Transcript Medicare Part D and New Options and Requirements for

Marketing
Medicare Part D Plans
Presented by
America’s Health Insurance Plans (AHIP)
and
The National Association of Health Underwriters (NAHU)
Medicare Part D Plans
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Part D plans include
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Prescription Drug Plans (PDPs),
Medicare Advantage – Prescription Drug (MAPD) plans,
Cost Plans that offer Part D prescription drug
coverage, and
Program of All-Inclusive Care for the Elderly
(PACE) plans.
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Providing Information to Make a Medicare
Health Plan Choice
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Ensuring Medicare beneficiaries have information
they need to make informed choices among the
coverage options available under the Medicare
Prescription Drug Benefit (Part D) is critical to the
new program’s success.
Participating health plan sponsors are committed to
providing beneficiaries with accurate and
understandable information.
CMS Marketing Guidelines are the foundation for
ensuring accurate information by developing proper
marketing materials and promotional activities.
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Marketing Guidelines: Background
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The Centers for Medicare & Medicaid Services (CMS) established
Marketing Guidelines for its Medicare health plans based on:
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Marketing Guidelines apply to:
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Federal regulations
Current industry practices
Technology advancements
Interest in protecting Medicare beneficiaries
Medicare Advantage (MA) plans,
Medicare Advantage Prescription Drug (MA-PD) plans,
Prescription Drug plans (PDPs), and
1876 Cost plans
Link to Medicare Marketing Guidelines:
www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/FinalMarketin
gGuidelines.pdf
Some State laws also apply to broker and agent marketing and sales
activity for Medicare health plans.
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CMS Definitions
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Marketing: Steering, or attempting to steer, an undecided
potential enrollee towards a plan, or limited number of plans,
and for which the individual or entity performing the
marketing activities expects compensation directly or
indirectly from the plan for such marketing activities.
“Assisting in enrollment” and “education” do not constitute
marketing.
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Assisting in enrollment: Assisting a potential enrollee with the
completion of an application/and or objectively discussing
characteristics of different plans to assist with enrollment based solely
on the enrollees needs and without compensation from the plan.
Education: Informing a potential enrollee about Medicare programs,
but not steering towards a specific or limited number of plans.
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Plan Sponsors May Contract with Brokers
& Agents to Market Medicare Health Plans
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To reach Medicare beneficiaries across the
country, Medicare health plan sponsors
frequently contract with brokers and agents
to:
 Carry out marketing efforts;
 Disseminate information about their
plans; and
 Sell Medicare health plan packages.
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Responsibility for Marketing the Plans
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Plan sponsors are responsible for all of the
marketing activities of third-parties contracted to
carry-out Medicare health plan business including
a person who is:
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Is directly employed by the organization;
With which an organization contracts; and
A downstream marketing contractor.
If a state requires, plan sponsors must use only a
state licensed, certified, or registered individual to
perform marketing.
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Plan Sponsors Ensure Compliance
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Plan sponsors must establish clear provisions
in the broker/agent contracts that the
organization is responsible for ensuring the
contractors comply with:
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applicable MA and/or Part D laws,
Federal health care laws, and
CMS policies and Marketing Guidelines
Plan sponsors must conduct monitoring
activities to ensure compliance.
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Plan Sponsors Require Training of
Contracted Brokers/Agents
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Plan sponsors typically establish certification
requirements that brokers/agents must meet to
qualify to market and sell the sponsor’s health and
Part D prescription drug plans.
Requirements often include completing at least a full
day of training for all potential brokers/agents.
After the training program, brokers/agents must
demonstrate they are knowledgeable about key
aspects of the Part D plans, policies, procedures, and
applicable CMS requirements.
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Broker/Agent Training Topics
Training programs typically address a range of topics, including:
 Medicare marketing rules - permissible and prohibited
practices;
 Product & benefit design;
 Medicare eligibility & enrollment rules;
 Enrollment forms & required disclosures that must be
made to beneficiaries;
 Grievance & appeals processes;
 Oversight & monitoring by plans; and
 Corrective & disciplinary action.
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Broker/Agent Training Updates
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Broker/agent training programs are frequently
updated.
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Plan sponsors often require brokers/agents to attend retraining sessions to remain certified.
Many plan sponsors:
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Hold regular conference calls to reinforce information
provided during training sessions,
Keep their brokers/agents informed of current issues, and
Offer other avenues for brokers/agents to ask questions.
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Continuous Oversight
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Plan sponsors have developed a variety of mechanisms to
continuously monitor broker/agent performance and
compliance with CMS, state, and sponsor requirements.
Oversight activities of the plan sponsor may include:
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Telephone calls to new members upon enrollment to ensure that
they understand the terms of the Part D plan they have joined;
Broker/agent phone call monitoring and review to ensure
compliance with appropriate marketing practices;
Targeted “ride-alongs” conducted by plan sponsor employees
based on complaints;
Attending community meetings to evaluate presentations; and/or
Monitoring of disenrollment rates and complaints for each
broker/agent.
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Compliance with State Law
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State marketing agent appointment laws do not apply to
Medicare plans because the Medicare Marketing Guidelines
address the use of marketing representatives.
However, because a plan sponsor is required to use only a
state licensed, registered, or certified individual to market a
plan (if a state has such a requirement), CMS expects plan
sponsors to comply with a reasonable request from a state
insurance department (or other state department):
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that licenses individuals for the purpose of marketing insurance plans
and
that is investigating a person who is marketing on behalf of a plan
sponsor if the investigation is based on a complaint filed with the state
insurance or other department.
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Reporting Violations to State Agencies
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Plan sponsors are encouraged to report a person that markets
on a its behalf to the appropriate state entity, if there is
suspected violation of a state’s licensing, registration,
certification, insurance, or other law.
States may take action against marketing representatives and
insurance producers for alleged violations of state marketing
representative licensing laws.
This requirement applies to any individual performing
marketing on behalf of a PDP sponsor or MA organization,
whether the individual is an employee, an independent agent
contracting with a PDP or MA organization, or a downstream
contractor.
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State Reporting Laws
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The plan sponsor must report to the state the
following information if state law requires
such reporting:
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The identity and other information of a
broker/agent who is marketing the organization’s
plan(s).
The termination for cause of a broker’s/agent’s
employment or contract.
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Broker Compensation Agreements
Compensation schedules must:
 Be specified in a written contract.
 Provide reasonable compensation that is in line with industry
standards for services provided.
Rate of payment:
 Must be related to a reasonable measure of service provided.
 May vary among plans (e.g., MA plan, MA-PD plan, or a
PDP).
 May vary among one organization’s plans.
 May not vary based on the health status or risk profile of a
beneficiary.
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Broker Compensation Agreements
Compensation structures must:
 Avoid incentives to mislead beneficiaries, cherry pick certain
beneficiaries, or churn beneficiaries between plans.
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NOTE: Special Needs Plans are permitted to market to individuals based on
the eligibility requirements of the plan.
Withhold or withdraw payment if an enrollee rapidly
disenrolls (e.g., disenrolls less than 60 days after enrollment).
Not include payments outside of the compensation schedule
set forth in the written contract.
Not include payments by persons performing marketing to
beneficiaries.
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Marketing: Outbound Telemarketing
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CMS allows outbound telemarketing to reach
beneficiaries under the following guidelines:
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Must be for health related products (e.g., discounts on
eyeglasses or health club memberships)
May not be for non-health related items ( e.g., discounts
on restaurants, entertainment, or travel) unless the
beneficiary provides prior written authorization.
Must comply with the National-Do-Not Call Registry.
Must honor “do not call again” requests.
Must abide by Federal and State calling hours.
Must not enroll beneficiaries over the phone.
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Marketing: Outbound Telemarketing
Outbound telemarketing may be used solely to:
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Solicit requests for pre-enrollment information;
Describe benefits;
Alert existing beneficiaries to new benefits or
health-related offers; and
Conduct follow-up calls to establish the receipt of
requested information and field questions
regarding programs.
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Marketing Materials - Approval
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Agents/brokers must use only CMS-approved
materials and scripts when calling prospective
clients and describing benefits.
CMS reviews marketing materials submitted
by the plan sponsor to ensure they:
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Are not materially inaccurate,
Are not misleading, and
Do not otherwise make material
misrepresentations.
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Marketing Materials – Outbound Script
Requirements
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Scripts must include a privacy statement clarifying the
beneficiary is not required to provide any information to the
plan’s representative and that the information will in no way
affect the beneficiary’s membership in the plan.
Plans may not request beneficiary identification numbers
including SSN, bank account, credit card, or HICN through
pre-enrollment scripts. (Information can be requested in the
application the enrollee completes.)
Plans may say they are contracted with Medicare to provide
prescription drug benefits or that they are a Medicareapproved MA-PDP/PDP, but they may not say they are
endorsed by Medicare, calling on behalf of Medicare, calling
for Medicare, or working for the federal government.
Plans cannot say their plan is the best plan.
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Marketing Activities:
Door-To-Door Solicitation Prohibitions
Marketing agents may not:
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Solicit beneficiaries door-to-door prior to
receiving an invitation from the beneficiary to
provide assistance in the beneficiary’s
residence.
Return uninvited to an earlier “no show”
appointment.
Marketing agents may market and distribute
and accept enrollment applications in common
areas of health care settings: e.g., cafeteria, rec.
room, conference room
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Marketing Activities:
Unsolicited E-mail Prohibitions
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Marketing agents may not:
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Send e-mail to a beneficiary, unless the
beneficiary agrees to receive e-mails from the
plan sponsor and provides his/her e-mail address.
Rent an e-mail list to distribute plan information.
Acquire e-mail addresses through any type of
directory.
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Promotional Activities –
General Guidelines
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Agents and brokers may not:
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Use free gifts, prizes, cash or rebates as an
inducement for enrollment.
Use cash promotions to induce a referral,
recommendation, or purchase of an item or
service of the Medicare program.
Offer post-enrollment promotional items to
compensate beneficiaries based on their
utilization of services.
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Promotional Activities – Nominal Gifts
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Agents/brokers may offer gifts to potential enrollees if they
attend a marketing presentation if:
 Gifts are of nominal value ($15 or less), based on retail
price;
 More than one gift is offered, the combined value of all
items does not exceed $15;
 Gifts are offered to eligible members without
discrimination;
 Gifts are provided regardless of whether the individual
enrolls in the plan; and
 Gifts are not in the form of cash or monetary reward (i.e.,
charitable contributions on behalf of an attendee, gift
certificates, gift cards)
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Promotional Activities: Drawings, Prizes,
Giveaways
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Brokers/Agents
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May offer a prize over $15 to the general public
as long as it is not offered just to Medicare
beneficiaries and is not routinely or frequently
awarded.
May not use free gifts or prizes to induce
enrollment.
Must include a disclaimer on any statement
concerning a prize or drawing that there is no
obligation to enroll in the plan.
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Promotional Activities: Referral Programs
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Brokers/agents may not use cash promotions as part
of a referral program, but may offer thank you gifts
of less than $15.
Thank you gifts are limited to one gift per member
per year.
A letter sent from an agent or broker to members
soliciting referrals cannot offer a gift for a lead.
An organization can request referrals from active
members including names and addresses, but not
phone numbers. (Information can be used for mail
solicitation.)
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Health Fairs & Health Promotional Events
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Policies for health fairs & health promotional events apply to:
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In a Sole-Sponsor event:
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Sole-Sponsor (single sponsor for an event)
Multiple-Sponsor (more than one sponsor for an event)
Both (single & multiple-sponsor events)
If offered, door prizes/raffles cannot exceed the $15 limit for each
item based on retail value.
In a Multi-Sponsor event:
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Door prizes/raffles can exceed the $15 limit if the agent/broker
contributes to a pool of cash for prizes (e.g., a get-away weekend) or
a pool of prizes so that the prize(s) is/are not individually identified
with the plan sponsor, but rather is identified with a list of
contributors.
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Health Fairs & Health Promotional Events
Both Sole-Sponsor and Multi-Sponsor events:
 Should be social and may not include a sales presentation.
 Responses to questions will not be considered a sales
presentation as long as no enrollment form is accepted.
 Ads for events may be distributed to enrollees or nonenrollees.
 Free items (food/entertainment) cannot exceed $15 retail
value per attending person based on projected attendance.
 Pre-enrollment ad materials (including enrollment forms) can
be made available as long as enrollment forms are not
accepted.
 Must have disability access and cannot be limited to affluent
areas.
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Questions?