Commercial Insurance 101

1. What is MarketPlace Insurance?

A type of Medicaid Plan

A Market where people can purchase affordable health insurance based on their Income during open enrollment periods.

A type of Managed Care Plan

An HMO Plan Erie does not accept

Use Info Connect: A Waukegan patient of Dr Beth Dunlap now has Aetna PPO Insurance. You have verified in Availity that the insurance is in network. Which of the following statements is true?

This patient can continue seeing any provider at Erie without additional out of network costs

This patient can continue seeing Dr Dunlap without additional out of network costs

If this patient is sick, she will need to wait for Dr Dunlap’s next available visit. She cannot see anyone else.

Doesn’t matter, Erie only accepts Blue Cross Blue Shield PPO for commercial Insurance

A New Patient with Healthlink is calling to schedule an appointment. You are unable to verify this in Availity. What is an acceptable way to handle this call?

Inform the patient we don’t accept that insurance

Email Patient Benefits the patient’s information in order to have coverage verified

Schedule the patient at their own risk

Enter a help desk ticket to have HealthLink added to Availity

What do the following plans have in common? Blue Cross Blue Shield PPO, Ambetter, Blue Cross Blue Choice, Medicare Part A.

They are all Medicaid Plans

They are all FHP Plans

They are all MCO Plans

They are all Non-MCO plans

Who is eligible for MMAI Managed Care plans?

Children under 19 years of age

Expectant Mothers

Persons with disabilities that have Medicaid but not Medicaid

Seniors and persons with disabilities that have Medicaid and Medicare

What MCO plans does Prentice Northwestern Memorial Hospital accept for pregnant women?

All FHP Managed Care plans

Blue Cross Community FHP and Aetna Better Health FHP

County Care FHP and Aetna Better Health FHP

County Care ICP and Aetna Better Health ICP

True or False: A new patient with Blue Cross Community ICP with Dr Lee Francis listed as PCP is calling to schedule a sick. This patient is considered Non-MCO because Dr Francis is closed to new patients.

True

False

A female patient who is currently pregnant needs to enroll in a Managed Care Plan. What type of plans will she be offered under Medicaid?

Integrated Care Programs

Medicare-Medicaid Alignment Initiative plans

Family Health Program

None

Please select the TRUE statement below

Insurance is not covered with any provider. Do not schedule patient

Insurance is Out of Network. Patient is responsible for Out of Network Fees

Coverage cannot be determined and an email should be sent to Patient Benefits

Advise the patient to contact their insurance for exact Out of Network Prices

When reading Out of Network results on Availity, what disclaimer should you give patients?

Your insurance only covers 40% of your visit which means that you only need to pay $60 to see your provider

Your Out of Network co-payment may not cover other services such as labs, referrals or vaccines. Please contact your insurance for more coverage information

Your insurance only has Out of Network services, this means Erie cannot provide you services

What is ICP?

Insurance for Natives of Alaska enrolled in Medicare

Integrated Care Program – for Adults with disabilities receiving Medicaid but not Medicare

Kid Care

Initiative Care Program – For Mom’s and babies

An established WT women’s health patient of CNM Jennifer Baxter no longer has Aetna Better Health FHP, instead she now has Cigna. Patient doesn’t want to pay out of Network fees or switch from WT to another clinic. What would be the best option for her?

There is no other option, she will need to pay out of network fees to see the midwife

There is no other option, she will need to be transitioned out of Erie

Send PBA’s a flag to have the patient switched to an IM provider, even though they are closed to new patients

Send PBA’s a flag to have the patient switched to an OB-GYN since the Midwifes do not accept Cigna

A new patient with Blue Cross Community FHP is looking to schedule an appointment with Erie. You are unable to verify the PCP through Availity or Passport. What can you do?

Do not schedule

Schedule the appointment but mark Insurance eligibility as “not Verified”. In Insurance note section add: not able to confirm PCP

Advise the patient that they have a plan we do not accept therefore we cannot check the PCP

Send an email to Patient Benefits

True or False: Insurance must be verified during each call?

True

False

Neither. Verification team checks insurance every night before going home

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