilepsy grand mal seizures Heart Attack Heart Rate or Rhythm Abnormalities Hepatitis B or C Hodgkin s disease Joint Disease, Severe Kidney Failure or Dialysis Leukemia Lupus Erythematosus Systemic Lupus Memory Loss Metastases, all sites Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neuropathy Non-Hodgkin s Lymphoma Organ Transplant, History of or Recommended Paget s Disease Pancreatitis Paralysis Parkinson s Disease, Parkinsonism Pericarditis MyPriority Medigap Agent Agent Field Field Guide Guide 11

12 Peripheral Vascular Disease Pernicious Anemia Phlebitis-Deep Vein Pituitary Gland Disorders Polycystic Kidney Disease Psychiatric/Psychological Disorders, Severe Pulmonary Fibrosis Pulmonary Embolism Pyelonephritis Raynaud s Disease Renal Failure Reye s Syndrome Rheumatoid Arthritis Sarcoidosis, Pulmonary Schizophrenia-Paranoia Scleroderma Sjogren s Syndrome Sickle Cell Anemia Spinal Deformity Stroke Substance Abuse Suicide Attempt Transient Ischemic Attack (TIA) Thrombocytopenia Tuberculosis Ulcerative Colitis Ventricular Arrhythmias Ventricular Septal Defect Von Willebrand s Disease Weight Loss, Unexplained 12 prioritymedicare.com mypriority.com

13 MyPriority Medigap Agent Field Guide Build Chart Medigap Build Chart Weights below the minimum or above the maximum will not be considered for Medigap. WEIGHT HEIGHT Minimum Maximum MyPriority Medigap Agent Agent Field Field Guide Guide 13

14 Policy administration Member communication Welcome kits (includes premium schedule and their Certificate of Coverage) are mailed out to members within two weeks of the effective date. Late enrollees will receive Welcome kits two weeks after effective date. If a Welcome kit was never received and another copy needs to be requested, agent can contact MyPriority@priorityhealth.com or Medigap customer service to request another copy. ID cards are mailed to the member within 7 to 10 business days of approval. Plan change If a member requests a change from one Priority Health Medicare Supplement product to another a new application must be submitted and is subject to full medical underwriting Change in member status Members may request address changes, demographic information corrections (SSN, DOB, Medicare claim number, etc) by contacting customer service Name changes (due to marriage or divorce) should be requested in writing via member change form Premium payments Members can choose to pay their premium either by Electronic Fund Transfer or direct bill. EFT on the first day of every month the checking or savings account the applicant designates will be debited the amount of their premium. Direct Bill your client will receive a billing statement approximately one week prior to their due date of the 1st of the month. Priority Health will charge a $50 fee for each payment that is not honored due to insufficient funds. If we don t receive premium payments by the last day of the month in which the premium is due, we will cancel the member s policy as of the last date your policy was paid in full. Please notify Priority Health of any changes to your designated account at least five business days before the last day of the month. 14 prioritymedicare.com mypriority.com

15 MyPriority Medigap Agent Field Guide Reinstatement policy Reinstatement rule applies when there is a lapse in coverage due to nonpayment of premium. A person who requests reinstatement must complete an application and will go through medical underwriting unless he/she is still in open enrollment period o If still in open enrollment period, we still require a new application but no underwriting is needed o If reinstatement is approved, new certificate will be effective on the 1st day of the month following approval Cancellation policy If your client changes their mind, they can send the certificate back to us within 30 days after it arrives. We will act as though the certificate was never issued and will return all of their payments. We can collect from them all costs for covered services that they received and we paid. Your client can also contact Medigap customer service and cancel their policy over the phone within the 30 day timeframe. If request is received or requested after 30 days, it will be treated as a termination request and any paid premiums will not be refunded. The certificate can be returned to: Priority Health Enrollment Department, MS East Beltline NE Grand Rapids, MI Termination policy To terminate policy, your client needs to notify Priority Health in writing 30 days prior to termination effective date -OR- your client can call Medigap customer service and request over the phone Termination date will be date of request or a future date, Priority Health will not retroactively terminate MyPriority Medigap Agent Agent Field Field Guide Guide 15

16 Resource guide Agent Center at priorityhealth.com You will receive an confirmation once your agent agreement has been processed and we will provide you with a username and password to access the Priority Health Agent Center. There is a special section just for Medigap plans. There you will find access to: Online quoting and application tools Product information Marketing materials Applications Supply request forms Training Contact the Individual Sales Representative in your area for more information. East region: Robin McDonald robin.mcdonald@priorityhealth.com West region: LaDominic Brandon ladominic.brandon@priorityhealth.com Lakeshore & the North region: Jim Hart jim.hart@priorityhealth.com Customer Service (Agent) Priority Health has a dedicated department that will handle all your questions related to Medigap plans including: 16 prioritymedicare.com mypriority.com

17 MyPriority Medigap Agent Field Guide Products and benefits Application status Provider network Membership (eligibility status) Billing Claims Online account support (finding usernames & resetting passwords) Online enrollment Contact the sales coordinator with questions about online enrollment. Commissions/Licensing/Online Account Support (option 3) or Call the agent service coordinator with questions about: Commissions Licensing Access and navigation for Priority Health Agent Center Commissions are paid the first of every month for premiums received the previous month. 1. When are commissions paid a. Commission is paid monthly and is dependent on the receipt of monthly premium payment. Agent will not receive commissions for any month for which the companies do not receive premiumi. i. If less than 100% of the monthly premium is paid, that percentage of commission paid will equal the percentage of premium paid. Until the premium monthly payment is paid in full we cannot release the commission in full ii. Commissions will not be paid for any time in which the Agent s Health and Life license is terminated b. Commission statements available on the Agent Center, 1st of every month c. Agents receive direct deposit on the 7th of the month as long as it is not a holiday or weekend. Statements are posted to the agent center. MyPriority Medigap Agent Agent Field Field Guide Guide 17

18 Glossary Guaranteed Issue Guaranteed issue rights (also called Medigap protections ) are rights you have in certain situations when health plans are required by law to sell or offer you a Medigap (also called Medicare Supplement ) certificate even if you have health problems (called preexisting conditions ). In most cases, you have a guaranteed issue right when you have other health care coverage that changes in some way, such as when Your Medicare Advantage plan is leaving Medicare Your Medicare Advantage plan stops providing coverage in the area you reside You have Original Medicare and an employer group health plan and your employer discontinues its group health coverage You joined a Medicare Advantage plan when you were first eligible for Medicare Part A at age 65 and within a year you leave the Medicare Advantage plan You dropped a Medigap plan to join a Medicare Advantage plan for the first time and within a year you leave the Medicare Advantage plan Open Enrollment Period Period which lasts for 6 months and begins on the first day of the month in which you are both 65 or older and enrolled in Medicare Part B. During this period, an insurance company cannot use medical underwriting. This means the insurance company cannot do any of the following: Refuse to sell you any Medigap policy it sells Make you wait for coverage to start (except as explained below) Charge you more for a Medigap policy because of your health problems a year you leave the Medicare Advantage plan. Original Medicare Federal government program of health insurance for those over 65. It consists of Part A (hospital insurance) and Part B (medical insurance). Medicare Advantage Private insurance designed to replace Original Medicare Part A and Part B. Sometimes referred to as Medicare Part C. Medicare Advantage Plans may provide additional benefits for higher premiums. Medigap Private insurance designed to supplement Original Medicare by helping to fill in gaps such as deductibles and copayments. 18 prioritymedicare.com

19 MyPriority Medigap Agent Field Guide Medicare Advantage Private insurance designed to replace Original Medicare Part A and Part B. Sometimes referred to as Medicare Part C. Medicare Advantage Plans may provide additional benefits for higher premiums. Medicare SELECT A type of Medigap policy that may require members to use hospitals and, in some cases, doctors within its network to be eligible for full benefits. Medigap Private insurance designed to supplement Original Medicare by helping to fill in gaps such as deductibles and copayments. Program of All-Inclusive Care for the Elderly (PACE) A managed care benefit for the frail elderly provided by a not-for-profit or public entity. The PACE program features a comprehensive medical and social service delivery system in an adult day health center that is supplemented by in-home and referral services in accordance with participants' needs. MyPriority Medigap Agent Field Field Guide 19

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