Transcription
BlueCross BlueShield of TennesseeMedicare Products Agent GuideMedicare Supplement – BlueElitePlans A, C, D, F, G, NMedicare AdvantageBlueAdvantage PPOBlueChoice HMOBlueCare Plus HMO SNPbcbstmedicare.com
Table of ContentsWelcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 1Medicare Sales Code of Ethics. . . . . . . . . . . . . . . . . . . . . . . . . . . page 2Introduction & Important Contacts List . . . . . . . . . . . . . . . . . . . . . . . page 3Medicare Supplement Products. . . . . . . . . . . . . . . . . . . . . . . . . . . page 4Creditable Coverage & Pre-Existing Determinations . . . . . . . . . . . . . . . . page 6Submitting BlueElite Applications . . . . . . . . . . . . . . . . . . . . . . . . . page 7SMMedicare Advantage Products. . . . . . . . . . . . . . . . . . . . . . . . . . . . page 8Available MA Products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 10Who is Eligible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 12Election Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 13Scope of Sales Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . .page 15Effective Date of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . .page 17Who May Sign an Election Form or Complete an Election Method. . . . . . . . page 18Incomplete Enrollment Elections. . . . . . . . . . . . . . . . . . . . . . . . .page 19Agent Enrollment Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 22Advertising and Marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 24
WelcomeDear Insurance Professional:This manual was developed to serve as a guide to assist you in understanding andmarketing BlueCross BlueShield of Tennessee and its subsidiaries (BCBST) availableMedicare Advantage products.You will find that a Medicare Advantage plan is not right for everyone. A MedicareAdvantage plan may not meet the needs of, or otherwise be appropriate for, thebeneficiary. In these cases, you might offer a Medicare Supplement, suchas BlueElite.We will also review the Marketing Guidelines. We are very serious about theseguidelines with the penalties for not observing them severe, up to and includingtermination of appointment.As a representative of BCBST, you are required to abide by a code of ethics.The Centers for Medicare & Medicaid Services (CMS) places certain requirementson all Medicare Advantage and Medicare Part D Contractors. Beyond that, BCBSTbelieves that it is only right to represent our products and us in an honest, forthrightmanner. Failure to abide by the Medicare Sales Code of Ethics will result in immediatedisciplinary action, up to and including appointment termination. Violation of CMS rulesmay result in criminal prosecution.1
Medicare Sales Codeof EthicsEthics is giving prospective memberswhat they need.We recognize Medicare beneficiaries asa very special segment of our society.Because health care is typically oneof the most important aspects of their lives, we bear the responsibility to conductourselves according to the highest standards of ethical behavior and fairness. Whenmarketed properly, Medicare Advantage products can bring about a tremendous senseof wellbeing.You represent BCBST and our Medicare Advantage products to prospective members.At the point of sale, you may be perceived as the first face of BCBST.Selling ethics consist of: A commitment to present all information in a fair and accurate manner, adheringrigidly to all published company and CMS requirements A determination to avoid, under all circumstances, any activity that could confuse,mislead or pressure a prospective mmber A mission to fully educate the prospective member about the benefits, limitationsand lock-in provisions of joining BlueAdvantage A decision to walk away from the sale and seek advice of BCBST managementwhen doubt existsCongratulations on your decision to sell BlueAdvantage (PPO) , BlueChoice (HMO) , andBlueCare Plus (HMO SNP) . BCBST is dedicated to service, growth,and innovation.SMSMWelcome aboard!2SM
Introduction & ImportantContacts ListThis Agent Guide will assist you in understanding and marketingBlueCross BlueShield of Tennessee (and its subsidiaries) availableMedicare Advantage products. This guide is a reference, not alegal document.Our Individual Field Agency Support Team, along with Single Pointof Contact, are available to answer your questions. Please refer tothe numbers below for more information.Field Agency SupportBroker AdministrationEast TennesseeCommission QuestionsDanielle Byers1-800-515-2121 ext. 4645(865) 588-4645Rhonda Ireland1-800-515-2121 ext. 8279(423) 535-8729Middle TennesseeJana Thomas1-800-515-2121 ext.7026(423) 535-7026Karen Tidwell1-800-515-2121 ext. 3371(423) 535-3371Licensing, E&O, Info UpdatesWest Tennesseeagents&brokers@bcbst.comCharlotte Sommersby1-800-515-2121 ext. 2215(901) 544-2215Single Point of Contact1-800-351-9325Preferred Partners StatewideLaShawn Hawkins1-800-515-2121 ext. 5487(423) 535-54873
Medicare Supplement ProductsBlueElite Plans A, C, D, F, G, NGeneral EligibilityRequirementsTo be eligible to enroll, the applicant: Must be a resident of Tennessee.(This must be a physical address;PO Boxes will not be accepted.) Must be age 65 or older. EffectiveJanuary 1, 2011, persons under age65 who are eligible for Medicare byreason of disability or end stage renaldisease are also eligible. Must be enrolled in Medicare Parts Aand B. Cannot have another federallyregulated Medicare Supplement(Medigap) policy.Open Enrollment Application should be submitted withinsix (6) months of when an individualis both 65 years of age or older and isenrolled for benefits in Medicare PartB. Any currently marketed BlueElitepolicy is available to the applicant on aGuaranteed Issue basis. Individuals under age 65 who areeligible for Medicare by reason ofdisability or End Stage Renal Diseaseare also eligible for a six (6) monthopen enrollment period. Eligibleindividuals under age 65 must be4offered the same policies with thesame standard benefits as the 65 andolder population. A person who becomes retroactivelyenrolled in Medicare Part B dueto a decision made by the SocialSecurity Administration will havesix (6) months from the date of thenotice of retroactive enrollment topurchase a policy. A person who loses access toalternative forms of health insurancecoverage such as individual healthpolicies, employer-sponsoredgroup health coverage or MedicareAdvantage plans due to terminationor cancellation due to the individual’semployment status, or due toan action by a health insurer oremployer that is unrelated to theindividual’s status, conduct, or failureto pay premiums will have six (6)months from the date of loss of thatcoverage to purchase a policy. A person who is involuntarilydisenrolled from Title XIX (Medicaid)or Title XXI (State Children’s HealthInsurance Program) of the SocialSecurity Act will have six (6) monthsfrom the date of disenrollment topurchase a policy.Guaranteed IssueIndividuals as described below will havecertain BlueElite plans available on aguaranteed issue basis with no preexisting condition limitations.
If the applicant does not fit one of thesecategories, the policy is subject tounderwriting and pre-existing conditionlimitations apply for six (6) months withcreditable coverage offsets. The applicant has lost group healthcoverage through no fault of their own.The guaranteed issue period ends 63days after termination. The applicant isentitled to BlueElite plans A, C,and F. The applicant has a MedicareAdvantage plan that has beendiscontinued, the individual is nolonger eligible, or the plan misledthe individual. The guaranteed issueperiod ends 63 days after termination.The applicant is entitled to BlueEliteplans A, C, and F. The applicant is enrolled in a Section1876 (Medicare cost) plan or Section1833 (health care prepayment) planthat ceases. The guaranteed issueperiod ends 63 days after termination.The applicant is entitled to BlueEliteplans A, C, and F. The individual has a MedicareSupplement policy, and enrollmentceases because the issuer goesbankrupt or misrepresented the policy.The guaranteed issue period ends 63days after termination. The applicant isentitled to BlueElite plans A, C,and F. The individual has a MedicareSelect policy and moves outside therestricted service area. The guaranteedissue periods ends 63 days aftertermination. The applicant would beentitled as follows: Select Plan C would be eligible forBlueElite Plans A and C; Select Plans F, J, and J withoutpharmacy, would be eligible for anyof the BlueElite Plans A, C, D, F, Gor N If the applicant dropped a MedicareSupplement policy to join a MedicareAdvantage Plan for the first time,they have been in the plan less than ayear, and they want to switch back toMedicare Supplement, they have theright to: Buy the Medicare Supplementpolicy they had with BCBST beforethey joined the Medicare AdvantagePlan, if BCBST still sells it. If itincluded drug coverage, they canstill get the same policy, but withoutthe drug coverage. If their former Medicare Supplementpolicy is no longer available, they canalso buy a BlueElite plan A, C, or F. The guaranteed issue periodends sixty-three (63) days aftertermination. The individual, upon first becomingeligible for benefits under Medicareat age 65, enrolls in a MedicareAdvantage plan and disenrolls fromthe plan or program within the firstyear. The guaranteed issue period endssixty-three (63) days after termination.The applicant is entitled to anyBlueElite plan currently issued –A, C, D, F, G or N.5
Creditable Coverage &Pre-Existing DeterminationsCreditable coverage and pre-existingcondition determinations have no directrelation to individual eligibility. These aretotally separate issues.Creditable coverage is health coverageof the individual provided by any of thefollowing: A group health plan; Health insurance coverage; Part A or Part B of Title XVIII of theSocial Security Act (Medicare); Title XIX of the Social Security Act(Medicaid), other than coverageconsisting solely of benefits undersection 1928; Chapter 55 of Title 10 United StatesCode (CHAMPUS); A medical care program of theIndian Health Service or of a tribalorganization; A state health benefits risk pool; A health plan offered under chapter 89of Title 5 United States Code (FederalEmployees Health Benefits Program); A public health plan as defined infederal regulation; and A health benefit plan under Section5(a) of the Peace Corps Act (22 UnitedStates Code 2504(e).6An individual is required to have had atleast six (6) months creditable coveragein place prior to applying for a MedicareSupplement plan under BlueElite. Ifcreditable coverage did not exist, theindividual will be subject to a pre-existingcondition determination.Pre-existing conditions would applywithout creditable coverage and servicesmay not be covered under the Plan forany period during the previous six (6)months where creditable coverage wasnot in place.
Submitting BlueElite ApplicationsBlueElite applications can be submittedvia the online broker enrollment tool or viafax or secure email scan. Online broker enrollment toolprovided via DestinationRx: Anyagent contracted under the MedicareSupplement Products AgentAgreement to market and sell theBlueElite products will be sent anemail link each year for access. The linkis normally distributed no later thanOctober 1 of each year. Fax: Applications may be faxed in theirentirety to BCBST at 423-591-9337 Secure email scan: Applications maybe scanned and sent via secure emailto BCBST at to IndSalesProc FAX@bcbst.comAgent of RecordAgent of Record (AOR) is the termedused by BCBST to indicate the agent whoassisted the member and is receivingcompensation for the enrollment. AOR isindicated by the use of an agent’s five (5)digit Agent ID assigned by BCBST.BCBST maintains AOR for the BlueEliteproducts except in the event of anapplication submitted for policy upgrade(for example, a change from Plan Cto Plan F) which would require themember to pass underwriting. Thisexample would allow the new agentsubmitting the upgrade to receive therenewal compensation for this member.7
Medicare Advantage ProductsBlueAdvantage (PPO) ,BlueChoice (HMO) ,and BlueCare Plus (HMO SNP)SMSMSMCertificationRequirementsTo sell and retain renewal compensationon Medicare Advantage products, agentsmust complete annual certificationtraining. This training is created to ensureagents understand and abide by the rulesand regulations associated with MedicareAdvantage per the requirements ofthe Centers for Medicare & MedicaidServices (CMS).Agents are required to complete thefollowing annually:1. America’s Health Insurance Plans(AHIP) annual Medicare Advantageand Medicare Part D Prescription DrugPlan Training.a. Agents must use the BCBSTsupplied AHIP link to login regardlessof whether they complete the AHIPtraining via our link or that of anothercarrier. CMS regulations prefer thatall training is tracked electronicallyand usage of the BCBST suppliedlink insures reporting.b. Fraud, Waste & Abuse and GeneralCompliance training are a CMSrequirement. AHIP provides thistraining currently through CMS’supplied training adhering to CMSMarketing Guideline updates.8c. Agents must complete all requiredmodules of the AHIP training,including the Fraud, Waste &Abuse and General Compliancemodules provided through CMS,and pass the final exam with ascore of at least 90%. BCBSTallows agent three (3) attempts atthe final quiz before certification isdenied.2. BCBST Product Specific Traininga. Agents must complete all trainingmodules released annually. Thistraining covers each productoffered (PPO, HMO, HMO SNP) aswell as Administrative Guidelinesand Compliance related informationb. Agents must complete and passall modules with a score of atleast 85%. BCBST allows an agentthree (3) attempts to pass beforecertification is denied. Failure topass any module within the threeattempts will result in the agentnot being allowed to attemptcertification again until the nextyear’s training is released.Agents who have completed all necessarytraining will receive a “CertificationConfirmation” email. Agents should neverassume their training is complete untilthis email notice is received.Agents will be notified also if they did notcomplete and pass all required training
elements with the required score orwithin the number of allowed attempts.Agents who do not pass the trainingfor a specific year will not be allowedto attempt to train again until the nextMedicare Advantage product year.What is MedicareAdvantage?Medicare Advantage products offer themember additional choices in healthcareas well as the convenience of combiningall medical and prescription benefits underone plan with one ID card. MedicareAdvantage plans are not supplementalpolicies, but instead take the placeof Original Medicare while providingadditional benefits.How does MedicareAdvantage Work?BCBST is contracted with the Centersfor Medicare & Medicaid Services (CMS)for our Medicare Advantage health plans.CMS pays BCBST a monthly fee for eachMedicare beneficiary enrolled in one ofour Medicare Advantage products. In turn,BCBST is responsible for the claims of thebeneficiaries, assuming the entire risk.How does MedicareAdvantage compare toOriginal Medicare?Each plan covers the same benefits thatare covered under Original Medicare, butin a different way. Under Original Medicarethe member is responsible for either adeductible or coinsurance percentage.Many Medicare beneficiaries carry aMedigap, or Medicare Supplement, policyto pick up those additional dollar amounts.Some preventive services (such as annualwellness exams, mammograms andprostate screenings) are covered at 100%.Under a Medicare Advantage plan,the member pays a fixed co-pay amountfor most medical services. MedicareAdvantage plans are “managed care”plans with a network. For example, PPOplans maycontain coverage outside ofthe contracted network while HMOplans are limited to coverage within aspecific network. Medicare AdvantagePrescription Drug Plans (MA-PD)contain prescription drug coverage.Medications should be checked on eachPlan’s formulary (list of drugs) to ensurecoverage of each medication.More than OriginalMedicareMedicare Advantage plans also providebenefits that Original Medicare and aMedigap policy does not cover. Underour Medicare Advantage products,additional benefits may include routinephysicals, routine vision and hearingexams, preventive dental, and eyewear.Worldwide coverage is available foremergencies and urgently needed care onthe BlueAdvantage PPO and BlueChoiceHMO plans.9
Available MA Products BlueAdvantage (PPO) plans contain anetwork of providers. Members willpay a set co-payment or coinsurancefor services administered by innetwork providers. The BlueAdvantagePPO plans also allow members to seekservices outside the PPO networkwith an Out-of-Network Servicesbenefit. The out-of-network providerwould have to agree to accept theterms and payments of the planand, if the provider does not acceptMedicare assignment, the membermay also be liable cost sharing thatincludes the allowed Medicare LimitingCharge. If the out-of-network providerdoes not accept the out of networkconditions, they may refuse treatmentto the member except in cases ofemergency. These plans are available inall 95 counties in Tennessee.BCBST’s Medicare AdvantagePlans are available in threedifferent types:1. BlueAdvantage is offeredunder a Preferred ProviderOrganization (PPO) plan;2. BlueChoice and BlueChoicePlus are offered undera Health MaintenanceOrganization (HMO) plan; and3. BlueCare Plus is offered undera Dual Eligible Special NeedsPlans (HMO SNP).10 BlueChoice/BlueChoice Plus(HMO) plans have a set networkand members must use networkproviders. These members may,of course, seek services from anyprovider for emergent and urgentlyneeded care as mandated by CMS.This market is expanding and agentsneed to check their certificationtraining for the 65 counties whereHMO plans are available. BlueCare Plus (HMO SNP) plans havea set network and members must usenetwork providers. These membersmay, of course, seek services fromany provider for emergent and urgentlyneeded care as mandated by CMS.This plan is available in all 95counties in Tennessee.
Agents should ensure that thebeneficiary’s Primary Care Provider (PCP)is indicated on enrollment forms forany of the three (3) available MedicareAdvantage products. PCP designation isrequired for both the BlueChoice HMOand BlueCare Plus HMO SNP products. Ifthe beneficiary does not designate theirPCP, the Plan will auto-assign a PCP tothem in their area.Even the BlueAdvantage PPO enrollmentsshould be completed/submitted withthe beneficiary’s PCP indicated as theirID card will be pre-printed with thisinformation. Designation of PCP for theBlueAdvantage PPO product will assistthe Plan in enhancing its ManagedCare programs.A PCP is the main provider the membergoes to for care. The member shouldcultivate a relationship with their PCPso they: Provide preventive care and teachhealth life choices Find and treat medical conditions Direct the member to the best placefor care Refer the member to a medicalspecialist when necessary11
Who is Eligible?To be eligible for the Medicare AdvantagePPO (BlueAdvantage) and HMO(BlueChoice) plans, beneficiaries must bea resident of the
Medicare Advantage products . You will find that a Medicare Advantage plan is not right for everyone . A Medicare Advantage plan may not meet the needs of, or otherwise be appropriate for, the beneficiary . In these cases, you might offer a Medicare Supplement, such as B
