Compliance Performance Indicators
CMS holds all agents who enroll clients in Medicare Advantage and Part D prescription drug plans responsible for their marketing behavior. All of the carriers have compliance oversight teams that monitor the activities of agents selling their products.
Many of the indicators that are commonly used by both CMS and the carriers to monitor agent performance are explained below. There are also some helpful tips to assist agents in staying compliant with CMS Medicare Communications and Marketing Guidelines and the various carrier compliance programs. Note: disciplinary or corrective action by the carrier for not meeting expectation in these areas may include re-training up to termination and formal reporting to a state Department of Insurance.
Complaints and Marketing Incidents
Both the carriers and CMS field complaints from consumers about agent marketing practices. Carriers track the volume and types of allegations that are made. If you receive a complaint from the carrier, respond within the timeframe given with all necessary documentation, keep the response non-emotional and do not contact the client during the complaint process.
Timely handling and processing of enrollment applications is important. A late application is defined differently by each carrier. Usually, applications must be in the carrier’s possession within two calendar days of receipt by agent. Try to use electronic methods or fax. And beware that there are often two separate fax lines for Part D applications and Medicare Supplement applications. Avoid holding onto applications for any reason.
Monitors the number and percentage of enrollments cancelled before the effective date of coverage.
Monitors the number and percentage of disenrollments within 90 days of the effective date (excludes disenrollments due to death, out-of-area moves, loss of Part A or loss of Part B).
Scope of Appointment (SOA) Forms
Beneficiaries must complete a Scope of Appointment form before all one-on-one appointments/meetings (whether in person or over the phone) to discuss MA, MA-PD and/or PDP products. If the client wishes to discuss a product not included on the original SOA form, you must complete a new SOA to include the new product line. SOA forms are not required to attend a formal or informal marketing/sales event.
The following requirements must be on the scope of appointment form or on the recorded call:
PCP Auto Assign
Some plans (usually HMOs) require the client to have a designated Primary Care Physician (PCP) and it will be noted on their member ID card. If the enrollment application contains Name and ID fields for PCP information, then a PCP is required and the agent should work to populate the section. If the PCP fields are left blank, or invalid PCP information is entered, some carriers will auto assign a PCP to the client. A PCP auto assignment is a negative mark for the agent, as it can lead to member dissatisfaction, delay member services, etc.
Permission to Contact (PTC)
Agents aren’t allowed to call prospective clients about MA-PD or Part D unless the client specifically asks to be called. CMS has relaxed its position on unsolicited direct email contact, but some carriers still do not allow email contact unless compliant PTC is first obtained. Agents can only call a potential client when the client has given express written permission to contact them. PTC can be obtained by a prospect returning a business reply card that discloses who will contact, what products will be discussed and by what specific method the consumer can expect contact. The following is the recommended disclaimer: “By providing your name and contact information you are consenting to receive calls, text messages and/or emails from a licensed insurance agent about Medicare Plans at the number provided, and you agree such calls and/or text messages may use an auto-dialer or robocall, even if you are on a government do-not-call registry. This agreement is not a condition of enrollment.” Adding this to bottom of the business reply card (postal or electronic) will allow agents to obtain valid permission to contact the prospect that submits the form about Medicare Advantage or Part D Prescription Drug Plans.
Permission to Call Primer
Before calling a consumer about Medicare Advantage or Part D Prescription Drug plans, make sure you are well versed in Permission to Call (PTC) guidelines. This reference tool provides you with common situations when an agent may or must not contact a consumer telephonically. If you still have questions, contact your marketer or send an email to email@example.com.
Prior to calling a consumer, you must obtain PTC. PTC may be obtained by receiving a completed Business Reply Card (BRC) or lead card. PTC is always limited to the method of contact and product scope defined in the BRC or lead card. Unsolicited direct contact with a consumer is prohibited.
Agent prohibited activities
Prohibited activities include, but are not limited to, the following:
Agent compliant activities
Agents may conduct the following activities: