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Aetna Cert
| Term | Definition |
|---|---|
| Core Values | Be local, improve health, make it simple, attract and inspire, optimize performance, lead the change |
| Medicare Compliance Program | Affects members, program, + trust fund - fighting WFA through Prevent, Detect, Correct - |
| Code of Conduct (general) | Must comply with CVS Health Code of Conduct and Aetna Annual Certification (integrity) |
| Heart of Integrity (protect the company reputation, medicare program, medicare members) | Honest and Lawful Behavior, Ethical Business Practices and Compliance (laws, regulations, standards) |
| Conflicts of Interest | ones interest is taken over the interest of their employer, must eliminate or get manager approval, report immediately, CVS Health Conflict of Interest Line (non-compliance hotline) |
| Confidential Member Information (HIPAA) | decrease chance of misuse of personal data, must protect PII and PHI (PII - personally identifiable information + PHI - Protected Health Information) |
| Code of Conduct (responsibilities) | Gifts/Entertainment (involving government employees) - no payments, no gifts or anything value can be offered Record Retention - all related records must be retained for 10 years Fair Competition and Fair Dealing - honesty, accuracy, protect PII/PHI |
| Take Compliance Seriously | Employees, Producers, Managers, Vendors must comply equally with federal/state laws, regulations, requirements through a comprehensive plan to combat FWA |
| Compliance Concerns | report: ethics line (phone/web), medicare compliance (email) |
| Reporting an Issue | welcomed and encouraged - you will be protected if you make complain/report, collaborate with investigation, provide info about breach of law/policy |
| Non-Compliance Consequences | re-training, disciplinary action, termination, compensation forfeiture |
| Producer Guide | contains everything needed to do business with Aetna (can get on producers world) *sections in guide include broker services, ready to sell, compensation, compliance, marketing materials, enrollment, etc |
| Producer Cert Guidelines | "2019/2020 Individual Medicare Products" says on front |
| Producers who Contract to Market | make sure you know code of conduct and producer guide |
| Cert Testing | will be tested on both code of conduct and producer guide |
| Ready to Sell Requirments | pass aetna cert, have active contract, receive RTS notice, attend training (www.aetnamedicareagenttraining.com) |
| Using the Producer Cert | read producers guidelines, need at least 90%, open note |
| 2021 SILVERSCRIPT RX PLAN REVIEW (CVS acquired Aetna on November 28, 2018) | 2021 SILVERSCRIPT RX PLAN REVIEW CVS acquired Aetna on November 28, 2018) |
| What is the SilverScript Rx plan? | sponsored by Etna - largest national Rx plan - contracts with medicare - all 50 states and DC - benes get peace of mind, expertise, consistency |
| What are the key differentiators of the SilverScript Rx plan? | highest star rated, nationally available PDP plan in US (4/5) - enhanced MTM program - award winning enrollment platform |
| What is the enrollment process for SilverScript Rx plan? | Speak with client - get eSOA - fill/sign eApp - submit to client - client confirms/signs eApp - complete |
| Enrollment guidance for SilverScript Rx plan? | can follow up once complete, processing starts immediately, agent can access copies online after submit - can enroll during IEP, AEP, SEPs - paper (still needs to be entered in the sales portal!) or eapp |
| Disenrollment guidance for SilverScript Rx plan? | voluntary/involuntary - when changing, the old plan is considered voluntary disenrolled |
| Additional product-specific compliance information SilverScript Rx plan? | out-of-network excuses: traveling, ran out/ill, timely, outpatient/inpatient, not stocked - flu shots always covered under part B |
| Memory Check: some Rx is covered under Part B or Part D - pharmacists typically select which one pays - what is covered by Part B in relation to this topic? | B - diabetic (blood sugar/glucose test strips and related devices) |
| Can a bene using SilverScript use a third party online pharmacy? | No - the only one covered under the plan is CVS/SilverScript |
| What can the agent portal do? (agent support line: 866-714-9301) | Enrollment portal can show enrollment status/reports, kit orders/tracking, SilverMail (secure mail room), email notifications, pharmacy locator, Rx pricing, enrollment tool, downloadable reference materials + user guide |
| What is important to know about the Rx pricing tool in the portal? | Provide cost estimates, estimated budget, drug price details, report printing, data analysis, medicine cabinet (must provide disclaimer script) |
| Avoiding complaints (ex. Annual Cost Estimate) | verify drug name, verify dosage and how many days the script is for, communicate quantity limits, check Rx price changes (coinsurance=%) |
| What is the SOA process if we are using an online portal? | Term: eSOA - see the process guidelines - essentially same as SOA, but with e signatures from both the bene and agent *valid for 14 days + not automatically sent to enrollment |
| Memory Check: who is eligible for a medicare PDP? | 1) entitled to A and/or enrolled in B (MA pffs does not offer D) 2) current part D enrollee (only 1 at a time tho!) 3) perm res in service area 4) us citizen/lawfully present in US |
| How are premiums billed/payed? | if ACH, draft between 8th and 10th of month - if deducted from other benefit, member pays until confirm received (Aetna sends bill if rejected) - can also pay with CC (option on monthly invoice) |
| If a bene income above specified amount, bene responsible for larger portion of total cost of Part D benefit coverage, what is that called and who gets paid? | in addition, those benes need to pay Part D IRMAA - which is paid directly to medicare |
| Premium payment reports show (3)? | current unpaid premium balance, LIS/LEP (if any), and billing method for account |
| Exceptions to the non discrimination requirements? What specifically is prohibited? | benes with certain diagnoses (chronic illnesses is example), enrollment is LIS prohibited: targeting higher income area, implying plans only available to seniors |
| What are the three SNPs? | CSNP (diabetes, chronic heart failure, cardiovascular disorders), DSNP (entitled to Medicare and Medicaid), ISNP (90+ days have had/expected to need higher level of services from skilled nursing, LTC, and other inpatient scenarios) |
| Characteristics of DSNPs (other than obvious) | live in service area, meet qualifications (tailored benefits, providers, Rx prices) - Medicaid determines eligibility + cost-sharing |
| What are the yearly limits for LIS? | individuals: $19,140 income/$14610 resources) married: $25,860/#29,160 (except DC, Alaska, Hawaii) |
| Difference between full and partial subsidies for LIS | full - premium paid in full aka "100% LIS eligible" partial - adj premium based on sliding scale |
| LIS $s | formulary: 15% - out of pocket $6,550 - $3.70/9.20 Rx - no coverage gap or late fees |
| MSP (medicare savings program) key points | medicaid (4 basic categories + 3 additional) has costs (premiums, deductibles, copayments + coinsurance) |
| Full vs Partial "Duel Eligibles" | full - medicare eligible, meet MSP req, meet state medicaid req partial - medicare eligible, meet MSP req |
| MSP categories | QMB (partial), QMB plus (full), SLMB only (partial), SLMB Plus (full), QI (partial), QDWI (partial), + FBDE (full) |
| Selling DSNP | SEP (Jan - Sep) enroll/disenroll once per quarter and AEP (Oct-Dec) |
| DSNP advantages | coordination of services, model of care (improve quality, increase access...), care team (member + care manager) |
Created by:
cmazzariti
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