Ritter Insurance Marketing, Craig Ritter

More MIPPA 2009 Medicare Advantage Marketing Guidelines

This came in 3 parts. . .I’m linking all three together.  This is a lot!

Part 1:

New MA And Part D Regulations CMS 4131-F And CMS 4138- IFC
Two new rules implement MIPPA related provisions (e.g. marketing and SNPs) from the May 16, 2008 proposed rule (CMS 4131-P).  The complete regulations and initial guidance from CMS can be found at:  http://www.cms.hhs.gov/HealthPlansGenInfo/

(2008-21674_PI) Final Marketing Provisions 4131-F

(2008-21686_PI) Revisions to MA & PDP 4138-IFC

Guidance for Implementation of Regulations  Marketing Through Unsolicited Contacts

Prohibited activities include, but are not limited to, the following:

  • Outbound marketing calls, unless the beneficiary requested the call. This includes contacting existing members to market other Medicare products. 
  • Calls to market health plans or products to former members who have disenrolled, or to current members who are in the process of voluntarily disenrolling.
  • Calls to beneficiaries to confirm receipt of mailed information.
  • Calls to beneficiaries to confirm acceptance of appointments made by third parties or independent agents.
  • Approaching beneficiaries in common areas (i.e. parking lots, hallways, lobbies, etc.)
  • Calls or visits to beneficiaries who attended a sales event, unless the beneficiary gave express permission at the event for a follow-up call or visit.

Organizations may do the following:

  • Conduct outbound calls to existing members to conduct normal business related to enrollment in the plan, including calls to members who have been involuntarily disenrolled to resolve eligibility issues.
  • Call former members after the disenrollment effective date to conduct disenrollment survey for quality improvement purposes. Disenrollment surveys may be done by phone or sent by mail, but neither calls nor mailings may include sales or marketing information.
  • Under limited circumstances and subject to advance approval from the appropriate CMS Regional Office, call LIS-eligible members that a plan is prospectively losing due to reassignment to encourage them to remain enrolled in their current plan.
  • Agents/brokers who enrolled a beneficiary in a plan may call that beneficiary while they are a member of that organization.
  • Call beneficiaries who have expressly given permission for a plan or sales agent to contact them, for example by filling out a business reply card or asking a Customer Service Representative (CSR) to have an agent contact them. This permission applies only to the entity from whom the beneficiary requested contact, for the duration of that transaction, or as indicated by the beneficiary.


Marketing non-health care related products (such as annuities and life insurance) to prospective enrollees during any MA or Part D sales activity or presentation is considered cross-selling and is prohibited. (This eliminates confusion and the implication that the health and non-health products are a package.)

  •  Plans may sell non-health related products on inbound calls only when a beneficiary makes a request for the information about other non-health related products.
  • Marketing to current plan members of non-MA plan covered health care products, and/or non-health care products, is subject to Health Insurance Portability and Accountability Act (HIPAA) rules and anti-kickback rules.

Scope of Appointments

In-person appointment, the scope agreed upon must be documented in writing.
Phone appointment, the conversation of the scope agreed upon must be recorded.
Under current Medicare Marketing Guidelines, marketing representatives are to clearly identify the types of products that will be discussed before marketing to a potential enrollee.

  • Effective September 18, 2008, prior to any marketing appointment, the beneficiary must agree on the scope of the appointment.
  • The agent must document the scope of the appointment agreed upon in writing and must be signed prior to the appointment.  If the appointment is scheduled by phone, the scope of the appointment must be recorded by phone:
         –  If a beneficiary attends a sales presentation and schedules an appointment, the agent must obtain written documentation that is signed by the beneficiary agreeing to the products that will be discussed during the appointment.
         – Appointments made over the phone must be recorded to provide documentation.
         Appointments made over the phone in response to a reply card, may ONLY discuss the product(s) that were included in the advertisement.
  • Additional products or additional lines of business may not be discussed unless requested by the beneficiary, and the information to be discussed will require a separate appointment.
          Appointments may not be re-scheduled until 48 hours after the initial appointment.
         Marketing representatives may leave plan materials, but not enrollment applications.

Reminder:  When reviewing CMS regulations, it is acceptable to rely on official written guidance from CMS such as: regulations, HPMS memos and other guidance with a named CMS executive and one-on-one directives from Central Office or the RO.  Be careful of anything you hear on a conference call, summaries from other organizations and unofficial guidance such as power point slides. Trust but verify, in writing.

Part 2:

Implementing the Medicare Improvements For Patients & Providers Act Of 2008 (MIPPA):
New MA And Part D Regulations CMS 4131-F And CMS 4138- IFC

The September 23, 2008 issue of Coventry Connection outlined key details of the new CMS marketing regulations for Medicare Advantage and Medicare Prescription Drug programs that were implemented on September 18th.  Included were:

  • Marketing Through Unsolicited Contacts is Prohibited
  • What an Organization is Permitted to Do
  • Cross-Selling Non-Health Care Related Products is Prohibited
  • Scope of Appointments

In this issue we will discuss two more of the new regulations and CMS guidance: State licensing and appointments for agents/brokers, and annual agent training and testing requirements.

State Licensure and Appointment of Agents
Agents and brokers now are required to both be licensed and appointed in accordance with state laws where conducting marketing.

  • Applies to both contracted and employed agents/brokers
  • In most states, Customer Service Representatives can
    • Provide factual information
    • Fulfill a request for plan materials, and 
    • Accept an enrollment application at the initiative of the enrollee

Agent/Broker Training and Testing
All agents/brokers must be trained and tested annually. The following guidelines apply for training content and timeline: 

  • Medicare rules and regulations
  • Plan details specific to plan products being sold
  • Both contracted and employed agents must successfully complete training
  • Must be successfully completed before able to market for the plan  

New guidance, effective on September 18, 2008:

  •  Testing requires passing score of at least 85%

 Part 3:

Implementing the Medicare Improvements For Patients & Providers Act Of 2008 (MIPPA):
New MA And Part D Regulations CMS 4131-F And CMS 4138- IFC
  In the September 24, 2008 issue of Coventry Connection we outlined CMS guidance on the new regulations for agent and/or broker licensure and state appointment, as well as the scope and minimum passing score for training and testing.

In this issue, the third of our 3-part series this week on MIPPA updates that went into effect on September 18, 2008, we will highlight more of the new guidance such as:

  • Sales/Marketing Activities in Health Care Settings or Educational Events
  • Nominal Gifts provision
  • No Meals provision
  • Aggressive Sales Tactics Unacceptable

Sales / Marketing in Health Care Settings or Educational Events

  • Educational Event is an event that is sponsored by the
    Medicare plan or by outside entities, and promoted to be educational in nature, not to steer toward specific plans, and have multiple vendors. (Examples: health information fairs, conference expositions, state-or community-sponsored events.) 
  • Sales Event is an event that is sponsored by the Medicare Advantage plan or another entity with the purpose of marketing to potential members and steering, or attempting to steer potential members toward a specific or limited number of plans.

Beginning September 18, 2008, educational events may not include sales activities such as the distribution of marketing materials or the distribution or collection of plan applications.

CMS has clarified that the purpose of educational events is to provide objective information about the Medicare program in general (not specific plans) and/or health improvement and wellness.  These requirements apply regardless of whether the events are already scheduled.

Agents and/or Brokers who sponsor or participate in educational events must include a disclaimer on event advertising materials that the event is “educational only and information regarding the plan will not be available.”

Sales or marketing activity, presentations, or distribution/collection of plan applications and/or business reply cards in the following areas or events are prohibited:

  • In health care settings unless in common areas; common areas include areas such as hospital or nursing home cafeterias, community or recreational rooms, and conference rooms; areas where patients primarily intend to receive health care services.
  • Restricted areas, include, but are not limited to: waiting rooms, exam rooms, hospital patient rooms, dialysis centers, and pharmacy counter areas.  If a pharmacy counter is located within a retail store, common areas would include the space outside where patients wait for services or interact with pharmacy providers and obtain medications. 
  • Only upon a beneficiary’s request, the broker/agent is permitted to schedule an appointment with the beneficiary residing in long-term care facilities. Appropriate documentation of the beneficiary’s request and agreement for the appointment is required.
  • Medicare and/or health educational materials must contain no marketing information.  

Nominal Gifts

Effective September 18, 2008, Agents and/or Brokers, or an organization may only offer gifts of nominal value, based on retail purchase price regardless of actual cost, which is currently $15.00*, to potential enrollees only if:

  • The item/ gift is not readily convertible to cash and
  • The item/gift is provided to all whether or not the individual enrolls in the plan.  

* CMS will update the nominal value in guidance as necessary to account for inflation and other relevant factors.

Prohibition of Meals  Effective September 18, 2008, prospective enrollees to a Medicare Advantage and/or Medicare Prescription Drug Plan may not be provided meals, or have meals subsidized, at any event or meeting at which plan benefits are being discussed and/or plan materials are being distributed.

  • Agents and/or Brokers are allowed to provide refreshments and light snacks to prospective enrollees and must use their best judgment on the appropriateness of food products provided.
  • Agents and/or Brokers must ensure that items provided could not be reasonably considered a meal, and/or that multiple items are not being “bundled” and provided as if a meal. 
  • CMS does not intend to define the term “meal” or create a comprehensive list of food products that qualify as light snacks. Items similar to the following could generally be considered acceptable: fruit, raw vegetables, pastries, cookies or other small dessert items, crackers, muffins, cheese, chips, yogurt and nuts.

Aggressive Marketing Behavior or Scare Tactics Are Unacceptable  

Beneficiaries must not be subject to and must be protected from aggressive marketing behavior from agents and brokers.  Coventry takes this CMS mandate very seriously and will promptly investigate, track and discipline any such behavior.

Examples of behavior that are not acceptable are:

  • An agent who uses high pressure sales or scare tactics that are meant to cause concern, especially by implying a beneficiary’s Medicare benefits are at stake.  
  • An agent not ending the meeting if the beneficiary states he/she is not interested in the plan.

Posted by filed under 2009 MA Plans, Marketing MA Plans, Medicare Advantage, Training/Certification .

© Ritter Insurance Marketing