Module 4- Marketing Medicare Adv and Part D plans

Renewal year enrollment include plan changes between "like plans."

- A "like plan type" enrollment includes: o A PDP to another PDP o An MA, MA-PD, or MMP to another MA, MA-PD, or MMP o A section 1876 Cost Plan to another Section 1876 Cost Plan - An "unlike plan type" enrollment includes: o An MA or MA-PD plan to a PDP or Section 1876 Cost Plan o A PDP to a Section 1876 Cost Plan or an MA (or MA-PD) plan o A Section 1876 Cost Plan to an MA (or MA-PD) plan or PDP

Who releases the star ratings and what are the star ratings for?

- CMS releases the star ratings. - The star ratings allow beneficiaries to compare MA plans and Part D plans. These ratings include topics such as access to care, whether members got various screening tests, vaccines, and other check-ups to help them stay healthy, how members rate the plan, and customer service. The stars ratings must also be prominently posted on each plan's website.

Compensation includes monetary or non-monetary compensation of any kind relating to the sale or renewal of a policy including, but not limited to:

- Commissions - Bonuses - Gifts - Prizes or rewards - Referral or finder fees paid to agent/brokers

What are sponsors expected to include when documenting the scope of appointment (SOA)?

- Product type the beneficiary has agreed to discuss during the appointment, - Date of appointment - Beneficiary contact information - Written or verbal documentation of beneficiary or appointed/authorized representative agreement, - A statement that beneficiaries are not obligated to enroll in a plan; their current or future Medicare enrollment status will not be impacted and clearly explain that the beneficiary is not automatically enrolled in the plan(s) discussed.

What are the limits on Amount of Compensation?

- Compensation for initial year enrollments cannot exceed a FMV published annually by CMS, this is known as the FMV cut-off. - Compensation for renewal year enrollments cannot exceed 50% of the FMV cut-off. However, it can be less than 50% or not paid at all. - Referral or finders' fees paid to independent, captive or employed agents/brokers may not exceed $25 for PDPs or $100 for all other types of plans. - Referral fees paid to independent, captive or employed agents/brokers must be part of total compensation. Thus, any compensation paid for enrollments plus any referral fee paid to an agent may not exceed the FMV cut-off.

What activities represent unsolicited contact that marketing representatives are prohibited from doing?

- Door to door solicitation, including leaving leaflets, flyers, or door hangers at a residence or on someone's car. - Approaching beneficiaries in common areas such as parking lots, hallways, lobbies, or sidewalks. - Telephone calls - Text messages and other forms of electronic direct messaging (e.g. through social media platforms) The prohibition on making unsolicited contact does not extend to e-mail, conventional mail, and other print media such as advertisements.

When a beneficiary enrolls in a plan online, the plan sponsor must make these materials available how?

- Electronically e.g. via website links, the potential enrollee before the completion and submission of the enrollment request.

Beneficiaries and marketing representatives may access the following materials, as applicable to the plan, through each plan's website: Plans are required to post on their website these documents in a downloadable format.

- Evidence of coverage - Summary of Benefits - Annual Notice of Change - Provider Directory - Pharmacy Directory - Formulary These tools are used to help marketing representative determine if beneficiary's providers or pharmacies are in the plan network, whether the drugs the beneficiary takes are on the plan's formulary, whether the plan covers other benefits that are important to a beneficiary and whether or the extent to which the plan covers out-of-network services.

What does CMS regulate when it comes to communication with enrollees?

- How marketing representatives can contact potential enrollees. What marketing representatives may say to enrollees and potential enrollees

What are permitted contacts an agent may make?

- Initiate electronic contact through email. However, they must provide an opt-out process to no longer receive electronic communications. - Call a beneficiary who the marketing representative enrolled in a plan while the beneficiary is an enrollee of that organization. - Return calls or messages from individuals who initiate contact and request information. - Call beneficiaries who have expressly given permission for the contact, for example by filling out a business reply card or asking a plan customer service representative to have an agent contact them. - Call beneficiaries to confirm an appointment that has already been agreed to by a beneficiary. - Call beneficiaries who submit enrollment applications to conduct business related to enrollment. - Call current enrollees, including those in non-Medicare products, to discuss plan business, for example, they may: o Contact individuals enrolled in one of the MA organization's commercial producers when the individual is aging into Medicare, o Contact the MA organization's Medicaid plan enrollees to discuss Medicare products, o Contact current MA enrollees to promote other Medicare plan types or to discuss plan options/benefits, and o Contact the MA organization's Medigap enrollees regarding MA, PDP, or cost plan options. Call current enrollees of a plan to discuss/inform them about general plan information such as Annual Enrollment Period dates, availability of flu shots, upcoming plan changes, educational events, and other important plan information.

The Medicare marketing and communications rules apply to which types of Medicare health plans and Part D plans?

- MA only plans - MA-PD plans - PDPs - Medicare-Medicaid Plans MMPs - Section 1876 Cost plans o For MMPs, marketing requirements may be modified by state- specific requirements. Each state in which MMPs are offered has state-specific marketing guidelines and CMC-approved model documents.

During OEP marketing representatives may conduct marketing activities that focus on other enrollment opportunities, including but not limited to:

- Marketing to individuals turning 65 (who have not yet made an enrollment decision) - Marketing by 5-sar plans regarding their continuous enrollment SEP. - Marketing to dual-eligible and LIS beneficiaries who, in general, may make changes once per calendar quarter during the first nine months of the year. In addition, marketing representatives may send marketing material when a beneficiary makes a proactive request, at the beneficiaries request have one-on-one meetings with a sales agent, at the beneficiaries request provide info. On the OEP through the Plan's call center.

Compensation does not include:

- Payment of fees to comply with State appointment laws, training, certification, and testing costs. - Provision of a budget that must be used to pay for marketing, such as advertisements in local media. - Reimbursement for mileage for appointments with beneficiaries or costs associated with the beneficiary sales appointments such as venue rent, snacks, and materials.

Plan Ratings- Required Practices

- Plan sponsors must provide the plan's overall performance rating to the beneficiaries in the standard Plan Ratings information document. - New Plans/Part D Sponsors that do not have any star ratings information are not required to provide star ratings info. Until the next contract year. - Plan sponsors and their marketing representatives may only reference or mention a plan's rating on an individual measure in conjunction with the plan's overall performance rating (MA-PD), the contracts highest rating, Part C summary rating (MA-only), or Part D summary rating (PDP), with equal or greater prominence. - Plan sponsors and their marketing representatives may only market the star ratings in the service area in which the star rating is applicable.

When a beneficiary is provided with enrollment instructions/form, what else must they also receive?

- Plans ratings information - Summary of Benefits - Pre-enrollment checklist Dual Eligible Special Needs Plan- if Medicaid benefits are not included in the summary of benefits, a separate document including the Medicaid benefits must be included with the enrollment form.

During OEP marketing representatives may not:

- Send unsolicited materials advertising the ability/opportunity to make an additional enrollment change or referencing the OEP. - Specifically target beneficiaries who are in the OEP because they chose during the Annual Enrollment Period (AEP) by the purchase of mailing lists or other means of identification. - Engage in or promote activities that intend to target OEP as an opportunity to make further sales. - Call or otherwise contact former enrollees who have selected a new plan during AEP.

What marketing activities does CMS regulate?

- Setting- CMS has rules regarding marketing in a health care setting versus marketing in other settings and marketing at educational versus marketing events. - Who may market- CMS requires marketing representatives to comply with state laws concerning licensure; CMS places strict limits on marketing by health care providers. - Timing- CMS regulates when marketing representatives can begin marketing the next year's plans. - Contact- CMS regulates how marketing representatives can contact potential enrollees. - Content- CMS regulates what marketing representatives may say to enrollees and potential enrollees. CMS may require that certain disclaimers or other information be included in marketing materials. CMS also prohibits the use of certain claims or language. CMS requires all marketing materials be submitted to CMS for approval and/or review. o Unless specified by CMS, third-party and downstream entities are not permitted to submit materials directly to CMS, only the plan sponsor may do so.

Plan sponsors and their marketing representatives may not:

- Use a plan's star rating in an individual category or measure to imply a higher overall plan rating than is actually the case. - Use the plan's star ratings in a manner that misleads beneficiaries into enrolling in plans based on inaccurate information. - Specifically, target beneficiaries in poor performing plans. - Use updated star ratings until CMS releases star ratings on the Medicare Plan Finder - Continue to use an old star rating after 21 days from the release of a new star rating.

If a beneficiary disenrolls within the first 3 months of enrollment (rapid disenrollment), the entire compensation amount paid for the enrollment must be recouped, except under certain circumstances.

- When a beneficiary enrolls in a plan effective October 1, November 1 or December 1 and subsequently changes plans effective January 1 of the following year during the Annual Election Period. - When a beneficiary disenrolls in the first 3 months because the beneficiary: o Became dually eligible for both Medicare and Medicaid. o Qualified for another plan based on special needs. o Became LIS eligible. o Loss Medicare entitlement. o Moved out of the service area. o Failed to pay the plan premium. o Changed enrollment to a plan with 5-star rating or disenrolled from a LPI plan to move into a plan with 3 or more star. o Moved into or out of an institution. o Gained/dropped employer/union sponsored coverage.

What is the Medicare Advantage Open Enrollment Period (MA-OEP)?

A period during which an individual enrolled in an MA or PA-PD plan can make a one-time change to another MA plan, elect original Medicare, or can change Part D coverage.

What is dual-plan enrollment?

Enrollment in two plans at once. For example- enrollment in an MA-only plan like MSA and a stand-alone PDP or a cost plan and a PDP), the compensation rules apply independently to each plan.

Gifts and promotional items limits.

Gifts can be provided if they are of nominal value and provided regardless of enrollment and without discrimination. - Gifts are of nominal value if an individual item is worth $15 or less based on the retail purchase price of the item (it does not matter if the plan or representative pays less for the item) - When more than one gift is offered on one occasion, the combined value of all items must not exceed $15 - Multiple gifts given to a beneficiary on different occasions may not exceed $75 aggregate, per person, per year. - Gifts or prizes must not be in the form of cash or cash equivalents or other monetary reward or rebate even if their worth is less than $15 - Cash equivalents include: o Gift certificates or cards that can be readily converted to cash o Gift cards that may be used anywhere for anything, such as VISA gift cards o Debit cards - Rebates would include, for example, a discount on the first month's premium or on a copayment. Gifts or prizes may not be charitable contributions.

What is communication?

Is activities and material that provide information to current and prospective enrollees that: - Contains no marketing content; or - Are a material that includes marketing content but is explicitly designated by CMS as communication because it does not have marketing intent. For example: CMS designates the Evidence of coverage as a communication material, while the summary of benefits and an annual notice of change are marketing material.

What is marketing?

Marketing is activities and materials that provide information to current and prospective enrollees that include both marketing intent and content. - Marketing intent- the purpose of marketing activities and materials is to draw a prospective or current enrollee's attention to a plan or group of plans to influence a beneficiary's plan choice, including a decision to remain enrolled in his/her plan. - Marketing content- Marketing activities and materials include: o Information about benefits or benefit structure o Information about premiums and cost-sharing o Comparisons to other Plan(s)/Part D sponsor(s) o Rankings or measurements about other Plan(s)/Part D sponsors(s) o Information about Star Ratings

What are individual marketing appointments?

Personal/individual marketing appointments are those tailored to an individual or small group. They are not defined by the location. Before the appointment begins, the agent and beneficiary must complete a scope of appointment. During the appointment representatives may market only health care related products; such products include Medicare health plans, Medigap, and dental plans, but not accident-only plans. Before any marketing appointment, reps must identify the types of product(s) that will be discussed, obtain agreement from the beneficiary and documentation that agreement (scope of appointment).

When does rapid disenrollment apply?

When an enrollee moves form one parent organization to another parent organization, or when an enrollee moves from one plan to another plan within the same parent organization.

For telephone enrollments, the beneficiary must be told what verbally?

Where the summary of benefits and star ratings documents may be accessed.