2025 Blue Shield of California Medicare Certification ExamBy Brian Platte / August 19, 2024 Which form field(s) are critical when completing an enrollment? MBI Number Whether the prospect is a resident of a nursing home or other residential facility Both Answers are correct The amount a beneficiary pays for a prescription depends on the type of drug and its applicable cost-sharing tier. True False Who can enroll into the Blue Shield TotalDual Plan (HMO D-SNP) in Los Angeles and San Diego counties? Partial dual eligibles Any person who is Medicare eligible Only full dual eligibles What is Blue Shield of California’s Mission? Blue Shield is a non-profit organization, and its mission is to give back to the communities that we serve. Our mission is to ensure all Californians have access to high-quality health care at an affordable price. Our mission is to offer affordable healthcare plans for Medicare and Medi-Cal beneficiaries. Violations of Medicare sales and marketing standards: Will result in losing their appointment with Blue Shield after 5 disciplinary actions. Are investigated and may result in disciplinary action. Are forwarded to the Blue Shield Privacy office and are investigated. Enrollment kits are available in Spanish and other languages based on county demographics. True False Blue Shield of California offers Medicare Advantage PPO plans in: Northern California in select counties Southern California in select counties Both answers are correct If the beneficiary changes their mind at an individual sales appointment about which products to discuss, it is not required to obtain a new Scope of Appointment form prior to discussing additional products. True False Contacting a beneficiary at his or her home is door-to-door solicitation unless an appointment at the beneficiary’s home at the applicable date and time was previously scheduled. True False Inflation Reduction Act caps out-of-pocket costs for Covered Insulin cost sharing: At a maximum of $35 copay per month’s supply and applies to non-LIS beneficiaries throughout the deductible and initial coverage limit At $135 copay per month’s supply throughout the deductible, initial coverage limit, and coverage gap phases At a maximum of $85 copay per month’s supply and applies to LIS (Low Income Subsidy) beneficiaries through the coverage gap phase All sales calls with beneficiaries are to be recorded in their entirety; including individual brokers and/or call centers: True False Brokers must include a disclaimer on all materials that states:“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.” unless the third-party marketing organization (TPMO) truly offers every option in a given service area in which it would not be required. True False Appeals and Grievances are the two different types of complaints a beneficiary can make. True False Appeal or request for reconsideration, Independent Review Entity, Administrative Law Judge Hearing, Medicare Appeals Council Review, and Judicial Review are the five levels of appeals: True False Beneficiaries with Blue Shield’s Medicare Advantage HMO and HMO D-SNP (Dual Eligible Special Needs Plans) plans may self-refer to a network provider, without a referral or approval in advance, for Emergency services from network providers or from out-of-network providers. True False Which of the following is NOT an example of when a beneficiary may file an appeal? The Plan is stopping coverage of a service or benefit, and the beneficiary believes it is too soon to do so. The Plan has miscalculated the beneficiary’s True Out of Pocket amount. The beneficiary’s inquiry was not resolved during the first call. Blue Shield TotalDual Plan (HMO D-SNP) in Orange and San Bernardino counties and Blue Shield Inspire (HMO D-SNP) in Merced, Stanislaus, and San Joaquin counties are: Closed for all enrollments and current members are transferred to the Blue Shield 65 Plus (HMO) Closed for new enrollment due to DHCS requirements Open for new dual eligible enrollments Some of the most common issues that are noted during secret shopper assessments include: The agent offered snacks at the event (e.g. muffins, cookies, and coffee). The agent did not explain where to find information on covered prescription drugs and/or explain the prior authorization process (e.g., Step Therapy). The agent did not provide a Scope of Appointment prior to the marketing event. What sets Blue Shield of California apart from other healthcare plans? Blue Shield has the largest provider network in the state of California. We are the only healthcare insurer that offers Medicare products in all California counties. We are proud to be part of a non-profit company that has served Californians for over 80 years. At Blue Shield of California, we are constantly innovating to transform our healthcare system so all Californians can access the personalized affordable, and high-quality care they deserve. The Inflation Reduction Act (IRA) introduced several provisions to help lower the cost of prescription drugs for Medicare members. For 2025, the IRA: Caps out-of-pocket costs for high blood pressure medication to $35 copay Eliminates the coverage gap (donut hole) phase Reduces the annual out-of-pocket (OOP) threshold to $5000 Blue Shield TotalDual Plan (HMO D-SNP) is offered in: Northern California in select counties Southern California in select counties Throughout the entire state of California Which product does Blue Shield offer specifically for Dual Eligibles in 2025? Dual Special Needs Plans (D-SNPs) PACE SNP Look-Alike At an educational event: Agents must outline the materials they will present 24 hours before the educational event. Any sign-in sheets must clearly indicate that completion of any contact information is optional. Agents may provide a full meal (i.e. dinner or lunch) that does not exceed $25 per person. Selling Medicare products for Blue Shield of California, a broker: Must be appointed with Blue Shield of California or endorsed by an Agency appointed with Blue Shield of California. It is not required to maintain a current state license if working under an FMO as an endorsed agent. It is not required to be free or clear from any sanctions which would prevent them from participating in a federal program. A Sales Agent may correct anything on a signed enrollment form prior to submission to the Plan by initialing next to the change, EXCEPT for: The applicant's desired method of payment The applicant's date of signature The applicant's Medicare number Effective January 1, 2025, the following changes were made to dual eligible enrollment options in the state of California: Enrolling in a MA (Medicare Advantage) or D-SNP in select counties will trigger automatic matching Medi-Cal enrollment. Dual eligible beneficiaries can elect to enroll in a non-SNP MA plan during AEP only. Both answers are correct. Non-Medicare covered vision benefits are: Included with Blue Shield Medicare Advantage Plans (MAPD) Included with all Blue Shield Medicare Advantage Plans (MAPD) & Medicare Prescription Drug Plans (PDP) Available as additional plan buy-up options only Sales Agents/ Brokers must be trained and tested on Medicare rules, regulations, and on details specific to the plan products that they sell: Annually Every 5 years At the time of their appointment to Blue Shield of California only Blue Shield Medicare Advantage Plans and standalone Blue Shield Prescription Drug Plans (PDP) will generally cover the drugs listed in the formulary as long as: The drug is prescribed by an individual that is NOT on the Centers for Medicare and Medicaid Services (CMS) preclusion list. The prescription is filled at any California pharmacy. The drug is a generic brand and listed as Tier 6 on the formulary. The benefits of a Dual Special Needs Plan (DSNP) are: Beneficiaries get better care coordination Beneficiaries get a care plan Both answers are correct Non-Medicare covered transportation are: Available as additional plan buy-up options Included with all Blue Shield Medicare Advantage Plans (MAPD) & Medicare Prescription Drug Plans (PDP) Included with select Blue Shield Medicare Advantage Plans (MAPD) Blue Shield of California’s value proposition includes: Our 2% pledge to limit our annual net income to 2 percent of revenue and we will return the difference to our customers and the community, with approval by the Board of Directors. Offering the highest paid commissions for brokers and agents that sell our products. Ensuring a return on investment to our shareholders by ensuring at least a 2% profit on each of our plans that we offer. Blue Shield of California Medicare Advantage and Medicare Prescription Drug Plan members can use Amazon Pharmacy to fill their prescriptions. True False Blue Shield transportation services (non-Medicare covered) are offered: In Blue Shield Medicare Dual Special Needs Plans (DSNP) only In select Blue Shield Medicare Advantage Plans (MAPD) In all Blue Shield Medicare Advantage Plans (MAPD) and Medicare Prescription Drug Plans (PDP) If a member changes their Primary Care Physician for any reason by the 15th of the month, the change becomes effective on the 1st of the following month. True False ResultsVote
