Medicare Advantage Communications, Marketing and Training Rules 

Medicare-Medicaid Plan (MMP) Marketing Information & Resources

This is a technical page, that will cross most anyone’s eyes.

General Information

Model Material Updates

Model Materials

 

State-Specific Information

California

Can’t say this is the  “#Best Plan.”

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
logos/taglines.
 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)

best.plan 

 

Don’t

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

#Scope of Appointment Forms SOC
Permission and agreement to hear a presentation on

Medicare Advantage or Part D Rx

AARP – UHC  fillable pdf and you can type your signature!
It’s Generic, so it can be used for ANY company.

 

 

 

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)

 

Interpretation?

 

Humana’s guidance & interpretation  10.2015  Click to enlarge

Excerpt of Humana's Rules

Definition Marketing Activities

20 – Communications and Marketing Definitions 42 CFR §§ 422.2260, 423.2260 

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.

FAQs / Ask Us a Question

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?   

Email me, [email protected] or set a meeting time.  

Well this get’s confusing…

Guidance on Plain Meaning Rule and how to read and interpret law, rules & statutes

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

2016 Research

70.9.3 Scope of Appointment 2016 – Medicare Marketing Rules

When conducting marketing activities, a Plan/Part D Sponsor may not market any health care related product during a marketing appointment
 
The term used in the actual guidelines is Marketing Appointment – NOT Face to Face!  This is one reason why I hate the crappy slide presentations in AHIP and most training seminars.  They don’t show you the actual code or reference material.
 
beyond the scope that the beneficiary agreed before the meeting with that individual.

42 CFR 422.2262 Review & Distribution of Marketing Materials

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

telephone

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

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Video

Video understanding medicare advantage mapd

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!

Medicare Learning Network

Medicare Learning Network logo
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

What are Medicare Plan #Star Ratings?

 

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.

 

More links

Health Affairs.org

Medicare 2020 Part C & D Star Ratings Technical Notes  184 pages

cms.gov

q1medicare.com

42 CFR Part 422, Subpart D – Quality Improvement

Fact Sheet

cms.gov/PerformanceData

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

Medicare Managed Care Manual

 

Part C—MEDICARE+CHOICE PROGRAM

Legal Codes

Plain English on Part C – Medicare Advantage

Sec. 1851. Eligibility, election, and enrollment

Sec. 1852. Benefits and beneficiary protections

Sec. 1853. Payments to Medicare+Choice organizations

Sec. 1854. Premiums and Premium Amounts

Sec. 1855. Organizational and financial requirements for Medicare+Choice organizations; provider–sponsored organizations

Sec. 1856. Establishment of standards

Sec. 1857. Contracts with Medicare+Choice organizations

Sec. 1858. Special Rules for MA Regional Plans

Sec. 1859. Definitions; miscellaneous provisions

42 CFR Part 422 – MEDICARE ADVANTAGE PROGRAM

General information for organizations currently offering Medicare Advantage plans, or those planning to do so in the future ◦

http://www.cms.gov/HealthPlansGenInfo/

•Applications for organizations seeking to offer a Medicare Advantage plan ◦

http://www.cms.gov/MedicareAdvantageApps/

 

 

Medicare Managed Care Manual

2 comments on “Marketing Rules – Best Plan – SOC Scope of Appointment

  1. 17 comments on “Scope of Appointment – Telephone & Face to Face Meetings”

    1. Evan says:

      Hello Steve, thanks for getting into the weeds of this. It can be confusing even after AHIP.

      My question is:

      are communications with the prospect still considered ‘marketing’ even after the SOA has been signed?

      If so, the rules requiring plan benefits information to only be communicated through specific CMS-approved formats would seem to prevent an agent from discussing any plan benefits via email, or even over the phone if not following an official CMS-approved script.

      For instance, if a prospect sends me an email requesting that I share information about $0 premium MA plans and I have them fill out an SOA, I might then send an email saying ‘Company X and Y both have zero-premium plans in your area, let’s schedule a call to talk more…’

      In effect, by typing out that email I’ve just shared plan benefits information in a non-cms approved format. This interpretation of the rules seems prohibitively burdensome. My upline tells me that marketing rules don’t apply the same way after the SOA, but I’ve never seen that stated as such in any compliance training I’ve taken. What am I missing?

      Thank you,

      – Evan

      Reply
      • My biggest grip with AHIP and company training, is that they don’t show the actual law, brochure or Medicare Official Information, but use power point and then forbid agents to show it to anyone. IMHO it’s worthless!!!

        See above, where I cut and pasted the definition of marketing

        Definition Marketing Activities

        20 – Communications and Marketing Definitions 42 CFR §§ 422.2260, 423.2260

        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.

        These rules change… here’s the draft for 2019 See page 6, it looks like the same defintion

        So, IMHO it’s marketing. I think your question is, do you need a new scope of appointment each time you contact a prospect?

        Reply
        • 70.4.3 – Scope of Appointment

          42 CFR 422.2262, 422.2268(g) and (h), 423.2262, 423.2268 (g) and (h)

          When conducting marketing activities, in-person or telephonically, a Plan/Part D Sponsor may not market any health care related product during a marketing appointment beyond the scope that the beneficiary agreed to before the meeting. The Plan/Part D Sponsor must document the scope of the appointment prior to the appointment. Distinct lines of plan business include MA, PDP and Cost Plan products. If a Plan/Part D Sponsor would like to discuss additional products during the appointment in which the beneficiary indicated interest, but did not agree to discuss in advance, the Plan/Part D Sponsor must document a second scope of appointment (SOA) for the additional product type to continue 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.
           Date of appointment
           Beneficiary contact information (e.g., name, address, telephone number)
           Written or verbal documentation of beneficiary or appointed/authorized representative agreement
           The product type(s) (e.g., MA, PDP, MMP) the beneficiary has agreed to discuss during the scheduled appointment
           Agent information (e.g., name and contact information)
           A statement clarifying that:
          – beneficiaries are not obligated to enroll in a plan
          – current or future Medicare enrollment status will not be impacted
          – that the beneficiary is not automatically enrolled in the plan(s) discussed

          A beneficiary may sign an SOA at a marketing/sales event for a future appointment. Marketing/sales events, as defined in section 70.5, do not require documentation of beneficiary agreement.

          Note: Business reply cards (BRC) separate and independent from a marketing piece, must be submitted in HPMS if benefits and/or costs information is mentioned or the BRC is used as an agreement to be contacted, confirmation of attendance to a sales/marketing event, or request for additional information. Plans/Part D Sponsors should
          include a statement on the BRC informing the beneficiary that a sales person may call as a result of their returning a BRC. See section 90.2 for information on the material submission process.

          https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/CY-2018-Medicare-Marketing-Guidelines_Final072017.pdf#page=45

          I don’t find this in the current version…

          So, it appears that one only needs an SOC for appointments, not answering questions via email.

          Reply
      • I myself love Zoom meetings with screen sharing, as I can show the benefits using the approved summary of benefits for the respective company. That way, I’m not saying anything, the prospect and I are simply reviewing approved material. So, I wouldn’t say Company X & Y have Zero premiums, I’d send the Summary of Benefits and let the client look.

        While not required and I don’t represent Humana… I’ve taken their advise to heart, in all my sales endevors. That way no one can say I said something that wasn’t correct. I insist they go by the law or actual brochure, not what they think I said or may have said in error.

        I don’t see any difference in emailing before or after a SOC

        humana advise

        Reply
    2. Anonymous says:

      Is a scope of appointment required if benefits are going to be discussed prior to a beneficiary enrolling on their own via the PURL?

      Personalized URL (PURL): Receive commissions when Medicare beneficiaries use your personalized URL (non-agent-assisted) to enroll online in a WellCare plan.

      Reply
      • I don’t see any way around the mandate to get a scope of appointment. Check with your agency manager.

        https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/CY2019-Medicare-Communications-and-Marketing-Guidelines_Updated-090518.pdf

        Scope of Appointment Must be documented for all marketing activities, in-person, telephonically, including walk-ins to Plan/Part D sponsor or agent offices

        The term “marketing” is referenced at Section 1851(h) and 1860 D-4 of the Social Security Act (the Act), as well as in CMS regulations. The scope of the definition of “marketing materials” extends beyond the public’s general concept of advertising materials.

        70.4.2 – Personal/Individual Marketing Appointments 42 CFR 422.2268(f)-(h), 423.2268(f)-(h)
        All Plans/Part D Sponsors conducting one-on-one appointments with beneficiaries, regardless of the venue (e.g., in home, telephonic, or library), must follow the scope of appointment (SOA) guidance (see section 70.5.3).

        Reply
        • Lee M says:

          If a person registers for a marketing seminar for a specific plan/carrier and wants to sign up, is A scope of appointment still required since they obviously registered for the event.

          Reply
          • Yes! One of the things I hate about all these rules, is the AHIP and Company training that we are not allowed to share and is secret.

            Here’s excerpts from something I found it google to answer your question:

            https://www11.anthem.com/agent/noapplication/f1/s0/t0/pw_e235866.pdf?refer=ahpagent&state=va

            There are two types of sales events, formal and informal. At a marketing/sales event, plan representatives may discuss plan specific information like premium, cost-sharing, and/or benefits, as well as, distribute and/or collect enrollment applications.”

             Formal marketing/sales events are structured events of an audience/presenter style with a sales person providing specific plan information via a specific CMS approved sales presentation.

            Don’ts

            Require or otherwise use personal contact information, collected for purposes of a raffle or other event giveaway, as means of permission for future contact.

            Require the completion of or pressure event attendees to fill out a sign in sheet or business reply card (‘thank you’ card).

            ***Thus, there is NO Registration!

            SCOPE OF APPOINTMENTS (SOA) and Individual Appointments Practices

            Don’t

            Begin discussing MA or PDP plans prior to the beneficiary signing the SOA Form.

            https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/CY2019-Medicare-Communications-and-Marketing-Guidelines_Updated-090518.pdf

            50.2 – Marketing/Sales Events
            42 CFR §§ 422.2268(b)(1-5), 423.2268(b)(1-5)
            Marketing/Sales Events are designed to steer or attempt to steer potential enrollees, or the retention of current enrollees, toward a plan or limited set of plans. The following requirements apply to all marketing/sales events:

             Plans/Part D sponsors must submit scripts and presentations to CMS prior to use, including those to be used by agents/brokers;
             Sign in sheets must clearly be labeled as optional;
             Health screenings or other activities that may be perceived as, or used for, “cherry picking” are not permitted;
             Plans/Part D sponsors may not require attendees to provide contact information as a prerequisite for attending an event; and
             Contact information provided for raffles or drawings may only be used for that purpose.

            Scope of Appointment (Communications)

            Must be documented for all marketing activities, in-person, telephonically, including walk-ins to Plan/Part D sponsor or agent offices

            Reply
  2. CA Insurance Code 787 (i) All advertisements used by agents, producers, brokers, solicitors, or other persons for a policy of an insurer shall have written approval of the insurer before they may be used.

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