Medicare Advantage Communications, Marketing and Training Rules
Illegal to say this is the “Best” plan
What are Star Ratings?
Official Medicare & You with Steve’s Introductory Video
This is a technical page, that will cross most anyone’s eyes.
- Medicare Communications & Marketing Guidelines:
- Marketing Website: cms.gov
- PFFS Plans
- Addendum: Model Language for Sales Presentation cms.gov
Model Material Updates
- Quality Improvement Organization (QIO) Updates (PDF)
- CY 2021 MMP & MSHO Member Material Updates Memo (PDF)
- MMP & MSHO Plan Errata (04/15/2019) (DOCX)
- CY 2020 Explanation of Benefits – Drug-Only (DOCX)
- CY 2020 Explanation of Benefits – Integrated (DOCX)
- CY 2020 California MMP Model Materials Memo (PDF)
- CY 2020 California MMP Marketing Guidance Memo (PDF)
- CY 2020 California MMP Marketing Guidance (PDF)
- Member ID Card (2020) (ZIP)
- Member Handbook English (2020) (ZIP)
- Member Handbook Spanish (2020) (ZIP)
- Provider & Pharmacy Directory – English & Spanish (2020) (ZIP)
- Summary of Benefits – English & Spanish (2020) (ZIP)
- List of Covered Drugs – English & Spanish (2020) (ZIP)
- Delegated Notices (2020) (ZIP)
- Integrated Denial Notices (2020) (ZIP)
- Annual Notice of Change – English & Spanish (2020) (ZIP)
When referring to Medicare Advantage Plans
40.4 – Prohibited Terminology/Statements
You can’t Use absolute superlatives (e.g., “the best,” “highest ranked,” “rated number 1”) and/or qualified superlatives (e.g., “one of the best,” “among the highest rank”) unless they are substantiated with supporting data provided to CMS as a part of the marketing review processes or they are used in logos/taglines.
If the material is submitted via the File & Use program, the supporting data must be included, along with the materials that use an absolute superlative.
The superlatives used and the data provided must be in context and may not mislead consumers. For example, a Plan/Part D Sponsor that is the only plan in the area that received a 5-star rating in customer service, but received an overall rating of 3 stars, may not promote itself as the highest ranked plan in a service area where other plans have a higher overall rating. CMS.gov 2015 * 42 CFR 422.2262, 422.2264, 423.2262, 423.2264, 422.2268(e), 423.2268(e)
30.7 – Prohibited Terminology/Statements
Plans/Sponsors are prohibited from distributing communications that are materially inaccurate, misleading, or otherwise make misrepresentations or could confuse beneficiaries.
Plans/Part D sponsors may not:
Claim that they are recommended or endorsed by CMS, Medicare, or the Department of Health & Human Services (DHHS);
Use unsubstantiated absolute or qualified superlatives or pejoratives;
Note: Unsubstantiated absolute and/or qualified superlatives may be used in
Market that they will not disenroll individuals due to failure to pay premiums; or,
Use the term “free” to describe a zero-dollar premium, reduction in premiums (including Part B buy-down), reduction in deductibles or cost sharing, low-income subsidy (LIS), cost sharing for individuals with dual eligibility.
Note: Medical Savings Account (MSA) plans may not imply that the plan operates as a supplement to Medicare. CMS.gov 9.2018 * 42 CFR §§ 422.2264, 423.2264, 422.2268(a)(2), 423.2268(a)(2)
Use qualified or absolute superlatives.
EXAMPLE: ”One of the best”, “among the highest ranked” or refer to the plan you are marketing/selling as “the best, the highest ranked”, “rated number one”, etc.
Compare an Anthem Plan (including Amerigroup and Simply Healthcare) to another Plan by name or inference unless you have written concurrence from all plan sponsors being compared, or using CMS Star rating documents. Anthem.com
Medicare plans and people who work with Medicare can’t:
- Charge you a fee to process your enrollment into a plan.
- Steer you into a particular plan.
- Communicate incorrect information about their plan type or use inappropriate statements like their plan is “the best” or “highest ranked.” * CA Health Care Advocates * Medicare.Gov
MAPD & Part D Rx Telephone & Face to Face Meetings
require a Scope of Appointment
Before a sales meeting, the agent must obtain a completed and signed Scope of Appointment form from each for example both husband and wife Medicare-eligible consumer – prospect present at a telephonic or in-person one-on-one plan presentation of a Medicare Advantage and/or Prescription Drug Plan product
Agents are required that when conducting marketing activities, in-person or telephonically, that they nor their Plan/Part D Sponsor Insurance Company may not market sell or present any health care related product during a marketing appointment beyond the scope that the beneficiary agreed to before the meeting CMS 2018 Marketing Rules – 70.4.3
The Plan/Part D Sponsor must document the scope of the appointment prior to the appointment
SOA documentation is subject to the following requirements:
The documentation may be in writing, in the form of a signed agreement by the beneficiary, or a recorded oral agreement.
Any technology (e.g., conference calls, fax machines, designated recording line, pre-paid envelopes, and email) can be used to document the scope of appointment.
Marketing Standards (g) Market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary, and documented by the plan, prior to the appointment (48 hours in advance, when practicable). and (h), 422.2268(g)
Humana’s guidance & interpretation 10.2015 Click to enlarge
Communications means activities and use of materials to provide information to current and prospective enrollees. This means that all activities and materials aimed at prospective and current enrollees, including their caregivers and other decision makers associated with a prospective or current enrollee, are “communications” within the scope of the regulations at 42 C.F.R. Parts 422, 423 and 417.
Marketing is a subset of communications and includes activities and use of materials that are conducted by the Plan/Part D sponsor 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 (that is, retention-based marketing). Additionally, marketing contains information about the plan’s benefit structure, cost sharing, and measuring or ranking standards.
Hey fellow agents:
Let’s meet for lunch, video conference and talk about it.
My guess is, only other agents are googling for this page.
How about we meet and exchange ideas?
Well this get’s confusing…
Secret Shopper’s Check List 423.2262,
Review and distribution of marketing materials 423.2268 (g) and (h)
Standards for Part D marketing 42 CFR 422.2262, Marketing Materials
70.9.3 Scope of Appointment 2016 – Medicare Marketing Rules
422.2268(g) and (h) can’t market what’s not listed in the scope of appointment
423.2262 Part D Rx Review of marketing materials
423.2268 (g) and (h) Part D can’t market what’s not in scope of appointment
Medicare Training Wikipedia – Meeting
Agent ONLY COVID Rules
War Dogs Movie Trailer –
I feel that CMS wants to put agents in jail for the smallest infraction…
AEY’s plans ran into trouble in April, 2007, when they discovered that the 7.62 mm ammunition they had planned to buy from the Albanian Ministry of Defense was actually manufactured in Communist China. Following the Tien An Minh Square massacre, the United States Government had enacted an arms embargo that precluded purchases of ammunition made by any entity that was part of Communist China’s military establishment.
A clause noting this prohibition and precluding supplying the contract with Chinese-made ammunition was included prominently
[The AHIP and Insurance Company Training we get – IMHO is defective – It doesn’t reference the actual law or CMS Rule!] in the Army’s contract with AEY. Justice.Gov
I’d have to re review everything. There may have been some improvement
Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.
That's why the premium is very low or ZERO!
Get quick access to the information you need.
The Overall Star Rating combines scores for the types of services each plan offers: What is being measured? For plans covering health services, the overall score for quality of those services covers many different topics that fall into 5 categories:
- Staying healthy: screenings, tests, and vaccines: Includes whether members got various screening tests, vaccines, and other check-ups that help them stay healthy.
- Managing chronic (long-term) conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
- Member experience with the health plan: Includes ratings of member satisfaction with the plan.
- Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
- Health plan customer service: Includes how well the plan handles member appeals.
For plans covering drug services, the overall score for quality of those services covers many different topics that fall into 4 categories:
- Drug plan customer service: Includes how well the plan handles member appeals.
- Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
- Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
- Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.
For plans covering both health and drug services, the overall score for quality of those services covers all of the topics above.
Medicare 2020 Part C & D Star Ratings Technical Notes 184 pages
42 CFR Part 422, Subpart D – Quality Improvement
- § 422.152 — Quality improvement program.
- § 422.153 — Use of quality improvement organization review information.
- § 422.156 — Compliance deemed on the basis of accreditation.
- § 422.157 — Accreditation organizations.
- § 422.158 — Procedures for approval of accreditation as a basis for deeming compliance.
Capitalist – Not Communist
G-d Father Emilio Barzini: [during a meeting with the Five Families] Times have changed. It’s not like the Old Days, when we can do anything we want. A refusal is not the act of a friend. If Don Corleone had all the judges, and the politicians in New York, then he must share them, or let us others use them. He must let us draw the water from the well. Certainly he can present a bill for such services; after all… we are not Communists. imdb.com
Part C—MEDICARE+CHOICE PROGRAM
AKA MAPD Medicare Advantage
- SUBPART A — General Provisions (§§ 422.1 – 422.6)
- SUBPART B — Eligibility, Election, and Enrollment (§§ 422.50 – 422.74)
- SUBPART C — Benefits and Beneficiary Protections (§§ 422.100 – 422.133)
- SUBPART D — Quality Improvement (§§ 422.152 – 422.158)
- SUBPART E — Relationships With Providers (§§ 422.200 – 422.220)
- SUBPART F — -Submission of Bids, Premiums, and Related Information and Plan Approval (§§ 422.250 – 422.270)
- SUBPART G — Payments to Medicare Advantage Organizations (§§ 422.300 – 422.324)
- SUBPART H — Provider-Sponsored Organizations (§§ 422.350 – 422.390)
- SUBPART I — Organization Compliance With State Law and Preemption by Federal Law (§§ 422.400 – 422.404)
- SUBPART J — Special Rules for MA Regional Plans (§§ 422.451 – 422.458)
- SUBPART K — –Application Procedures and Contracts for Medicare Advantage Organizations (§§ 422.500 – 422.527)
- SUBPART L — Effect of Change of Ownership or Leasing of Facilities During Term of Contract (§§ 422.550 – 422.553)
- SUBPART M — Grievances, Organization Determinations and Appeals (§§ 422.560 – 422.626)
- SUBPART N — Medicare Contract Determinations and Appeals (§§ 422.641 – 422.696)
- SUBPART O — Intermediate Sanctions (§§ 422.750 – 422.764)
- SUBPART P — S [Reserved]
- SUBPART T — Appeal procedures for Civil Money Penalties (§§ 422.1000 – 422.1094)
- SUBPART V — Medicare Advantage Marketing Requirements (§§ 422.2260 – 422.2276)
General information for organizations currently offering Medicare Advantage plans, or those planning to do so in the future ◦
•Applications for organizations seeking to offer a Medicare Advantage plan ◦
- Chapter 1 – General Provisions [PDF, 76KB]
- Chapter 3 – Marketing Guides Instructions [PDF, 47KB]
- Chapter 4 – Benefits and Beneficiary Protections [PDF, 522KB]
- Chapter 5 – Quality Assessment [PDF, 387KB]
- Chapter 6 – Relationships With Providers [PDF, 146KB]
- Chapter 7 – Risk Adjustment [PDF, 1MB]
- Chapter 8 – Payments to Medicare Advantage Organizations [PDF, 194KB]
- Chapter 9 – Employer/Union Sponsored Group Health Plans [PDF, 208KB]
- Chapter 10 – MA Organization Compliance with State Law and Preemption by Federal Law [PDF, 44KB]
- Chapter 11 – Medicare Advantage Application Procedures and Contract Requirements [PDF, 294KB]
- Chapter 12 – Effect of Change of Ownership [PDF, 70KB]
- Chapter 13 – Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans) [PDF, 426KB]
- Chapter 14 – Contract Determinations and Appeals [PDF, 54KB]
- Chapter 15 – Intermediate Sanctions [PDF, 45KB]
- Chapter 16a – Subchapter A – Private Fee-for-Service (PFFS) Plans [PDF, 198KB]
- Chapter 16b – Subchapter B – Special Needs Plans [PDF, 273KB]
- Chapter 17a – Subchapter A – TEFRA Cost Based Payment Processes and Principles [PDF, 132KB]
- Chapter 17b – Subchapter B – Payment Principles for Cost-Based HMOs and CMPs [PDF, 283KB]
- Chapter 17c – Subchapter C – Cost Apportionment for Cost-Based HMOs and CMPs [PDF, 60KB]
- Chapter 17d – Subchapter D – Medicare Cost Plan Enrollment and Disenrollment Instructions [PDF, 381KB]
- Chapter 17f – Subchapter F – Benefits and Beneficiary Protections [PDF, 227KB]
- Chapter 18a – Subchapter A – Cost-Based Payment Process and Principles [PDF, 100KB]
- Chapter 18b – Subchapter B – Payment Principles for Cost-Based HMOs and CMPs [PDF, 168KB]
- Chapter 18c – Subchapter C – Cost Apportionment for Cost-Based HMO/CMPs [PDF, 145KB]
- Chapter 21 – Compliance Program Guidelines and Prescription Drug Benefit Manual Chapter 9 – Compliance Program Guidelines [PDF, 289KB]
- Help with File Formats and Plug-Ins
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Technical & Research Links
Medicare Modernization Act Wikipedia
Guidance for Eligibility, Enrollment and Disenrollment procedures for Medicare Advantage (MA) plans, including MA-PD plans, is provided in Chapter 2 of the Medicare Managed Care Manual.
Congressional Budget Office on how Medicare Advantage Plans Work
Medicare Marketing Website
Medicare Marketing Guidelines
The Medicare Improvements for Patients and Providers Act (MIPPA)
Summary Public Law No: 110-275 Text – 105 Pages
- § 422.2260 — Definitions concerning marketing materials.
- § 422.2262 — Review and distribution of marketing materials.
- § 422.2264 — Guidelines for CMS review.
- § 422.2266 — Deemed approval.
- § 422.2268 — Standards for MA organization marketing.
- § 422.2272 — Licensing of marketing representatives and confirmation of marketing resources.
- § 422.2274 — Broker and agent requirements.
- § 422.2276 — Employer group retiree marketing.