September 16, 2013 Important Scope of Appointment Update Effective Immediately CMS recently published additional guidance 1 that impacts Humana s current SOA form and process used to document non-ma health products to be discussed during MA/PDP appointments. Effective immediately, if an agent plans on discussing any health product other than MA or PDP at an upcoming appointment, they MUST document this on our SOA form. Field agents: Until the new version of the SOA available, you will need to write in the additional health product a beneficiary wished to discuss with them in the following field on the second page of the SOA AND the beneficiary must initial the field: If the non- MA/PDP health products (see list below) are not clearly noted on the SOA, the agent will not be allowed to discuss those products during that appointment unless the beneficiary initiates the request for it. If the agent brings it up and wants to present it, it will require a 48 hour waiting period, when practicable, before they can be presented. If the beneficiary initiates a discussion regarding another health product during the appointment, a new SOA must be secured with the additional health product field completed and initialed by the prospect. If the SOA was secured via the IVR, you will need to redo the SOA on paper indicating all products previously agreed to as well as any additional ones with the required field completed. Additional health products can include, but are not limited to: Dental Vision Medicare Supplement Call center agents: You must adhere to your CMS-approved telesales script for MA/PDP products.
Please contact LeClair Group if you have any questions. 1 When conducting marketing activities, a Plan/Part D Sponsor may not market any health care related product during a marketing appointment beyond the scope that the beneficiary agreed before the meeting with that individual. The Plan/Part D Sponsor must document the scope of the agreement before the appointment. Distinct lines of plan business include MA, PDP and Cost Plan products. If a Plan/Part D Sponsor would like to discuss additional products during the appointment that the beneficiary did not agree to discuss in advance, they must document it 48-hours in advance, when practicable. If it is not practicable and the beneficiary requests to discuss other products, the Plan/Part D Sponsor must document a second scope of appointment for the additional product type to continue the marketing appointment. The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the material/information.
September 24, 2013 Policy on Privacy Requirements for Protection and Use of Member PHI/PH Changes This notice is being sent to advise our strategic alliance partners and their agents of the pertinent revisions made to Federal Legislation 45 CFR Parts 160 and 164 of HIPAA, HITECH, Privacy and Confidentiality effective September 23, 2013.This communication outlines only three of the updated 2013 requirements. It includes changes made to: 1. Restrictions of disclosures to health plans 2. Right to access PHI in an electronic format 3. Prohibition on the sale of PHI Restrictions of Disclosure to Health Plans Individuals may ask their provider to not disclose PHI (claims, prescriptions, and/or medical records) to a health insurer by choosing instead to pay for the services or drugs themselves without involving the insurer. This means the provider or pharmacist is prohibited from sending the claim or prescription to the carrier. Important: When the member pays for services in full and requests that PHI related to the service rendered not be disclosed to the health plan (insurer), it is the responsibility of the health care provider or pharmacy to comply with this privacy request. When paid in full and requested by the member, the provider is not to submit a claim or disclose any PHI related to that service to the insurer. Members who choose to pay the service in full may pay by either cash, credit card or use of an FSA or HSA account. When the member chooses to pay the health care provider or pharmacy in full at the time service is rendered, the payment is being made without involving the patient's health plan and without benefit of insurer negotiated (contracted) rates. In this case, the member can attempt to negotiate their own discount with the provider prior to or at the time the service is rendered. Should the member approach you about information that was sent to Humana in error, agents should inform the member of the following: The provider, not Humana, was responsible to guarantee the claim or prescription was not sent to Humana. Complaints are to be directed to the provider who submitted the information to Humana in error. The patient should refer to the Provider's Notice of Privacy Practices and contact the provider' s privacy office or officer. Right to Access PHI in an Electronic Format This requirement addresses changes made to Federal Legislation 45 CFR Parts 160 and 164 of HIPAA, HITECH, Privacy and Confidentiality effective September 23, 2013. It states that Humana must comply with a member request for copies of PHI (claims and records) which Humana has on record for that member. Humana is required to provide that information in the format requested by the member (i.e., PDF format, Word format). If Humana does not have the capability to supply the PHI in the format requested, alternative options can be discussed and used if the member is agreeable. If the PHI requested is maintained in an electronic designated record set and the member requests an electronic copy of
such information, the information must be provided in the electronic form and format requested by the individual, if it is readily producible in such form and format. If the form or format requested by the individual cannot be produced the information must be provided in such form that can be agreed to by both the entity and the individual. For example, if the patient asks for a copy of their medical records in a PDF file and the facility does not have that capability, they may discuss with the patient and agree on providing the information in a Word file format instead. Timeframes for responding to requests for Access to PHI in electronic format are unchanged. Information should be provided timely and not to exceed 30 days. An individual can request that their PHI be directed to another person. These requests must be made in writing, signed by the individual and clearly identify the designated person to receive the information and where to send the copy of PHI. Agents should have members complete a Consent for Release of Protected Health Information form to document the authorization of release to another party and send it to the address or fax number on the form. Signed requests should be retained by Humana for 6 years. Members also have the right to terminate previously granted permission for Humana to release or disclose a member s protected health information by filling out a Revocation of Consent for Release of Protected Health Information form. If a member specifically requests unsecure mailing, the member must be informed of the risk. If the member still wants the information sent in an unsecure manner the insurer is required to send it in that manner requested by the member. Agent s default processes for communicating PHI pursuant to an access request should always be in a secure manner. Prohibitions on the Sales of PHI This requirement addresses changes made to Federal Legislation 45 CFR Parts 160 and 164 of HIPAA, HITECH, Privacy and Confidentiality effective September 23, 2013. It states that Humana must obtain written permission from the member or patient prior to using or disclosing PHI for marketing purposes. Additional guidance pertaining to when written permission must be received from the member will be disclosed in the near future. Please contact LeClair Group if you have any questions. The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the material/information.
September 26, 2013 Compliant Sales Presentations CMS requires agents to give a complete sales presentation with full disclosure of all information regarding plan benefit for any MA or PDP plan during each and every appointment with a prospective member. In addition to the flip chart presentation, the Summary of Benefits and other important documents, we have created an additional tool to assist agents in conducting professional and compliant sales presentations. 2014 Sales Presentation Videos Now Available! Humana has produced videos designed to work with the Humana sales presentation. We encourage you to use these videos when presenting Humana plans to your clients as a way to communicate some of the critical compliance messages that CMS wants beneficiaries to hear. We ve heard from agents that using the video enhanced their sales presentation and helped them in their sales process. By watching their clients and identifying visual clues as they viewed the video, it helped agents identify the areas the clients understood as well ones that needed more attention. The videos can be downloaded to your computer and played from your laptop or web-enabled device for the prospective member. While the video does not cover all the aspects of the sales presentation, it does cover the important information that satisfies CMS requirements of full disclosure. You may access the videos by selecting the links below. PDF Sales Presentations Windows PC Videos Mac/ ipad/ Mobile Videos MAPD English / Spanish HMO English / Spanish HMO English / Spanish PDP English / Spanish PPO English / Spanish PPO English / Spanish PFFS English / Spanish PFFS English / Spanish Enhanced PDP English / Spanish Enhanced PDP English / Spanish Wal-Mart PDP English / Spanish Wal-Mart PDP English / Spanish ipad Workaround Videos cannot download directly to Apple devices (safety feature). Below are steps you may use as a workaround: 1. Download the videos to your computer 2. Sync the mobile device (iphone/ ipad) using itunes CMS rules require that the following materials be distributed along with an enrollment form. Therefore, at the conclusion of each successful sales presentation, the agent should leave behind the following documents: HMO/PPO/PDP Appointment Documents Star Rating Document Summary of Benefits Multi-language Insert PFFS Appointment Documents Star Rating Document Summary of Benefits Multi-language Insert PFFS Beneficiary and Provider Leaflet
September 30, 2013 Humana would like to share new information that we believe agents will find particularly useful as you prepare to start your marketing efforts for the 2014 AEP. 1. The first piece of information is about some VERY important news from CMS about a brand new requirement of plan sponsors this year. CMS is requiring that plan sponsors conduct an investigation of any applications where any agent or broker involvement is indicated when that application was received before the official start of the enrollment period (Oct. 15th ) to identify instances of solicitation by agents in violation of CMS rules. 2. Secondly, we are sharing a new marketing piece Humana has created called Benefits-at-a-Glance and how it should be used. This document provides a simple one page summary in an easy to compare format of Humana plans so you can help your client compare plan options. How you use this tool is important to keep in mind though, because it doesn t replace the CMS-required documents we must share with our enrollees. 3. Lastly, we re reminding you of the importance of telling people about the Multi-language insert and where to find it in our documents. 1. Pre-AEP Application Guidance As we fast approach the Pre-AEP period between October 1st and October 14th, it is important to note that there are some very specific and important application handling guidelines that ALL agents must follow in order to stay compliant. Please read these guidelines very carefully, as they will help you navigate the Pre-AEP waters compliantly. During Pre-AEP, agents are allowed to meet with beneficiaries, assess their needs, review plan changes and options, give a full product presentation, and make recommendations on coverage that will best meet beneficiaries needs over the next year. One of the most important things to remember during Pre-AEP is that while agents can assist a beneficiary in completing a paper application they cannot encourage completion, solicit, accept, take possession of, or just hold on to any applications for the 2014 contract year prior to AEP, October 15, 2013. Agents should instruct the beneficiary that they want to enroll in our plan, they should sign, date and mail in the application for receipt by Humana once AEP has started on October 15th. New CMS Guidance! New CMS enrollment guidance has been issued this year that demonstrates CMS concerted efforts to curtail agentsolicited applications during the pre-aep period. In Chapter 2 & 3 it states: Paper AEP enrollment requests received prior to the start of the AEP for which there is indication of sales agent or broker involvement in the submission of the request (i.e., the name or contact information of a sales agent or broker) must be investigated by the organization for compliance with the requirements in the Medicare Marketing Guidelines. This means that Humana must investigate any application that it receives prior to October 15, 2013 that has an agent s name on it. As a result, it is EXTREMELY important to reinforce to enrollees that the application should NOT be sent to Humana before October 15, 2013. Humana will be conducting an investigation for any paper application received by mail through October 15, 2013 (paper applications received on the 15th had to have been mailed/collected prior to the 15th). In instances where an agent is suspected of accepting and/or mailing an application, further investigation will be made with appropriate corrective action. Founded allegations where an agent collected or solicited pre-aep applications in the past have resulted in agent termination. Previous guidance from Sales Integrity indicated that agents should inform the enrollee to mail the application so that Humana receives it on or around October 15th. This may have
resulted in applications being received inadvertently prior to AEP. In order to avoid agent investigations going forward, we are changing this guidance. Agents should now direct enrollees to mail the application ON October 15th to ensure that the application is received during AEP. Important Pre-AEP Reminders No advertising of 2014 AEP or marketing of 2014 plan benefits may begin until October 1st. An agent may give a full disclosure presentation using the 2014 sales presentation and summary of benefits beginning October 1, 2013. An agent may assist a prospect in completing a 2014 paper enrollment application beginning October 1, 2013. The agent should place his/her name and SAN on the application, but the agent should NOT date the application. A signature date by the agent name would signify Humana taking possession of the application. Therefore, during Pre-AEP it is critical that you DO NOT date the application. Agents should not guide the applicant to sign or date it during the pre-aep, but instead should encourage applicants to sign and date it the day they actually mail it, between October 15 and December 7 (not earlier than October 15, 2013). Important note: The Humana enrollment department must receive the application by December 7, 2013 in order for it to be considered a valid AEP enrollment. CMS requires us to go by receipt date not postmarked date. An agent must leave the entire application with the member along with an envelope addressed to: Humana Medicare Enrollment, 2432 Fortune Drive, Lexington, KY 40509. The agent must also state that the application should be sent to Humana for receipt after October 15th. Do not coach applicants to send in the application to Humana for receipt prior to the October 15th date. As a reminder, any application received prior to the start of AEP with an agent name on it will result in an investigation to determine if the agent took possession of or solicited the application prior to AEP. Beginning October 15, 2013 agents can begin accepting enrollment applications and should date them appropriately. A complete set of the Chapter 3 Marketing Guidelines may be found on CMS website at the following web address: http://www.cms.gov/medicare/health-plans/managedcaremarketing/finalpartcmarketingguidelines.html 2. Using the New Benefits at a Glance Tool The Benefits at a Glance document can be used during the suitability assessment phase at the beginning of the sales appointment to assist beneficiaries in making plan comparisons. Or it can be used after the fully compliant sales presentation has been given to help the beneficiary decide which specific plan would be the best fit. To reiterate: The Benefits at a Glance document does NOT replace the use of the Summary of Benefits in the sales process. Coincidentally, if a beneficiary decides after reviewing the Benefits at a Glance document that a different plan than was originally presented might be a better fit, the agent must ensure that a full sales presentation was given and the Summary of Benefits is reviewed for the selected plan. (The Benefits at a Glance is shipped automatically with the Summary of Benefits.) Questions and Answers Q: Can the Benefits at a Glance document be used as a stand-alone piece? A: Yes, it can be used as a stand-alone piece to show beneficiaries what plans we have available. Agents can also place the document in the plastic sleeve found in the Enrollment Book. However, it does not replace the compliance requirement of covering the full Summary of Benefits and all other required documents that must accompany an enrollment form. Q: If an agent staffing a Walmart store has someone walk up and ask general questions about our products, could an agent pull out a Benefit at a Glance document and discuss the basics from it? A: Yes, however, if the beneficiary shows interest in hearing more about a particular plan, a scope of appointment should be secured and a fully compliant sales presentation must be given with the use of the Summary of Benefits.
Q: Since we are allowed to discuss the basics from the Benefits at a Glance document, can agents hand it to a beneficiary to take with them, even if no SOA is secured for a full presentation and Summary of Benefit discussion? A: Yes, however, an agent cannot enroll someone who has not received a fully compliant sales presentation which includes a comprehensive review of the Summary of Benefits. 3. Using Interpreter Services There is no way we can speak all the different languages of the beneficiaries we are trying to help. Luckily we don t have to. CMS requires all plans to provide an interpreter service notice (also known as the Multi-Language Insert) with enrollment kits. The notice must be left with the prospect at every appointment. The notice includes the following statement translated into 15 languages (Spanish, Chinese, Tagalog, French, Vietnamese, German, Korean, Russian, Arabic, Italian, Portuguese, French Creole, Polish, Hindi, and Japanese): We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at [1 xxx xxx xxxx]. Someone who speaks [language] can help you. This is a free service. What Should Agents Do? The Multi-Language Insert is incorporated into the Summary of Benefits document again this year. Make sure you review this insert with each prospect. Regardless of the sales setting, you will want to call the prospect s attention to the insert in the event someone in the room may need additional assistance. This is extremely important as CMS secret shoppers specifically look to see if agents are reviewing the insert! If you recognize the need for a language interpreter to participate during an appointment, call the number provided for interpreter assistance. The Medicare beneficiary can also call this number after the appointment or anytime in the future for assistance.
Agents are also responsible for providing a sign language interpreter for the hearing impaired upon request from any beneficiary, prospect or member ( customer ) for any type of meeting. This is required by the American s with Disabilities Act ( ADA ) and Humana s policies and procedures. The locations at which agents may provide sign language interpreters include, but are not limited to: In-home presentations Informational tables or kiosks at retail locations (such as Walmart), or other locations (like shopping malls or health fairs) Other locations as determined by circumstances and/or request by customers Agents should work with their local Humana sales management to arrange for a sign language interpreter. The cost of providing the sign language interpreter is at Humana s expense. IMPORTANT! - If an agent is not aware of the need for a sign language interpreter prior to the appointment or meeting but learns that a hearing impaired customer desires to have one present, the agent should reschedule the appointment for a time when he/she can arrange for a sign language interpreter to be available. In addition, agents may access Humana s TTY number for assistance in communicating with hearing impaired customers. TTY Users Call Humana s TTY number for assistance: Toll Free: 1-800-372-2147; TTY Users: 711. The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the material/information.
October 2, 2013 Non-Renewing Plans and Service Area Reductions CMS recently published guidance about the handling of Medicare Advantage plans that are not going be renewed for the coming year (non-renewals) and service area reductions where the members who reside in that part of the service area will lose coverage. For members impacted by either of these actions, they will be have to choose some other form of coverage for the 2014 plan year. In its guidance, CMS has specifically addressed marketing to those impacted by a non-renewal or service area reduction. The CMS guidance specifically states the following: Please note that no information about the non-renewal or service area reduction may be released to enrollees, providers, or to the public prior to September 18, 2013. Any marketing to members of a non-renewing plan, whether the plan s own members or a competitor s, may not take place until October 2, 2013. This CMS guidance means that agents may not call, mail or contact clients who will be impacted by a non-renewal or service area reduction to discuss other plan options ANY EARLIER than October 2nd. That is the date that all impacted members across the country are required to have received a notice from their plan informing them that the plan they have is not going to be available for 2014. If the member has already received notice that their plan is one that is not renewing and asks the agent about the letter they received, the following is an appropriate agent response to be given to the member inquiry: The letter you received means that the plan you have now won t be available next year so you will have to select some other coverage. Information about our 2014 plan options are available in Oct. If you d like, we can set up an appointment to meet starting to review other plan options you might want to consider since your plan is not going to be available. If you d like to meet, I can mail a form to you that I need you to complete and mail back to me before our meeting that will outline what plan types you want to learn more about when we do get together. As a reminder, those impacted by a non-renewal or service area reduction qualify for the SEP for non-renewing plans (SEP-NON). That SEP begins Dec. 8 and runs through the end of February. If the member selects a plan via the AEP, and it becomes effective January 1st, they still have an SEP election they can use if they wish to change their mind. If you have questions, please contact LeClair Group.