Agent Enrollment – CCA Health MI

Agent Enrollment – CCA Health MI

  • 2. Enrollment Consent

    Can you please confirm that the purpose of your telephone call today is to enroll in a Medicare Advantage prescription drug plan and you are the enrollee or an authorized representative for the enrollee?

  • 3. Enrollee and Plan Information

    Please read the <Medicare Claim / Medicare Beneficiary Identification> number that appears on the card, including any letters.

    (Enter claim number without hyphens or spaces. Read back the name and the Medicare claim number. Make corrections as requested by the caller. Confirm with caller that changes made are correct.)

    Do you have Hospital (Part A) insurance listed on the Medicare card?

  • 4. No Permission

    I am unable to take your enrollment over the phone without your permission. You may choose to enroll online or by mail.

    Is there anything else I can help you with today?

  • 5. Enrollment Closing

    Thank you for calling CCA Health MI Medicare Advantage Have a good day.

  • 6. Sales Script

    Please be aware we can only enroll one person at a time.

    Plan representatives, sales agents or brokers may not be physically present with the beneficiary or present on the phone at the time of the request.

    Do you have any questions before we start the enrollment?

  • 7. Respond Accordingly

  • 8. Part A effective date

    What is the effective date of your Part A insurance?

  • 9. Medical (Part B)

    Do you have Medical (Part B) listed on the Medicare card?

  • 10. Part B effective date

    What is the effective date of your Part B insurance?

  • 12. No Part A and or B

    (If they do not have either Medicare Part A or Part B coverage, they may not be eligible for the plan. Read the following to the caller)

    To be eligible for the CCA Health MI Medicare Advantage , you must be enrolled in to Medicare Part A and Medicare Part B. We can continue to complete the enrollment form but you should be aware that if you do not meet these requirements, Medicare may not approve the enrollment.

    Do you want to continue?

  • 14. Choose Plan

    We offer three plan options: Principle MAPD, Cardinal MAPD and Dual Care Plus.

  • 15. Enrollee Information

    Permanent Residence Address

    Do you prefer that we send you information in a language other than English or an accessible format?

  • 16. Confirm Address

    (Read the caller’s permanent address to confirm it is correct. Make sure it is a residential address, not a Post Office Box. Enter second address if necessary. Correct information as needed.)

    I have your stated address as:

    Do you use a mailing address that is different than your physical address?

  • 17. Second Address

  • 18. End Enrollee Information

    Thank you. This completes the personal information section. Now let’s move on to the CCA Health MI MAPD plan you’ve selected.

  • 19. Enrollment Details

    (Callers must identify one of the following enrollment periods in order to enroll in the plan. If they cannot, you cannot enroll them by phone. If the caller has said why they’re calling – because of AEP, IEP or SEP – go directly to that item in the list below and check it. If the caller did not identify the reason for the call yet, probe to determine if the caller is new to Medicare or calling during the AEP to switch plans. Once the caller has answered one of the questions, skip the rest and proceed to the end of this section. Also skip the question(s) if the call is outside the time period noted and move immediately to the next question.) Typically, you may enroll in a Medicare Advantage Plan only during the annual enrollment period from October 15 through December 7 each year. There are exceptions that may allow you to enroll in a Medicare Prescription Drug Plan outside of the annual enrollment period. I am going to read you some statements and you can tell me which statement best applies to your situation. By selecting a statement, you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. A choice of effective dates is only allowed in certain enrollment situations. In all other cases, or if you do not specify an effective date, your effective date will be the first of the month after your form is received by the plan. (Some of the enrollment periods ask for a requested effective date. Callers are not required to select an effective date. If a date is selected, it does not have to match the move date or coverage ending date entered earlier. The requested effective date cannot be guaranteed and may change once coverage is approved.)

    If none of these statements applies to you or you’re not sure, please contact CCA Health MI Medicare Advantage at 1-855-959-5855 to see if you are eligible to enroll. We are open 8 a.m. to 8 p.m., daily, local time. TTY users should call <711>.

  • 20. Other Information

  • 21. Primary Care Physician

    Please chose the name of your Primary Care Physician (PCP)

  • 22. Emergency Contact

    Emergency Contact

  • 23. Payment Options

    You can pay your monthly plan premium, (including any late enrollment penalty you may owe), each month by mail (receive a paper bill), Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

    What is your preferred payment method? Your options are: Paper bill, electron funds transfer, automatic deduction from your socials security benefit check or automatic deduction from your Railroad Retirement Board benefit check.

    If enrolling in a health plan with a $0 monthly premium: If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it.

    Would you like to hear more about these options?

  • 52. Payment Option Details

    Paper Bill Electronic Funds Transfer (EFT) From Your Bank Account: It may take up to two months to process your request. Please pay your premiums billed to you on paper until your EFT is active. Any unpaid premiums due when EFT takes effect will be deducted at that time to bring your account up-to-date. Automatic deduction from your Social Security benefit check: You may also choose automatic deduction from your Social Security or RRB checks after you are enrolled. If Social Security/RRB does not approve your automatic deduction request, we will send you paper bills for your monthly premiums and resubmit your request. Once approved, it can take two or more months for the deduction to begin. During this time, you will receive paper bills and be responsible for paying your premium directly to the plan until the deduction begins. If you do not pay your premium for the months before the deduction takes effect, you may be disenrolled from the plan. Neither Social Security nor RRB allow retroactive withholding requests.

    Automatic deduction from your Railroad Retirement Board (RRB) benefit check: You may also choose automatic deduction from your Social Security or RRB checks after you are enrolled. If Social Security/RRB does not approve your automatic deduction request, we will send you paper bills for your monthly premiums and resubmit your request. Once approved, it can take two or more months for the deduction to begin. During this time, you will receive paper bills and be responsible for paying your premium directly to the plan until the deduction begins. If you do not pay your premium for the months before the deduction takes effect, you may be disenrolled from the plan. Neither Social Security nor RRB allow retroactive withholding requests. If you are assessed a Part D-Income Related Monthly Adjustment Amount (IRMAA), the Social Security Administration will notify you. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security or RRB check or be billed directly by Medicare. Do NOT pay the Part DIRMAA.

  • 53. Select Payment Method

  • 54. Payment Note: Limited Income Options:

    People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75 percent or more of your drug costs including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213, 7 a.m. to 7 p.m. ET, Monday - Friday. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug cost, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn't cover. If you don't select a payment option, you will receive a bill each month.

    For EFT election at a later time, contact Customer Service at 1-855-959-5855 8 a.m. to 8 p.m., daily, local time, TTY hearing impaired users call 711. Sign and date the form and send it along with a voided check or savings deposit slip to the plan.

  • 55. Electronic Funds Transfer (EFT) From Your Bank Account

    It may take up to two months to process your request. Please pay your premiums billed to you on paper until your EFT is active. Any unpaid premiums due when EFT takes effect will be deducted at that time to bring your account up-to-date.

  • 56. Automatic deduction from your Social Security benefit check

    You may also choose automatic deduction from your Social Security or RRB checks after you are enrolled. If Social Security/RRB does not approve your automatic deduction request, we will send you paper bills for your monthly premiums and resubmit your request. Once approved, it can take two or more months for the deduction to begin. During this time, you will receive paper bills and be responsible for paying your premium directly to the plan until the deduction begins. If you do not pay your premium for the months before the deduction takes effect, you may be disenrolled from the plan. Neither Social Security nor RRB allow retroactive withholding requests.

  • 57. Automatic deduction from your Railroad Retirement Board (RRB) benefit check

    You may also choose automatic deduction from your Social Security or RRB checks after you are enrolled. If Social Security/RRB does not approve your automatic deduction request, we will send you paper bills for your monthly premiums and resubmit your request. Once approved, it can take two or more months for the deduction to begin. During this time, you will receive paper bills and be responsible for paying your premium directly to the plan until the deduction begins. If you do not pay your premium for the months before the deduction takes effect, you may be disenrolled from the plan. Neither Social Security nor RRB allow retroactive withholding requests. If you are assessed a Part D-Income Related Monthly Adjustment Amount (IRMAA), the Social Security Administration will notify you. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security or RRB check or be billed directly by Medicare. Do NOT pay <MII Product> the Part DIRMAA.

  • 58. Coordinate Benefits

    (Answers to several questions must be provided on the enrollment form. If the caller has already answered the question, for example, “Do you reside in a longterm care facility?” complete the enrollment form rather than asking the question again.)

    Some individuals may have other drug coverage, including other private insurance (such as through a Medicare supplement plan or an employer or union), TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

    Will you have other prescription drug coverage in addition to CCA Health MI Medicare Advanatage Plan?

  • 59. Will you have other prescription drug coverage?

    (If the answer is “Yes,” use the paragraph below to explain to the caller that if the coverage is from an employer or union, joining CCA Health MI Medicare Advantage may change how their current coverage works. Joining CCA Health MI Medicare Advantage may also disenroll them from their current coverage and they may not be able to get it back once they change to CCA Health MI Medicare Advantage. If they have questions about this, they should check with whoever answers benefit questions for their former employer or union.)

    If you are currently a member of a Medicare Advantage plan, joining CCA Health MI Medicare Advantage, will automatically disenroll you from your existing prescription drug plan or Medicare Advantage Prescription Drug plan. This could affect your doctor and hospital coverage as well as your prescription drug benefits. Also, if you have health coverage from an employer or union, joining CCA Health MI Medicare Advantage may change how your current coverage works. You could lose your employer or union health coverage if you join. CCA Health MI Medicare Advantage You should contact your current Medicare Advantage plan or whoever answers questions about your current plan if it’s from an employer or union and confirm whether you have a prescription drug benefit before you enroll in CCA Health MI Medicare Advantage.

  • 60. Enrollment Authorization

    1. I am going to read the Terms of the Enrollment Authorization to you.I understand CCA Health MI Medicare Advantage is a Medicare Advantage Prescription drug plan and has a contract with the Federal government. Coverage is available to residents of the service area.

    2. I understand that I will need to keep my Medicare Parts A and B.

    3. I understand that I can only be in one Medicare Advantage plan at a time, and I understand that my enrollment in the plan will automatically end it my enrollment in another Medicare health plan or prescription plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future.

    4. I understand that if I don’t have medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future.

    5. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15-December 7) unless I qualify for certain special circumstances.

    6. I understand CCA Health MI Medicare Advantage serves a specific service area. If I move out of the area that CCA Health MI Medicare Advantage serves, I need to notify the plan, so I can disenroll and find a new plan in my new area. I understand that once I am a member of CCA Health MI Medicare Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from CCA Health MI Medicare Advantage when I get it to know which rules I must follow to get coverage.

    7. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

    8. I understand that beginning on the date the coverage begins , I must get all my health care from CCA Health MI Medicare Advantage, except for emergency or urgently needed services or out-of-the area dialysis services. Services authorized by CCA Health MI Medicare Advantage and other services contained in my CCA Health MI Medicare Advantage Evidence document (also known as a member contract or subscriber agreement) will be covered. Without authorization, Neither Medicare nor CCA Health MI Medicare Advantage will pay for the services.

    9. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with CCA Health MI Medicare Advantage, he/she may be paid based on my enrollment in CCA Health MI Medicare Advantage.

    10. Release of Information: By joining this Medicare health plan, I acknowledge that CCA Health MI Medicare Advantage will release my information to Medicare and other plans as necessary for treatment, payment and health care operations, and as otherwise permitted by law. I also acknowledge that CCA Health MI medicare Advantage will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes that follow all applicable Federal statutes and regulations.

    Do you understand the Enrollment Authorization terms I have read?

  • 61. Explain Again: Enrollment Authorization

    Do you wish to hear the Enrollment Authorization terms again?

  • 62. Agree with Terms

    Do you agree with the terms as described in this Enrollment Authorization?

  • 63. Voice Enrollment Authorization

    I understand that my name on this application means that I have read and understand the contents of this application, including the Enrollment Authorization information you read to me.

    If this is submitted by an individual who is the Authorized Representative of the enrollee and authorized to act on his/her behalf under the laws of the State where the enrollee lives, this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by Medicare.

    The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provided false information on this form, I will be disenrolled from the plan.

    Do I have your permission to electronically sign your application?

  • 64. Voice Enrollment Recording

    Please state your first name, last name and today’s date for the recording

    I certify that I am the Writing agent for this application:

  • 65. Review Information

    I will now read to you the information as it appears on your application:

    The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

    Do I have your permission to submit the application?

  • 66. Permission to Submit Denied

    I am unable to take your enrollment over the phone without your permission.

    Is there anything else I can help you with today?

  • 67. Further Help

    (respond accordingly)

  • 68. Confirmation and Customer Service Numbers

    Congratulations, you have completed the online enrollment for CCA Health MI Medicare Advantage.

    Your confirmation number is

    Your confirmation number is Please wait...

    Here’s what to expect next.

    1. Your application will be submitted to Medicare

    2. An acknowledgement letter will be mailed within 10 calendar days of application submission. This document states we received your Application.

    3. If you worked with an Agent, a verification letter is mailed within 15 calendar days of application submission. This letter will have information about CCA Health MI Medicare Advantage and your enrollment.

    4. A confirmation letter is mailed within 10 days of when Medicare approves your enrollment.

    5. An ID card will be mailed to you after Medicare confirms your enrollment into CCA Health MI Medicare Advantage

    6. You will receive a CCA Health MI Medicare Advantage new member Welcome Kit

    Please note that benefits, formulary, pharmacy, network, premium and/or copays/coinsurance may change annually. You will be notified of any changes in the Annual Notice of Changes which you’ll receive by September 30.

    If you have any questions or concerns about CCA Health MI Medicare Advantage, please contact Customer Service toll-free at 1-855-959-5855. The TTY/TDD telephone number is 711. We’re open 8 a.m. to 8 p.m., daily, local time, from October 1 through March 31, and Monday through Friday, same hours, the rest of the year.

  • 71. Reason for special enrollment

  • 72. Other language

Last updated: 3 August, 2022 1:15 am

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