Predictika · Aetna-style Medicare Advantage enrollment quotes
An AI sales agent prepares an enrollment quote for an Aetna-style Medicare Advantage plan, in US dollars per month. Before it goes out, the agent sends it to Predictika, which checks it against a declarative model of the election-period, eligibility, drug-coverage, plan-limit and pricing rules, compares the monthly cost the quote states with the computed one, and returns every finding together with the line-item member cost. This is an illustrative model built from public Medicare rules with fictional premiums; it is not Aetna's internal rule set.
This validator checks a Medicare Advantage enrollment quote of the kind Aetna sells: eight plans across Philadelphia, Bucks, Harris, Broward and Franklin counties, including special needs plans, an MA-only giveback plan and a draft plan for next year. It handles any enrollment built from these plans and counties, not only the scenarios shown on this page. It does not cover Medigap, employer group plans, claims, clinical eligibility or other insurers' plans.
8 scenarios in 4 groups · each group runs from the agent’s first attempt to the outcome · click one to switch
Illustrative agent statement. The validator receives the structured request below.
Proposing agent: AI sales agent (scripted)
Before sending, the agent must call Recorded run
What this means
Our assessment of what a typical rules-based CPQ (product rules, price rules and validation rules, as in Salesforce CPQ) does with the same cases. It is a judgment about effort and reliability, not a claim that nothing can be built.
| What the validator caught | Typical rules-based CPQ | Predictika |
|---|---|---|
| Which election period allows an enrollment, given current coverage | Only with workarounds Whether a member can join depends on the election period (initial, annual, MA open enrollment, special periods), current coverage, whether the one MA open enrollment change has been used, and whether a move, Medicaid or a 5-star plan is on file. A picklist cannot hold that decision table; it ends up in custom code. | Every election-period rule is evaluated on every call, and the finding says which one blocks the enrollment. |
| Special needs plans: dual status and condition match | Only with care Each plan type has its own eligibility test (full Medicaid or QMB for a dual-eligible plan, a named chronic condition for a chronic-care plan). They can be written as eligibility rules, but they multiply with every plan and have to stay in step with the member data. | Plan type, Medicaid level and condition are checked together on every call. |
| Standalone drug plan pairing | Only with workarounds A standalone Part D plan is not allowed with a plan that already includes drug coverage, and with a plan without drug coverage only if it is a PPO or private fee-for-service plan, not an HMO. This depends on the plan type and its drug coverage together. | The pairing rule reads the plan attributes, so the same member passes with an MA-only PPO and is blocked with an HMO or a plan that includes drug coverage. |
| Extra Help credit, Part B giveback and Medicaid-paid Part B arithmetic | Only with care The credit is capped by the Part D portion, the benchmark and the premium; the giveback and Medicaid payment change the Part B line. These are calculations across lines that a price book handles only with scripting. | The member cost is computed on every call and shown as line items, deductions included, that add up to the total. |
| Stated monthly cost that must match the computed one | Only with workarounds A validation rule can compare a stated figure with a calculated one only if the stated figure is a field on the quote, which it rarely is. | The monthly cost the agent states travels with the quote and is compared with the computed cost on every call; a difference blocks the quote. |
Every rule is checked on every call, in any order the choices arrive; one problem never hides another. Blocking findings stop the quote; approval findings need a person to sign off; everything else is computed.
| 1 | Aetna Medicare Assure Plan HMO D-SNP is a dual-eligible special needs plan and needs full Medicaid or QMB; Medicaid status is SLMB. |
| 2 | Aetna Medicare Choice PPO 2027 draft filing has an in-network MOOP of $9800, above the CMS mandatory limit of $9250; the plan cannot be sold. |
| 3 | Aetna Medicare Chronic Care Diabetes HMO C-SNP is a chronic-condition SNP for Diabetes; the applicant condition is CHF. |
| 4 | Aetna Medicare Eagle Giveback PPO MA-only has no Part D and no other creditable drug coverage is on file; the member must acknowledge the Part D late enrollment penalty. |
| 5 | Aetna Medicare Eagle Plan PPO is not offered in Harris County TX; the member must live in the plan service area. |
| 6 | Aetna Medicare Value Plan HMO already includes Part D; joining a standalone PDP would disenroll the member from the MA plan. |
| 7 | Aetna Medicare Value Plus HMO MA-only is an HMO without drug coverage; a standalone PDP can be paired only with an MA-only PPO or PFFS plan. |
| 8 | Medicare Advantage requires both Part A and Part B (Part A True, Part B False). |
| 9 | Only one change is allowed in the MA open enrollment period and it has already been used this year. |
| 10 | Stated monthly cost does not match: the agent stated $214.90 per month; the validator computes $226.90 per month. |
| 11 | The 5-star special enrollment period can only be used to join a 5-star plan; Aetna Medicare Choice PPO 2027 draft filing is not rated 5 stars. |
| 12 | The Jan 1 - Mar 31 MA open enrollment period is only for people already in a Medicare Advantage plan; current coverage is OriginalMedicare. |
| 13 | The dual or Extra Help special enrollment period requires Medicaid or a Medicare Savings Program. |
| 14 | The initial enrollment period runs 3 months before to 3 months after the Part B start month; this is month 4. |
| 15 | The optional supplemental dental rider is not offered on Aetna Medicare Eagle Giveback PPO MA-only. |
| 16 | The scope of appointment was signed 24 hours before the sales meeting, under the 48 hour rule; compliance must review (walk-in or beneficiary-initiated exception). |
| 17 | The special enrollment period for a move requires a permanent move out of the old service area. |
The recorded result of the validator for each scenario on this page: the request the AI agent sent, the verdict, and every finding, in the order they appear above.
The agent's request. Enrollment quote for a member in Philadelphia County, PA who is on Original Medicare: Aetna Medicare Eagle Plan PPO with the dental rider, enrolling during the Jan 1 - Mar 31 MA open enrollment period. Member cost $265.90 per month. It is ready to send.
Verdict: Blocked.
The agent's request. Enrollment quote for a member in Philadelphia County, PA who is on Original Medicare: Aetna Medicare Eagle Plan PPO with the dental rider, enrolling during the annual enrollment period. Member cost $265.90 per month. It is ready to send.
Verdict: Allowed.
The agent's request. Enrollment quote for a member in Philadelphia County, PA on Original Medicare with Extra Help: Aetna Medicare Value Plan HMO plus a standalone Part D plan, annual enrollment period. Member cost $202.90 per month. It is ready to send.
Verdict: Blocked.
The agent's request. Enrollment quote for a member in Philadelphia County, PA on Original Medicare with Extra Help: Aetna Medicare Eagle Giveback PPO MA-only plus a standalone Part D plan, annual enrollment period. Member cost $77.90 per month. It is ready to send.
Verdict: Allowed.
The agent's request. Enrollment quote for a member in Franklin County, OH who has a Medicare Advantage plan today: Aetna Medicare Elite Plan HMO with the dental rider and Extra Help, using the 5-star special enrollment period. The scope of appointment was signed 24 hours before the sales meeting. Member cost $226.90 per month. It is ready to send.
Verdict: Needs approval.
The agent's request. Enrollment quote for a member in Franklin County, OH who has a Medicare Advantage plan today: Aetna Medicare Elite Plan HMO with the dental rider and Extra Help, using the 5-star special enrollment period. The scope of appointment was signed 48 hours before the sales meeting. Member cost $226.90 per month. It is ready to send.
Verdict: Allowed.
The agent's request. Enrollment quote for a member in Broward County, FL on Original Medicare with diabetes: Aetna Medicare Chronic Care Diabetes HMO C-SNP with the dental rider, annual enrollment period. Member cost $214.90 per month. It is ready to send.
Verdict: Blocked.
The agent's request. Enrollment quote for a member in Broward County, FL on Original Medicare with diabetes: Aetna Medicare Chronic Care Diabetes HMO C-SNP with the dental rider, annual enrollment period. Member cost $226.90 per month. It is ready to send.
Verdict: Allowed.
The text of the narrated walkthrough, step by step.