UnitedHealthcare Assisted Living Plan
Sometimes, despite best intentions and desires to live independently, beneficiaries have to rely on assisted living institutions to best provide their loved ones with the healthcare and services that they need. These institutions can be prohibitively costly, which puts more stress on an already often-difficult decision for beneficiaries or their loved ones to make. This is why the ISNP exists – the ISNP is an institutional special needs plan. These plans provide insurance coverage for beneficiaries who will need, for a period of 90 days or longer, care that exceeds what a reasonably skilled nursing facility or an inpatient intermediate care facility. Marketing of the UnitedHealthcare Assisted Living Plan is an exclusive offer with us!
Major insurance carrier UnitedHealthcare has released an ISNP called the UHC Assisted Living Plan. It is a five-star Medicare Advantage PPO (preferred provider organization). Beneficiaries can be eligible for this plan if they are in assisted living facilities, independent living, congregate housing, and memory care units. Even those receiving care at home qualify. It is also available to dually enrolled beneficiaries.
The ISNP is meant to assist those who need help with what are known as the “activities of daily living,” which include housekeeping, food preparation, money management, transportation, or medication management and administration. UnitedHealthcare’s ISNP has a clinical component that other ISNPs lack – there will be a physician’s assistant, nurse practitioner, or nurse on site to provide care to members of the plan at no additional cost to the beneficiary. This is beneficial for the facilities as well as the beneficiaries. It increases the average stay of the beneficiary by six months while increasing the quality of care at the same time.
United HealthCare contracted (Wellsky) as a third party. Wellsky conducts a phone assessment to determine eligibility.
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In order to sell this plan, agents need to complete an additional certification and training. Exclusive training will familiarize agents with all the components and properly represent the benefits of this ISNP.
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Medicare Final Rule 2024
Every year, the Center for Medicare and Medicaid Services (CMS) adjusts and makes amendments to the requirements and regulations that govern Medicare Advantage plans. For this coming year, 2024, there are important new requirements for third-party marketing organizations (TPMOs). Aetna, one of the primary carriers of Medicare Advantage insurance plans, sent a press release explaining the key points of the final ruling for the new marketing requirements. What is the Medicare Final Rule 2024?
Beginning September 30, 2023
These are some of the most pertinent changes and new regulations that will govern how brokers can market Aetna Medicare Advantage plans in the coming year. The following changes will be effective on September 30 of 2023:
Third-party marketing organizations that are authorized to sell Medicare Advantage must submit their multi-plan marketing materials to the Health Plan Management System (HPMS). This happens after it has been pre-reviewed by Medicare Advantage organizations. Health Plan Management System is a website where health insurance and prescription insurance plans, plan consultants, third-party vendors (like agents), and pharmaceutical manufacturers can fulfill the compliance requirements of Medicare Advantage and Medicare Part D plans.
Superlatives (best, most, etc.) are no longer to be used in marketing communications unless certain pre-existing documentation needs are met.
Any marketing materials that use the Medicare ID card image must be approved and authorized by CMS before use.
When marketing any products, plans, costs, etc., the Medicare Advantage organization name must be visible as it is listed in the HPMS.
Plan benefits must be advertised in the area that is eligible for their services.
Marketing materials cannot compare the costs of the uninsured in order to advertise potential savings due to a Medicare Advantage plan.
In addition to these new requirements, CMS has updated the definition of marketing. This new, clarified definition broadens the content that is classified as marketing. Any type of materials that mention plan benefits is now considered marketing material.
Medicare Final Rule 2024 – Marketing Materials
In order to be in compliance with the updated regulations from CMS (the Center for Medicare and Medicaid Services), third-party marketing organizations (TPMOs) such as brokers must make sure their sales and marketing materials are in line with the following requirements:
It is always prohibited to visit a beneficiary without an appointment. This is the rule even if the beneficiary has expressed that they are interested in a Medicare Advantage insurance plan or product.
Medicare Advantage organizations need to provide customers with an annual opportunity to opt out of plan marketing calls. There will likely be further clarification on this topic from carriers such as Aetna to their third-party marketing organizations (TPMOs).
Events
If a Medicare Advantage organization is holding an educational event, they can no longer set up personal marketing appointments for the future at said educational event. The organization is also prohibited from asking beneficiaries to complete the Scope of Appointment forms at the educational event. There needs to be a sharp divide between educational and marketing events.
Marketing events and educational events must take place more than 12 hours apart in the same location. When the regulation uses the term “same location,” it means the same building or adjacent buildings.
There must be at least 48 hours between the beneficiary completing the Scope of Appointment forms and the beginning of the personal marketing appointment.
A beneficiary’s request for information is valid for 12 months from the signature. This applies to Scope of Appointment forms, business reply cards, and any other requests to receive additional information.
Before enrollment, the beneficiary must be provided with a pre-enrollment checklist (PECL). This applies to enrollments made over the telephone.
In their disclaimer, TPMOs must provide the number of plans and products they offer. Those who offer all plans and products must also provide a version of this information in their disclaimer.
Beneficiary health plan needs will be reviewed before enrollment.
TPMOs must record the entirety of all of their marketing, sales, and enrollment calls. This includes the audio of any web-based marketing calls. Other types of calls do not need to be recorded in their entirety.
As is evident by the new requirements for compliance from CMS, the industry takes the ethics of marketing and selling Medicare Advantage very seriously and will continue to adjust to a changing marketplace.
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2024 CMS call recording requirements
Because there are strict regulations for selling Medicare, the 2024 CMS call recording requirements is a very important subject. Due to some confusion among sales agents, CMS has clarified that agents must record only marketing , sales and enrollment calls in the their entirety,
Additionally, CMS will require agents to record any virtual/video or other telepresence calls for enrollment, marketing, or sales.
If you are calling to schedule an appointment, invite someone to an event or see if they received materials or have questions, you do not need to record the call.
Effective October 1, 2023; all third party Medicare marketing for calendar year 2024 must contain the following disclaimer:
“We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov,1–800–MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.”
2024 CMS call recording requirements – A few more updated rules (not about calls) for anyone who offers Medicare plans:
Click here to view a more details of the Medicare final rule for 2024
There will now be restrictions on appointment planning at educational events
Agents cannot collect SOAs or schedule appointments during an educational event. You may however, collect permission to contact forms as well as business reply cards (BRCs). The distribution of business cards is also permitted.
You may not schedule a marketing event in either the same location, building or adjacent buildings within a 12 hour time period of an educational event.
See more rules for health plan marketers
Time limits for SOAs & BRCs
Any SOA or BRC you collect is now valid for a limited time; 12 months from the date of the beneficiary’s signature. Once the time limit has expired, you must collect a new scope or PTC form.
SOAs must be collected 48 hours before a scheduled sales meeting
Yes, the 48-hour SOA (scope of appointment) rule is back in place. However, there are a couple Exceptions to this rule.
- If the beneficiary is 4 days or less from the end of a valid election period.
- Walk -in (un-scheduled) meetings initiated by the beneficiary
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Humana HMO Network Change
There is a Humana HMO network change for the Medicare Advantage insurance plans . Humana is now partnering with two different companies that provide durable medical equipment (DME) for Medicare Advantage beneficiaries. These changes will streamline providers and offer them all one source of DME, making it easier to connect people with the products they need. It is also to save Humana, and therefore the beneficiaries of their Medicare Advantage plans, money. The designated durable medical equipment providers will need to transition their existing rentals to providers that are now in-network with Humana. They will have 90 days to do so.
The press release from Humana stated that the two DME companies that they are now partnered with are AdaptHealth Corp. and Rotech Healthcare Inc. Their goal will be to help their Humana Medicare Advantage HMO beneficiaries achieve their best health at home with durable medical equipment. This is a more unified approach to sourcing DME and will allegedly provide a higher level of service to the beneficiaries who need these vital pieces of equipment for their quality of life.
Humana HMO Network Change – Impacted Items
The following bulleted lists are from the Humana press release and give a succinct grouping of what DME rentals must be transferred and which can remain un-transferred.
These DME groupings should be submitted to the designated DME provider (e.g. AdaptHealth Corp. for the Southeast Region) under this network change. Respiratory supplies are included. Beds and support services transferred. Mobility aids, including wheelchairs and standard power mobility also transfer.
What’s Not Changing
Additionally, DME suppliers who focus on the following areas are not imp acted by this change. Prosthetics, custom orthotics, and diabetic shoes remain unchanged. Mastectomy items and wigs, hearing aids, custom power wheelchairs also remain unchanged. And finally, there is no change to ostomy, urology and diabetic supplies.
With these changes in mind, what does an agent need to do now? Agents are free to reach out to their clients on a Humana Medicare Advantage HMO plan who use DME and notify them on the coming changes. Providers must take note of these changes and submit referrals accordingly when sourcing DME. These changes are effective on July 1st of 2023. The carrier itself, Humana, will be notifying its members of the coming changes as well.
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Medicare Advantage and VA Benefits
Veterans who receive benefits often feel like they have to choose between purchasing a Medicare Advantage plan and getting health insurance coverage from their VA benefits. However, Medicare Advantage plans issued by reputable carriers can be a complement to VA benefits. It does not have to be an either or question but rather a question of how to get the best possible and fullest coverage for those who have served our country.
A Medicare Advantage plan can offer more options for care than the VA does because there are more options for plans and more institutions and doctors to choose from. These options could be closer to home and even more cost effective. Some veterans may even be eligible for Medicare Advantage plans that have $0 premiums and offer what VA benefits do not, like dental care. By choosing a plan that includes prescription drug coverage, some veterans may even be able to use their local, in-network pharmacy.
Reducing Gaps
While all Medicare Advantage plans work to reduce gaps in healthcare coverage, there are certain plans that were designed for veterans specifically, including those using their VA benefits. The Humana Honor Medicare Advantage plans, for example, offer additional benefits such as a $0 premium and dental care, which compliments the VA benefits while working to get veterans the care they need.
Choosing a Plan
Choosing an MAPD in addition to VA coverage is particularly beneficial for prescription drug coverage. While the VA does cover prescriptions written by a VA doctor and would continue to do so after the veteran enrolls in their Medicare Advantage plan, there are some things they will not cover. These include some types of injectables and infusion medications. A Medicare Advantage plan with prescription drug coverage would cover those medications if prescribed by an in-network doctor.
Medicare Advantage and VA Benefits – TRICARE and CHAMPVA
Medicare Advantage plans can also work with TRICARE and CHAMPVA. If a veteran who is covered by either of those decides to enroll in a Medicare Advantage plan, that plan will then become their primary coverage. This would require that the beneficiary see in-network providers. If a veteran using TRICARE or CHAMPVA does not mind being limited to a network of providers and can coordinate billing, considering enrolling in a Medicare Advantage plan may help them reduce gaps in coverage and cover more of their healthcare needs closer to home.
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Medicare Questions
Best Medicare Questions for a Sales Meeting with a Prospective Client: Basics and Healthcare
Medicare agents have a number of ways to reach prospective clients. One of those ways is to hold education and sales events. While education events cannot lead to enrollments, sales events can and should. With these questions, agents will be able to learn about their prospective and offer them the best plans and support for their insurance needs.
Medicare Questions – Basic
Other than the obvious starters like “how can I help you today?” there are a number of basic information questions that agents will need to ask during their sales meeting:
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Do you make your own health care decisions?
Agents need to know this because they must speak to the person who is making the healthcare decisions directly.
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What is your date of birth?
This determines what the perspectives are eligible for.
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Which zip code and county do you live in?
This answer determines which plans are available to the prospective.
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Are you currently on Medicare? Have you applied for Medicare?
Some people receive Medicare earlier than 65 due to disability.
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Do you receive Social Security payments?
If they are receiving SS payments prior to the age of 65, they will automatically be enrolled in Medicare A and B.
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Do you/your spouse still work? Do you plan to work past 65? Do you get coverage from your job?
If this is the case, the perspectives may want to waive their initial application for Medicare part B, which would not result in a sale.
Medicare Questions – Health
Although it is prohibited to ask a prospective customer about their health directly, agents will need to know certain things in order to best serve their clients.
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How often do you go to the doctor?
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Have you had any inpatient stays or outpatient surgeries?
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Do you have any scheduled for the future?
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Please provide a list of the medications you take and the doctors you visit
This will enable the agent to make sure that they can find a plan that covers their needs as well as has as many of those doctors in-network as possible.
All of this information will give the agent a good idea of whether or not the prospective will need a Medicare Supplement plan. The agent can also then run the list of medications through Connecture or Sunfire, both tools which will tell the agent which plan covers more of those necessary medications. Be sure to subscribe to our youTube channel for updated platform demonstrations.
These basic information and healthcare questions will give the agent what they need to begin the process of helping their prospective enroll in the Medicare insurance plan that is right for them. There are also financial questions and other information that are needed, which will be in a second blog post.
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AHIP 2024 test tips
Each year over 100,000 agents and brokers take the AHIP course. AHIP is a CMS compliant course. It is updated every year so that the training is both accurate and relevant to the current CMS regulations. That is why the AHIP 2024 test tips are a great resource to help ensure your successful completion of the AHIP exam.
You must receive a grade of 90% to pass the exam and you are allowed 3 attempts to pass. You have 2 hours to complete the 50 question exam. If you do not pass after the third attempt, you will need to retake the course and pay again. It is important to note; some carriers will not allow you to sell if you do not pass the exam in the first 3 tries.
This year the 2024 exam is available starting June 21st, 2023. The exam will cover any business you write from now until the end of 2023 as well as through 2024.
Most carriers require you to take the AHIP, although UHC does not require AHIP. UHC does however, require certifications for Med Supp sales.
The cost for the AHIP course:
The cost of $175 includes the exam although you can get a $50 discount by taking it through one of the major carrier’s sites (UHC, Aetna, Humana, etc.). Agents who are part of the Pinnacle financial team are eligible for a $50 discount as well. All you need to do is go to pfsinsurance.com sign in, click on AEP Toolkit and from there you will scroll down and see a link for the:
Pinnacle AHIP discount.
Please note; this year’s 2024 AHIP is very similar to last year’s 2023 AHIP
There are some new concepts and rules you need to be aware of. Click on the link below to watch our video and learn more:
Take a look at our YouTube video ” AHIP Test Tips 2024″
Here is what the AHIP course covers:
The first part of the course covers Medicare and consists of 5 modules
- Medicare basics; fee-for-service and eligibility as well as benefits
- The different types of Medicare Advantage & prescription drug plans (Part D)
- Who is eligible and what is covered
- Nondiscrimination training
- Learn the requirements for the marketing and enrollment of Medicare Advantage as well as Part D prescription drug plans
You can download each module once you click on it. This is allowed and suggested to help you complete the test later. If you took the AHIP in 2023, you only need to click through the slides on modules 4 & 5 although, we recommend clicking on modules 1-3 as well so you can download the content. It is also not a bad idea to complete the practice tests at the end of ALL modules since those are the questions that will be on the test.
Each of the 5 modules has a 20 question practice test at the end. Pay very close attention to the practice questions; most of the test questions come from there.
Once you finish the 5 modules and the exam, remember to take the second part of the AHIP.
The second part of the course covers fraud, waste, and abuse
- Learn how to spot fraud, waste, and abuse (FWA)
- Find out what the Medicare industry is doing to detect fraud
- What are the legal tools that combat FWA
- Understand the human as well as the financial cost of fraud waste and abuse
- Review general compliance requirements for Medicare Parts C and D fraud, waste, and abuse.
- Find out who commits fraud, waste, and abuse
- What are loophole and obligations to reporting fraud, waste and abuse
After everything is successfully finished, remember to download your AHIP certificate. In many cases you can transmit your score to the carriers from the AHIP site, but some will need you to upload it into their dashboards yourself.
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Medicare Dual Plans
Medicare dual plans are also called dual eligible special needs plans. A Dual Eligible Special Needs Plan are know as a D-SNP. Plans are Medicare insurance plans that enrolls beneficiaries who are entitled to both original Medicare on a federal level and their state’s Medicaid plan. Depending on the state, many individuals on these plans will receive assistance with out-of-pocket costs, among other things. D-SNP plans are Medicare Advantage plans.
There are limited eligibility categories for this plan. To be eligible for dual enrollment, individuals must meet at least two categories simultaneously, one from Medicare eligibility and one from Medicaid eligibility.
To be qualified for original Medicare, an individual must be 65 years or older, a citizen of the United States of America, and live here the majority of the year. For some people who have chronic conditions such as end-stage renal failure, some cancers, or ALS, Medicare eligibility can come earlier because of their condition.
Medicaid requirements for enrollment are more complex, however, because they are state-dependent and can differ greatly by where an individual lives in the country. Generally speaking, those who are eligible for Medicaid must fall under a certain income threshold to be eligible for these benefits. There are some exceptions in Connecticut. For example, there are some disabilities that automatically qualify people for Medicaid benefits, known as Husky in Connecticut. The majority of the time, people who are 65 years or older and make under a certain percentage of their state’s income thresholds are considered dual eligible, or qualified to enroll for a D-SNP.
How Do You Know If You Qualify for One of the Medicare Dual Plans?
Despite the differences in state qualifiers, individuals who answer yes to the following questions are typically qualified for a D-SNP.
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Do you qualify for Medicaid or get financial assistance from your state?
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Enrolled in Medicare parts A and B?
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Do you live in the coverage area of the dual enrollment plan’s insurance carrier?
Potential beneficiaries able to answer yes to these three questions are likely eligible for a Dual Enrollment Special Needs Plan.
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Chronic Special Needs Plan
What is a Chronic Special Needs Plan? A C-SNP is an acronym that stands for a Chronic Conditions Special Needs Plan. This is a type of Medicare Advantage plan specifically designed for beneficiaries who have a chronic illness or condition. Many of the insurers who provide these plans claim that the purpose of the benefits of a C-SNP is to allow those with the coverage to have improved health outcomes and more flexibility and choice while managing their condition(s).
Conditions
There are many conditions that qualify beneficiaries for a C-SNP. Some of the more common ones are diabetes, end-stage renal disease, chronic lung diseases, chronic heart failure (or CHF), and cardiovascular disorders. For beneficiaries with diabetes, an endocrinologist will work with their primary care doctor to determine the best course of action. For those beneficiaries with end-stage renal disease, their care team will include their primary care doctor and a nephrologist, or kidney specialist. This specific coverage is available in Connecticut. Those with chronic lung disorders who qualify for a C-SNP will have coverage for oxygen supplies and other medical equipment, and for ongoing care for beneficiaries with heart diseases, a cardiologist will join their individual health care team.
In some parts of the country, there are C-SNP plans that consider a multitude of other conditions for enrollment. Coverage includes some mental conditions. These include schizophrenia, certain autoimmune disorders, dementia, Some neurological disorders such as Parkinson’s, and HIV or AIDS are also included. C-SNP aims to provide better health outcomes for beneficiaries with these specific pre-existing conditions.
Although beneficiaries enrolled in a C-SNP will still have to pay their Medicare part B premiums, they often have access to more services with fewer out-of-pocket expenses. Some of these services can include meal delivery if necessary, prescription drug coverage, transportation to health-related appointments, preventative care such as routine screenings and physicals, dental, vision, and hearing coverage, and even a fitness membership benefit at no additional cost.
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Medicare Sales vs Educational Events
There are strict guidelines for how to ethically market and sell Medicare insurance plans. According to the Center for Medicare and Medicaid Services, the Marketing Guidelines reflect their interpretation of the marketing requirements and related provisions of the Medicare Advantage and Medicare Prescription Drug Benefit rules. Regulations apply to both types of event. In addition, different regulations apply to how each can be marketed. Learn the differences of Medicare sales vs educational events.
Medicare Sales vs Educational Events: Medicare Educational Events
These events are purely for education and communication. This is not a sales event. However, for many agents and agencies, this is a good time to get to know their prospective clients and teach them about what kind of services they can provide. Most of the people who attend these educational events are future beneficiaries, current beneficiaries, and their caregivers, all looking for information to make the best informed decisions they can about their healthcare.
Agents may not discuss specifics of plans during educational events. However, the are permitted to hand out generic marketing materials, and even collect the contact information of interested parties. Set up all sales appointments for a later time. This is a hard and fast rule. Educational events must be advertised as education, as well. Snacks, promotional materials, business cards, and education materials are all encouraged to be given out or displayed during educational meetings. Agents are allowed to answer questions that are asked, but may not provide information beyond those answers related to sales. These educational meetings must be in a group format, and should not be one on one.
Medicare Sales vs Educational Events: Medicare Sales Events
Medicare Sales Events are events in which the purpose is to discuss plan-specific information and enroll beneficiaries in a Medicare plan. There are typically two categories of sales events: formal sales events and informal sales events. Formal sales events entail presenting plan-specific information to an audience. Agents present Informal sales events at a kiosk or a table. These present information at an individual’s request, not to a captive audience. The marketing materials for sales events may include things like carrier benefits, benefit structures, premiums, cost-sharing, and comparisons to other plans, as the purpose of these events is to eventually collect enrollment applications.
Just like an educational event, clearly advertise sales events as such. Additionally, the rule includes both informal and formal events. Prohibited marketing tactics include requiring attendees to sign in or provide contact information. Prohibited items include full meals or subsidized meals, give away rebates and cash prizes. Do not discuss non-healthcare related products. Prizes etc are prohibited at Medicare sales events. This rule maintains the ethics of the agents and the agencies that provide the services advertised.
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UHC assisted living IESNP
The UHC assisted living IESNP plans are a great option for clients who are either moving into an assisted living, independent living, or memory care community and congregate housing. The plan is also available to people receiving care at home. Additionally, members that need help with Activities of Daily Living (ADL’s) or instrumental Activities of Daily Living (IADL) are likely eligible for the plan. A few examples of IADL’s are: housekeeping, managing money, food prep, transportation or even managing medications.
Click here for additional UHC Assisted Living Plan information
This is a 5 star Medicare Advantage PPO plan!
This plan provides much needed resources to help clients navigate the transition and make life much easier. Plans are available to both Dual and non-dual members.
It is very important to note:
These plans are exclusively offered by agents contracted with either Crowe and Associates or Pinnacle Financial Services!
If you would like to get contracted with Crowe and Associates to offer these plans; click this link
Click here for a map of the IESNP coverage area
Before you can offer these plans, there are 2 steps for training:
- Use the link below to complete the first step. Once you have completed the fist step ( IESNP training video) be sure you scan the code using the camera on your phone.
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Click here for IESNP training page (Need to be logged into the PFS site to access) (Training called “UHC Assisted Living Plan Training”)
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- After you complete the first step, you will receive a notification. In a couple days, the certs are loaded into your Jarvis portal. You will find the certification in Jarvis’ knowledge center in the “Invitation only” section.
Use this link for step by step screen shot instructions on the entire certification process
There are many great benefits offered with these plans:
The UnitedHealthcare Assisted Living Plan (IESNP) includes a dedicated care team– including a nurse practitioner and physician assistant- that help to customize a plan of care that covers your client’s needs. This team has over 20 years experience in care coordination. They work with both families and providers to keep everyone updated on the client’s healthcare needs. The care team is available by phone 24 hours a day, 7 days a week to help assure any concerns your client has are addressed.
To view the ALC flyer, click here
Another important benefit of these plans is the extremely low OOP. The OOP for the plans is between $1,500 and $1,600 annually! The plan has a very low OOP vs. other non dual Advantage plans. A member needs to be eligible for the plan but they DO NOT need to be a dual member to qualify. As a result, this can be an increadible option for those not receiving any type of help from the state or for members that are drug help only.
Take a look at some additional benefits including great dental coverage!
Verification of eligibility:
Option 1: Check eligibility in UHC Jarvis portal
You must have log in credentials for the PFS website to access the page:
CLICK TO ACCESS PAGE Click on “2023 LOC Process”
This plan has dual-type extra benefits but as well as a clinical element. Members have access to in-person care either at a facility or in their own home from a UHC employed nurse, nurse practitioner or PA. They also have a care coordinator that would organize the care from the clinician and help with things like medication management.
Access to WellSky once certifications are completed:
Registration
1. User will receive an email from WellSky (no-reply@wellsky.com) with information provided for
registration.
2. User will select the link in the email, provide the temporary password, and the user will be
prompted to create a new password.
3. Remember to save the URL, username, and password for future use. Users do not have to
access the portal to keep their account active.
Enhancements to Medicare Advantage for 2024
CMS is constantly looking at the regulations that govern the sale, provision, and use of Medicare and Medicaid. They examine the experiences of the insurers that are contracted by the government to provide the insurance plans. Additionally, they examine the experiences of the beneficiaries who purchase them. Any amendments they choose to make are intended to take effect the following year. In 2023, CMS looked at the rules surrounding Medicare Advantage in particular. What changes are planned for Medicare Advantage 2024?
CMS Final Rule
The CMS issued a final proposal on April 5th of 2023 for the enhancement of Medicare Advantage. They did not address the comments that the public had given on the proposed amendments. However, did say that they plan to address them at a later, more appropriate date. The amendments proposed have to do with prior authorization and how that affects beneficiaries’ access to healthcare. Previously, prior authorization meant that beneficiaries who had Medicare Advantage health insurance plans had to essentially request permission before receiving care. That indirectly means that beneficiaries could be denied care. (Traditional Medicare does not require prior authorization.) There were concerns that Medicare Advantage customers were not receiving the same quality of care as Original or Traditional Medicare beneficiaries because of these rules.
Changes to Medicare Advantage 2024
This is about to change, however, as the new rules proposed by CMS are designed to make sure that Medicare Advantage customers have the same access to necessary tests, scans, prescriptions, and procedures that their counterparts in Original Medicare to. The American Medical Association says that the new rules have, “taken important steps towards rightsizing the prior authorization process.” UnitedHealthcare, which is just one of the insurers with Medicare Advantage plans, says it plans to reduce their number of denials of care by nearly three million a year.
CMS’ new rule requires that prior authorization policies may only be used to confirm the presence of a diagnosis. This ensures that the treatment is medically necessary. CMS is also requiring that all Medicare Advantage plans develop committees to ensure that denials and approvals are working effectively to get beneficiaries the care they need within the new guidelines. Finally, the new rules require that a prior authorization approval is effective for the entire course of treatment as long as medically reasonable and necessary to avoid disruptions in care.
All together, beneficiaries and insurers alike hope that these new regulations will help ensure that Medicare Advantage plans provide equitable access to care moving forward.
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