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
What type of Insurance plan is Blue Cross Blue Choice PPO?
Medicare Plan
Managed Care Plan
Commercial Plan
Market Place
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
What type of Insurance is Ambetter?
Medicaid
MCO
Medicare
Commercial
Market Place
What Medicare Plan Covers Erie visits?
Part A
Part B
Part C
Part D
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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