medicare advantage sales agent compliance training · chief compliance officer direct phone: (405)...

©2018 GlobalHealth Holdings, LLC. All rights reserved. Confidential

Medicare Advantage

Sales Agent Compliance

TrainingPlan Year 2019

©2018 GlobalHealth Holdings, LLC. All rights reserved. Confidential2

Learning Objectives

To review and understand

CMS Rules for Marketing Medicare Advantage plans

GlobalHealth’s

Compliance Program

Sales Agent Do’s &

Don’ts

3 ©2018 GlobalHealth Holdings, LLC. All rights reserved. Confidential

GlobalHealth Compliance Program

As a GlobalHealth agent, you are expected to adhere to our Compliance Program and Code

of Conduct.

This includes complying with Medicare rules

and GlobalHealth policies for sales and marketing of Medicare Advantage products.


GlobalHealth Compliance Program

If you become aware of something that you believe is a violation of CMS Medicare rules or

GlobalHealth policy, you have an obligation to report it to our Chief Compliance Officer as soon as possible.


Contacting the GlobalHealth

Chief Compliance Officer

Direct phone: (405) 280-5711

Email: [email protected]

Mailing Address: ATTN: Nancy Reed

GlobalHealth210 Park Ave, Suite 2800 Oklahoma City, OK 73102

Confidential 24-hour Hotline: 1-877-280-5852


Compliance Hotline Call our 24-hour toll-free

anonymous hotline and leave a detailed message.

You can leave your name and number or remain anonymous.

Your message will be reviewed and investigated.


Compliance 101

CMS Rules for Medicare Advantage Plans


Requirements for enrollment in a

GlobalHealth MA Plan

Is the enrollee a current Medicare recipient?Must have BOTH Medicare A and B.

Does the enrollee permanently reside in GlobalHealth’s approved service area?

Eligible for MA Enrollment? (AEP, IEP, SEP*)

*Be sure you understand eligibility requirements for SEP.


Medicare Card

Always check the beneficiary’s Medicare card for eligibility – it must show both Part A and Part B. Beginning 2018, Medicare beneficiary ID numbers are random alpha-numeric.

Check ID number

Check A and B Check Effective Date


Annual Enrollment Period

(“AEP”)

October 15 – December 7

May switch from Original Medicare to a GlobalHealth plan.

May switch from another MA plan to a GlobalHealth plan or vice versa.


AEP Rule

May begin marketing upcoming AEP plan year beginning October 1.

GlobalHealth will begin marketing PY2019 on October 1, 2018.

GlobalHealth will stop marketing PY2018 on September 30, 2018 (except age-ins with effective date of Nov. 1 or Dec. 1, 2018)

Note: Make sure individuals enrolling with effective dates of Nov. 1, and Dec. 1 receive both 2018 and 2019 plan materials.


AEP Rule

Agents/Brokers cannot solicit or accept an enrollment application for AEP prior to the start

of the AEP (i.e., not before October 15).

Agents cannot encourage a beneficiary to mail an enrollment form to the health plan prior to

October 15.


*New for 2019 - “Open Enrollment Period”

(Replaces previous “Disenrollment” Period)

January 1 – March 31

MA enrollees may make a ONE-TIME:

Switch from a GlobalHealth plan to Original Medicare.

Switch from a GlobalHealth plan to another MA plan.

Switch from another MA plan to a GlobalHealth plan.

Original Medicare recipients cannot make changes – only MA enrollees.


NOTE: Open Enrollment Period Rule

Plans are not allowed to market the new Open Enrollment Period (“OEP”).

Agents are prohibited from contacting MA enrollees to solicit them to enroll in a

different plan.


Prohibited Activities related to OEP

Cannot send unsolicited materials referencing OEP.

Cannot engage in any activities targeting OEP.

Cannot call or contact former enrollees who selected a new plan during AEP (disenrollees).

Cannot target any beneficiary that enrolled in or stayed with their current MA plan during AEP.


Special Enrollment Period

(“SEP”)

Following a Qualifying Event, beneficiary has a two (2) month SEP. Examples:

Moved into a new service area. Released from jail or moved back to U.S. Moved home from a nursing home or SNF. Lost MA coverage. Loss of LIS status. CMS discretion.


Special Enrollment Period

(“SEP”)

SEP65 Rule:Beneficiaries that elect a MA plan during their IEP have a 12-month SEP to disenroll from the MA plan and switch to Original Medicare (+/- optional Part D PDP).

*Special Rule:Dual/LIS – may make ONE change per calendar quarter during the first 3 quarters each year.

*effective 1/1/19


Initial Enrollment Period

(“IEP”)

Age-in

• Individuals have a seven (7) month period to apply for original Medicare.• 3 months before turning age 65, the birth

month, and up to 3 months after the birth month.

Example: Born 8/15/53• Individual could apply May 1 – Nov. 30.

TIP: Watch for age-ins that are still working – may have employer group health coverage.


Initial Enrollment Period

(“IEP”)

Disability

• Individuals may qualify for Medicare after 24 months of receiving Social Security disability.


What to do if Beneficiary qualifies for

multiple enrollment periods

1. Ask the beneficiary for his/her preferred effective date.

2. If unknown, rank as follows:• IEP

• SEP• AEP


Centers for Medicare & Medicaid Services (“CMS”)

CMS is the Federal Agency with regulatory oversight over the Medicare, Medicaid, and

Medicare Advantage Program (Parts A,B,C,D).

General Guidance at www.cms.gov

Important Reference: Medicare Managed Care Manual – CMS Pub. #100-16, Chapter 3 – “Marketing Guidelines” New “Medicare Communications and Marketing Guidelines”

issued July 20, 2018.

http://www.cms.gov/


Consequences of Non-Compliance with CMS regulations

GlobalHealth must comply with all Medicare Advantage requirements.

Failure to do so could result in fines, sanctions, freeze on enrollments, or loss of the Medicare

contract.


Consequences of

Marketing Violations

by Agents/FMOs

Termination of appointment and employment or contract with GlobalHealth.

Forfeiture of future commission payments.

Reported to CMS.

Reported to state licensing agency.


Sales/Marketing Rules

Licensed Sales Agents


Who Can Sell/Market?

Anyone who markets & sells GlobalHealth Medicare products must be (1) licensed by

the State and (2) appointed by GlobalHealth.

All agents/brokers selling MA products must

complete mandatory GlobalHealth annual training and testing.


Agent/Broker Training

GlobalHealth requires agents to complete specific training & testing prior to appointment

and annually. Must pass the exam with a score of 85% or better.

Additionally, GlobalHealth requires all sales agents to be AHIP certified.


Marketing Definition

“Marketing” = Activities and use of materials with the intent to draw a beneficiary’s attention to a MA

plan or plans and to influence a beneficiary’s decision-making process when selecting a MA plan for enrollment or deciding to stay enrolled in a

plan (i.e., retention-based)


Marketing Materials

Marketing Materials include any materials targeted to Medicare beneficiaries that promote a Medicare

Advantage plan and contain information on:

Benefits

Cost-sharingStar Ratings

Other plan-specific informationComparison to other plans


Marketing Materials

ALL Marketing materials must be approved by GlobalHealth’s Compliance department and CMS.

ALL Marketing materials must have unique ID number for tracking and contain required

disclaimers.

Beginning 2019, marketing materials have an “M” at the end of the material ID.

For example:

Can’t use superlatives or prohibited terms (e.g., “CMS recommended”, “the best”, “number one”, “highest ranked”, etc.).

May use “Medicare-approved” or “one of the best”, etc. qualified terms.


Marketing Materials

Materials must not contain false, unsubstantiated, or

misleading information.


Marketing Materials

Materials that include an agent/broker’s phone number must indicate that calling that number

will direct the caller to a licensed agent/broker.

Any document distributed by a sales agent that

references GlobalHealth MUST be approved by GlobalHealth’s Compliance office.


Marketing/Sales Events

Sales Presentations must follow GlobalHealth’s CMS-approved script.

All Sales & Marketing presentations and scripts must be pre-approved by GlobalHealth’s

Compliance office and CMS prior to use.


Marketing/Sales Events

Beneficiaries must be informed they are attending a Marketing/Sales event.

Can’t call event an “educational” meeting if MA plan benefits are mentioned or

enrollments are conducted.

No “bait & switch” tactics (e.g., turn an educational event into a sales event immediately after).


Sales Events Cannot require contact information or sign-in sheet at events. Contact info must be optional.

Cannot provide meals at sales events.

May only give “nominal” giveaways, provided items are given to all attendees.

Giveaway cannot be cash or cash equivalent.


Promotional Items Can’t be tied to enrollment.

Must not inappropriately influence the beneficiary’s provider selection.

Must comply with fraud & abuse laws including prohibition on beneficiary inducements.


Promotional Items No more than $15 actual

value.

No cash or cash equivalent in any amount. Includes gift cards that

can be converted to cash and charitable contributions made on behalf of potential enrollee.

No meals or ‘meal equivalents’. Can offer light snacks / refreshments only.


Promotional Items Maximum aggregate of $75 per person / per year (can’t pile up a bunch of $15 items).

Must be offered to everyone (no cherry picking).

Can’t be in the form of a free health screening or health benefit or reduced out-of-pocket expense toward a covered health service.


What food items are allowed?

Allowed examples: Fruit Raw vegetables Cookies Nuts Chips

Prohibited examples: No food bars, sandwiches or appetizers that could be

compiled into a meal No alcohol


Educational Events

• Must be general education only. • No plan names.• No discussion of specific plan benefits.

• Cannot distribute any marketing materials.

• Cannot distribute MA enrollment forms.

• Cannot require sign-in sheet.

• Cannot contact attendees without their express consent

• May leave business cards or business reply card (BRC) for attendee to pick up.


Sales and Marketing Rules

No Sales or Marketing in areas where patients seek or receive health services

Includes waiting rooms Includes pharmacy waiting areas


Prohibited Provider Activities

Providers may not Accept/collect SOA or Enrollment forms Make phone calls or direct, urge, or attempt to

persuade their patient to enroll in a specific plan. Mail marketing materials on behalf of a MA plan. Offer inducements to persuade their patient to enroll

in a particular MA plan or to select them as their provider.

Distribute marketing materials where care is delivered.

Share patient names with sales agents or marketing team as potential prospects for sales/marketing.

Providers may:

Make available marketing materials in common areas such as conference rooms.


Sales and Marketing Rules

No unsolicited contacts!• No door-to-door or approaching in common or public

areas. • No leaving flyers on cars or at residence.

No unsolicited Phone Calls!• May use direct mail.• May use e-mail (provided that the email contains an opt-

out provision).

NOTE: contact with beneficiary must be incident to consent and a valid Scope of Appointment (SOA).


Initial Consent to Contact

Consent to contact may be obtained following beneficiary return of a business reply card (BRC) that has been approved by GlobalHealth Compliance and CMS.

Contact must be in the manner requested by beneficiary –e.g., mail, phone, email.• Don’t call if beneficiary requested materials to be mailed.

Consent is “event specific” – limited to scope/duration stated on the BRC. • If BRC is for AEP, consent expires on December 7. • If beneficiary was contacted following an AEP BRC and did not

wish to enroll or discuss further, this does not provide consent to re-contact the next year.

• Consent applies only to the entity from which the beneficiary requested contact.


Scope of Appointment (SOA)

Must complete SOA form signed by beneficiary prior to meeting.

Telephone SOA’s must follow GlobalHealth’s approved script.

SOA must describe what Medicare products will be discussed.

Can’t discuss other products not requested by beneficiary. (If beneficiary requests expanded scope during the appointment, must complete an additional signed SOA.)


Scope of Appointment (SOA)

A separate SOA form is required for each individual beneficiary meeting. If a husband & wife are both attending, the agent must obtain a separate SOA from each.

All SOA forms must be retained for 10 years for CMS audit purposes and a copy given to GlobalHealth as requested.


SOA / Sales / Enrollment

When conducting an Enrollment following a SOA and sales presentation, beneficiary must be clearlyinformed that the enrollment process is beginning.

Agents must follow GlobalHealth’s CMS approved Enrollment Script.


Sales & Enrollment Rules

Don’t use threatening or coercive tactics.

Do not get beneficiary to sign an Enrollment Form without making sure the beneficiary understands that he/she is enrolling in a GlobalHealth Generations Medicare Advantage plan that replaces their Original Medicare or previous MA plan.

Do review GlobalHealth materials with prospective enrollee including Summary of Benefits (SB), Explanation of Coverage (EOC), Star Ratings, Provider/Pharmacy Directory


Enrollment Forms

Beneficiary must review and sign enrollment application.

If agent completes form for the beneficiary, must have beneficiary review the entire form prior to signing and confirm information is correct.

Must provide confirmation of acceptance of a telephone enrollment (e.g., confirmation tracking number).

Must inform enrollee that he/she will receive a notice acknowledging receipt of the enrollment.

Must provide contact information for questions, including GlobalHealth’s toll-free number and TTY number.


Enrollment Forms

Must provide Star Ratings document and Summary of Benefits when an enrollment form is provided.

For online enrollment, the Star Ratings document and the Summary of Benefits must be made available prior to completion and submission of the enrollment request.

SOA → Pre-enrollment Checklist → Enrollment Form →Summary of Benefits → Star Ratings flyer.

Other documents to reference: Explanation of Coverage (EOC) and Provider/Pharmacy Directory


Telephone Enrollments

Must follow GlobalHealth’s approved telephone enrollment script.

All enrollment calls must be recorded, include statements of the individual’s agreement to be recorded and statement by individual of his/her intent to enroll in the plan selected.

Must ensure speaking directly with beneficiary or their authorized representative (verbal attestation).

Include a tracking mechanism – e.g., a confirmation number provided to enrollee.

Advise enrollee where to find online plan materials.


Enrollment Checklist

Beneficiary has both Part A and B.

ID number on enrollment form matches Medicare Card.

Demographic info is accurate and spelled correctly.

Eligible for AEP, IEP, or SEP.

Correct plan selected (including payment method if premium plan selected).

Correct effective date.



Primary Care Physician (PCP) is selected and confirmed in GlobalHealth’s network.

Desired specialists and pharmacies are in GlobalHealth network.

Enrollee understands benefits and HMO plan rules.

Enrollee has read entire enrollment form and signed & dated.

Enrollee has received Summary of Benefits and Star Ratings document.



Enrollee understands he/she is enrolling in a Medicare Advantage plan that replaces their Original Medicare or other coverage.

Enrollee advised to review the full list of benefits in the Evidence of Coverage (EOC).

Submit enrollment forms ASAP – within 24 hours of completion. This will help ensure timely processing.

• (GlobalHealth only has 7 days from date enrollment form completed to transmit enrollment application to CMS. )


HMO Rules

Agent must explain GlobalHealth’s HMO plan rules to prospective enrollees. For example:

Enrollee must see in-network providers or pay full cost for out-of-network services (except for emergency care, out-of-area urgent care, and out-of-area dialysis).

Enrollee must select an in-network primary care physician (PCP). If one isn’t chosen, GlobalHealth will assign a PCP.

Enrollee must have referral from the PCP AND written authorization from GlobalHealth to see a specialist.

Formulary rules – prior authorization and/or step therapy may apply.


Residency Requirements

Beneficiary must permanently reside in GlobalHealth’s approved 44-county service area to enroll AND must remain living in the service area to stay enrolled in that plan.

If beneficiary moves out of service area, he/she will be disenrolled.

NOTE: If a prospective enrollee is moving into GlobalHealth’s service area, do NOT enroll the beneficiary until they have actually moved and established residency.

Make


Premium Payment

Requirements

Beneficiary must pay any applicable MA premiums.

Beneficiary must also continue to pay monthly Medicare Part B Premium.

Be sure beneficiary understands obligation to pay premiums.


Summary

Agent Do’s and Don'ts


Agent/Broker Do’s and Don’ts

Don’t market Annual Enrollment Period prior to October 1.

Don’t solicit, collect or obtain beneficiary enrollments prior to October 15 for AEP.

Don’t market to current MA participants during the period January 1 – March 31.



Don’t sell/market outside GlobalHealth’s approved service area.

Don’t conduct sales/marketing activities at events promoted as educational.



Don’t conduct sales/marketing in provider settings or areas where health services are provided.

Don’t claim a product is endorsed by Medicare or CMS or use superlative terms such as “#1” or “highest rated.”



Do correctly reference plan’s STAR RatingsExample: “3.5 Stars on a scale of 1 to 5”

Distribute only CMS-approved plan materials.



Don’t provide promotional items that are more than $15 in actual value.

Don’t provide meals or serve alcohol. May provide light snacks such as cookies.

Don’t provide cash, or cash equivalent, or health service items.



Don’t require contact information on sign-in sheets at events. Sign-in sheets must be optional.

May hand out business cards or business reply cards (BRC) at Educational events.

Do NOT distribute any plan-specific materials at events promoted as educational (e.g., Medicare 101).



Don’t make unsolicited contact with beneficiaries: No “door-to-door” calls. No unsolicited phone calls. No flyers on cars or residences.

May send unsolicited direct mail.

May send unsolicited email provided that all emails have an “opt-out” provision for beneficiary to stop getting further emails.



Do not call beneficiaries who attended an event, unless the beneficiary expressly requested to be called.

Agents may contact their own clients periodically but may not make unsolicited calls about other business as a means to generate leads for Medicare plans.

Don’t call prospective enrollees to confirm receipt of mailed information – this is considered an unsolicited call.



Do obtain a valid, signed SOA prior to each individual meeting with a beneficiary.

Do remember to timely submit Enrollment forms and other paperwork required by GlobalHealth (e.g., agent checklist, SOA).



Don’t meet with a Medicare beneficiary without an agreed-upon appointment and a valid telephone SOA.

Do follow-up telephone SOA with written, signed SOA prior to face-to-face meeting.



Don’t discuss anything other than what enrollee agreed to in SOA. If beneficiary wants to discuss something else, you must obtain another SOA.

Don’t ask beneficiary to give you names and contact information for other possible enrollees. You may leave business cards with the individual to give to their family and friends.



Do explain GlobalHealth plan benefits and HMO rules to potential enrollees.

Make sure enrollee reads entire enrollment form, confirms information is correct, and understands that he/she is enrolling in a GlobalHealth MA plan before signing.

Don’t ask enrollee to sign enrollment form before the enrollee is ready to join GlobalHealth.



Do ASK a GlobalHealth representative if you have any questions!

GlobalHealth GenerationsCustomer Care 1-844-280-5555


Compliance Monitoring

GlobalHealth’s Compliance department monitors complaints from current and prospective enrollees concerning sales agents.

Agents with significant volume of complaints, disenrollments, or confirmed compliance violations are subject to corrective action up to and including termination of appointment.


Information Resources

General info: www.cms.gov. www.medicare.gov

Marketing guidance at CMS Pub. #100-16, Chapter 3: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/CY-2018-Medicare-Marketing-Guidelines_Final072017.pdf

Statute: 42 CFR Parts 422 and 423

http://www.cms.gov/

http://www.medicare.gov/

https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/CY-2018-Medicare-Marketing-Guidelines_Final072017.pdf


The Health Insurance Portability &

Accountability Act (“HIPAA”)

This law sets forth rules for how a health plan handles, maintains, and discloses Protected Health Information (PHI). There are two main rules.

Privacy Rule Security Rule


Protected Health

Information or “PHI”

PHI is information in any form that identifies an individual in any way AND has anything to do with the individual’s health.

PHI Examples:• Paper• Computer • FAX• Verbal discussion

-Enrollment forms contain PHI


HIPAA

Agents are required to comply with the HIPAA privacy and security rules.

Agents are expected to secure and protect PHI or other confidential information entrusted to them.

Agents may review information provided by enrollee to assist in choosing the correct plan (e.g., discussing current Rx meds).

Don’t write confidential “notes” in the margin of an enrollment form.


Safeguarding

Confidentiality

Don’t request or maintain medical information from a Medicare beneficiary (other than what is allowed on the enrollment form).

Properly safeguard all paper enrollment forms or other confidential beneficiary information.


Ensuring Security

Do not send unsecured emails containing a beneficiary’s confidential health information.

Password protect all mobile devices.

Do not share account passwords.

Secure paperwork and mobile devices in the trunk of your car.


HIPAA Compliance

If you have any questions or concerns about privacy, security, or confidentiality matters,

please contact our Chief Compliance Officer at Direct phone: (405) 280-5711 or Email [email protected]

To report a privacy or security violation

anonymously, call the hotline at 1-877-280-5852.

mailto:[email protected]

medicare advantage sales agent compliance training · chief compliance officer direct phone: (405)...

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