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Aetna Cert

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 (
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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