Marketing Medicare Part D Plans Presented by America’s Health Insurance Plans (AHIP) and The National Association of Health Underwriters (NAHU)

August 14, Medicare Part D Plans  Part D plans include Prescription Drug Plans (PDPs), Medicare Advantage – Prescription Drug (MA- PD) plans, Cost Plans that offer Part D prescription drug coverage, and Program of All-Inclusive Care for the Elderly (PACE) plans.

August 14, Providing Information to Make a Medicare Health Plan Choice  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.

August 14, Marketing Guidelines: Background  The Centers for Medicare & Medicaid Services (CMS) established Marketing Guidelines for its Medicare health plans based on:  Federal regulations  Current industry practices  Technology advancements  Interest in protecting Medicare beneficiaries  Marketing Guidelines apply to:  Medicare Advantage (MA) plans,  Medicare Advantage Prescription Drug (MA-PD) plans,  Prescription Drug plans (PDPs), and  1876 Cost plans  Link to Medicare Marketing Guidelines: gGuidelines.pdf gGuidelines.pdf  Some State laws also apply to broker and agent marketing and sales activity for Medicare health plans.

August 14, CMS Definitions  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. 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.

August 14, Plan Sponsors May Contract with Brokers & Agents to Market Medicare Health Plans  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.

August 14, Responsibility for Marketing the Plans  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:  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.

August 14, Plan Sponsors Ensure Compliance  Plan sponsors must establish clear provisions in the broker/agent contracts that the organization is responsible for ensuring the contractors comply with: 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.

August 14, Plan Sponsors Require Training of Contracted Brokers/Agents  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.

August 14, 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.

August 14, Broker/Agent Training Updates  Broker/agent training programs are frequently updated. Plan sponsors often require brokers/agents to attend re- training sessions to remain certified.  Many plan sponsors: 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.

August 14, Continuous Oversight  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: 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.

August 14, Compliance with State Law  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): 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.

August 14, Reporting Violations to State Agencies  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.

August 14, State Reporting Laws  The plan sponsor must report to the state the following information if state law requires such reporting: 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.

August 14, 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.

August 14, Broker Compensation Agreements Compensation structures must:  Avoid incentives to mislead beneficiaries, cherry pick certain beneficiaries, or churn beneficiaries between plans. 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.

August 14, Marketing: Outbound Telemarketing  CMS allows outbound telemarketing to reach beneficiaries under the following guidelines: 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.

August 14, Marketing: Outbound Telemarketing Outbound telemarketing may be used solely to: 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.

August 14, Marketing Materials - Approval  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: Are not materially inaccurate, Are not misleading, and Do not otherwise make material misrepresentations.

August 14, Marketing Materials – Outbound Script Requirements  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 Medicare- approved 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.

August 14, Marketing Activities: Door-To-Door Solicitation Prohibitions Marketing agents may not: 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

August 14, Marketing Activities: Unsolicited Prohibitions  Marketing agents may not: Send to a beneficiary, unless the beneficiary agrees to receive s from the plan sponsor and provides his/her address. Rent an list to distribute plan information. Acquire addresses through any type of directory.

August 14, Promotional Activities – General Guidelines  Agents and brokers may not: 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.

August 14, Promotional Activities – Nominal Gifts  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)

August 14, Promotional Activities: Drawings, Prizes, Giveaways  Brokers/Agents 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.

August 14, Promotional Activities: Referral Programs  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.)

August 14, Health Fairs & Health Promotional Events  Policies for health fairs & health promotional events apply to: Sole-Sponsor (single sponsor for an event) Multiple-Sponsor (more than one sponsor for an event) Both (single & multiple-sponsor events)  In a Sole-Sponsor event: If offered, door prizes/raffles cannot exceed the $15 limit for each item based on retail value.  In a Multi-Sponsor event: 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.

August 14, 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 non- enrollees.  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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