2014 - Qm - Final 1

Medigap Plan N covers 100% of Part B coinsurance after you meet your yearly Part B deductible. This means that once you have paid the deductible amount ($147.00 for 2014), the plan will cover the remaining coinsurance costs for Part B services. However, for some office visits, you may still have to pay a copayment of up to $20, and for emergency room visits, you may have to pay a copayment of up to $50. Therefore, the correct answer is B, indicating that the deductible that needs to be met is Part B.

Yes, this is a prohibited practice. The BA is copying and sending plan information from the Summary of Benefits to the customer via email. This violates the rules and regulations set by the organization, as it is not allowed to transmit sensitive information through insecure channels like email. The BA should have found an alternative method to communicate the plan information securely, such as using a secure messaging platform or arranging a face-to-face meeting.

If the BA states that the customer's HICN (Health Insurance Claim Number) is the same as their social security number with a letter, it would be marked as a Prohibited Practice. This is because disclosing or using a social security number in conjunction with other identifiers is considered a prohibited practice under HIPAA regulations.

Adjusting the words in the MIR (Message Impact Ratio) is acceptable as long as it does not change the meaning. This means that salespeople can modify their sales calls to better suit their audience or to emphasize certain points, as long as the overall message remains the same. This allows for flexibility in communication and tailoring the sales pitch to individual customers without compromising the core message.

If the ADP has to clarify a question on page 4 for the customer and then does not re-state the question, it would be acceptable for Carefirst BlueCross BlueShield of Maryland.

The statement in the scenario where the ADP tells the customer that he works for the Centers of Medicare and Medicaid Services would be considered a Prohibited Practice. This is because the ADP is misrepresenting themselves as an agent of Medicare, Social Security, or any agency of the federal government.

The correct answer is no because although the BA did not explicitly ask for consent, it can be considered as implied consent. However, the QM would still advise the BA to ask the customer if they would like the person added as a HIPAA representative.

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The statement provided does not mislead, confuse, or misrepresent to potential members about Medicare or competitive plans. It simply states the correct information about the Medicare Annual Enrollment Period. Therefore, it would not be considered a Prohibited Practice.

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The ADP will not lose points if they do not ask for the four digit year because the customer's date of birth is already provided as 5/31/36. Although it is standard practice to ask for a four digit year, it is not mandatory in this case as the customer has already stated their date of birth. Therefore, not asking for the four digit year will not result in any penalty or loss of points.

The BA/ADP is only allowed to not read the closing script after completing a Medigap application if they will also be completing a PDP application and reading the closing script after the PDP. This means that if they are going to complete both applications and read the closing script after the PDP, they do not need to read the closing script after completing the Medigap application.

The given statement, "The Plan F is the cream of the crop," would be considered a Prohibited Practice. This is because it uses an absolute superlative, asserting that Plan F is the best plan. Prohibited Practices include making statements that claim a certain plan is the best or lowest cost, which this statement does.

The statement "This question is always marked No on each application for every carrier" is false. The question is asking whether the individual intends to replace their current healthcare coverage with the Medicare Supplement policy. The answer to this question may vary depending on the individual's circumstances and preferences. Some individuals may choose to replace their current coverage, while others may not. Therefore, the answer to this question is not always marked as "No" on every application for every carrier.

The customer's statement that they do not need the TTY number before it was provided indicates that the BA successfully anticipated and addressed the customer's needs. This demonstrates effective communication and customer service skills, resulting in a positive interaction. Therefore, the answer "Yes" is correct.

The statement is false because according to the given information, if the BA skips the questions about Current Age, Height, Weight, and BMI on a guaranteed issue application, the QM will score line item 41 as a Major. Therefore, the correct answer should be True, not False.

The correct answer is "Doing an enrollment when there is not an applicable enrollment period." This is because the customer called on December 8th to complete an enrollment into a different drug plan for 2015, which is outside the annual enrollment period. Therefore, the enrollment should not have been processed as there was not an applicable enrollment period for the customer to make changes to their plan.

The three parts of the voice signature that the customer must state for it to be valid are the Full Name, Today's date, and They agree. The Plan Name, Premium, and Effective Date are not necessary components of the voice signature.

The correct answer is "No. As long as they read them all accurately." This answer states that the ADP should not be marked down as long as they read all the benefits accurately. It implies that reading more than the required four benefits from the HMO-POS section does not result in a lower QM score.

The BA would need to read the MIR prior to quoting even if it was read on the initial call because the customer called back on a different day. It is important for the BA to refresh their memory and ensure they have the most up-to-date information before providing a quote to the customer.

The statement "The Plan N has no deductibles" would be considered a Prohibited Practice because it conflicts with the information contained within CMS-approved materials. It is misquoting the plan benefits by stating that there are no deductibles when there actually might be.

The BA made a mistake by enrolling the customer in the exact same plan that he already has. This is a red flag because it suggests that the BA did not properly assess the customer's needs or provide appropriate guidance. The customer's request does not justify enrolling him in the same plan, as the customer must be enrolled in a Medical plan through One Exchange to qualify for funding.

The given statement is false. The BA/ADP does not need to read the closing script to each customer individually when completing a joint application.

The BA's failure to discuss any plan benefits during the sales calls after providing two Medigap premiums indicates non-compliance. It is essential for the BA to inform and discuss the plan benefits with the customers to ensure transparency and compliance with regulations. By not doing so, the BA is not fulfilling their responsibilities and may be violating compliance standards.

The explanation for the answer being False is that the statement in the question suggests that if the ADP (presumably a form or document) does not ask for the AARP membership number on the first page, then the QM (quality management) scores Major on question number 41. However, this does not necessarily mean that the answer is False. It is possible that the QM scores Major on question number 41 in this scenario, making the statement True. Therefore, the given answer is not a correct explanation for the answer being False.

If the question regarding how the customer would prefer to pay the premiums is asked twice on a Medigap application, the ADP/BA may skip it the second time it appears. This means that if the question is repeated, the ADP/BA has the option to not ask it again.

The closing script information can be received by both the Power of Attorney (POA) and the customer themselves. The authorized representative and HIPAA are not mentioned in the question as eligible recipients of the closing script information.

The LBS is required to read the intent to enroll scripting before dropping off the call when a new plan is added to the cart. This ensures that the customer is fully informed about the plan and its details before making a decision.

All aspects of an enrollment must be completed on an inbound call

The correct answer is the one that clearly states that the individual is not required to answer any health or prescription related questions, and that their answers will not affect their eligibility to enroll in a Medicare plan. This statement ensures that the call is compliant because it does not put any pressure on the individual to answer the questions and does not imply that their eligibility will be affected by their answers.

The correct answer is "Minor- The BA/ADP did not read the statement verbatim (the year was not stated)". This is because the statement mentioned the day and month but did not include the year, which is part of reading the statement verbatim.

The given statement "Humana is a better company than Health Net. You should have chosen Humana" falls under the category of recommending, advising, or urging a potential insurance customer or a current policyholder to choose one insurance carrier over another. This is considered a prohibited practice because it involves promoting one company over another, which may be misleading or unfair to the customers.

The BA does have to secure the call even if the customer calls back within 2 minutes and is routed to the same BA.

The correct answer is to check with a supervisor before scoring it down. This is because there is a discrepancy between the customer's stated first name and the name that appears on the application. To ensure accuracy and avoid making a mistake, it is important to consult a supervisor for guidance before taking any action.

The correct answer is "Minor- The ADP/BA did not obtain consent to record the call." This is because Mrs. Wayne did not provide explicit consent to record the conversation, which is a requirement. Even though Mr. Wayne said "Yes you do," it does not cover both parties and therefore the ADP/BA did not obtain proper consent.

This statement is false. Both BenefitsBA's and ADPs are allowed to skip benefits for a Plan F.

The correct answer is "Medical Expenses-Covers 100% of Part B coinsurance after you meet your yearly Part B deductible ($147.00 for 2014). You have to pay an additional copayment of up to $20 for some office visits and up to $50 for ER visits." This is the correct answer because it accurately describes the specific benefits related to medical expenses that are required to be read for a Medigap Plan N. It mentions the coverage for Part B coinsurance, the yearly deductible, and the additional copayments for office visits and ER visits.

The customer already mentioned that they had all their questions answered and found the BA to be helpful. Therefore, it can be inferred that the customer does not have any additional questions. Hence, the BA does not need to ask if the customer has additional questions before transferring to an ADP.

The ADP did not need to secure the customer's account because the question states that the ADP "secured the customer's record," indicating that the customer's information was already protected. Additionally, the ADP completed the customer's applications, suggesting that they had access to the necessary information without needing to secure the account further.

If the POA started the application and the customer completes it by giving their voice signature after the disclaimer, only line items 3-10 on the QM form should be marked down. This means that the customer provided their voice signature and completed the necessary steps from line 3 to line 10. The other options, 6-10 only, 9 only, and 53 only, do not accurately reflect the scenario described. The final option, "We would only coach this," suggests that coaching would be provided in this situation, but it does not specify which line items should be marked down on the QM form.

If the BA/ADP skips the entire second paragraph of the closing script for a MAPD, the QM score will be considered as "Minor". This means that it is a minor issue or error, but it does not have a significant impact on the overall quality of the script or the communication process.

The question asks whether the Quality Management (QM) would score this situation as a Prohibited Practice because the BA did not go over the benefits or premium. The answer is "No" because the customer already knew what plan he wanted, so there was no need for the BA to go over the benefits or premium. The QM would not consider this as a Prohibited Practice as long as the customer's needs and preferences were already known and met.

The given statement is false. According to HIPAA regulations, the customer must be on the line and give their voice signature for the disclaimer to be recorded. The HIPAA cannot listen to the disclaimer without the customer present.

The answer is No because the HIPAA (Health Insurance Portability and Accountability Act) already secures the call. Since the record was already secured by the HIPAA, the customer does not need to secure it again when they join the call. The HIPAA ensures the privacy and security of health information, so once it has been secured, there is no need for additional measures from the customer.

The answer is Major because the Business Analyst (BA) allowed someone who is not authorized to listen to the disclaimer, which is a violation of HIPAA regulations. The HIPAA rep should not have been given access to sensitive information without proper authorization. This is a serious breach of privacy and could result in significant consequences for the company.

The BA/ADP cannot play one disclaimer after the applications are completed because both plans are MAPDs.

The customer called in specifically asking to speak with a specific BA. The BA transferred the call to another agent without securing the call. This implies that the customer's request was not related to any sensitive or confidential information that would require the call to be secured. Therefore, it is true that the BA that the customer called to speak with does not need to secure the record.

The statement/question (number 10) does not need to be read/asked on every application according to HIPAA regulations.

The correct answer is that the customer, the legal guardian/conservator, and a person who holds the appropriate Power of Attorney for the customer can provide the voice signature. These individuals have the legal authority to make decisions on behalf of the customer and can therefore provide the necessary confirmation for the voice signature.

The BA/ADP did not read the phrase "including brand drugs treated as generic" in the verbiage for Catastrophic Coverage. This phrase indicates that even brand drugs that are treated as generic will have a copay of $2.55. Since the BA/ADP did not include this information in their reading, it suggests that they did not fully understand the coverage details. Therefore, the QM score number 24 should be marked as Major, indicating a significant error in understanding the information.