Compliance

In an industry of rules and guidelines that are constantly changing from different regulatory bodies, compliance can be a very scary thing for agents and agencies selling and marketing Medicare products. It doesn't have to be, we're here to help; in fact it's part of our job!

Our staff, leadership team, and full-time compliance officer all have an in-depth understanding of what you can and can't do when selling Medicare products. We'll ensure that whether you're selling over the phone or in person you know what you can and cannot do.

Here are some of the most common trends in agent compliance infractions, and items that CMS is very focused on at the moment

Unlicensed sale. Sometimes agents sell plans in other states where they are either not licensed to do so, they only have a personal license but not their business license, or they're not properly appointed with the insurance carrier before they sell the policy. Please do not make this mistake. Before you sell in a non-resident state, check with our staff to ensure you are properly licensed, contracted, appointed and ready to sell (RTS). And please, do not let your license lapse, forget and then make this mistake. Agent fails to obtain a scope of appointment (SOA) before or at the beginning of a sales presentation. This is a requirement of all Medicare Advantage (MA) and Prescription Drug Plan (PDP) sales encounters, unless it is performed at a registered sales event.

Agent fails to review or read aloud the proper disclaimers or statement of understanding. When conducting a sale in person, it is on the last page of the paper application before the beneficiary signs. If it's a telephonic enrollment over the phone, it will be in the disclaimers at the end and you are required to read them aloud on a recorded line and have the consumer say "yes" or agree. No consent to enroll provided. This infraction occurs when a beneficiary tells an insurance carrier that they never gave the agent permission to enroll them in a plan or they did not understand that they were actually changing their insurance benefits. Agents need to be very transparent in plan and benefit presentation so consumers understand they are altering or changing their insurance coverage by completing an enrollment. It cannot be under the guise of simply performing a small update or enhancing benefits without disclosing that their plan coverage is changing.

Agents fail to do a proper needs analysis during the sales encounter process and have rapid disenrollments. Most commonly, we see that agents review copays or coinsurance, but don't properly review all the prescription drugs, doctors, facilities and providers that the beneficiary may be utilizing. Within a very short period of time the consumer suddenly has a plan that does not fit their health care needs and they cancel the plan due to poor needs analysis and recommendation by the agent. An agent sends out marketing pieces or conducts activities that are not compliant or approved. Generic marketing pieces such as direct mail, trifolds, websites, radio ads, call scripts and any other form of advertisement we can now file on your behalf with CMS and get a CMS approval number on your piece, prior to your advertising. Contact us today to help you with this process.

Agents don't understand the difference between educational vs. sales events and formal vs. informal. Each one of these event types has specific rules and guidelines that must be followed; don't sweat it, we'll walk you through it. Click Here to download our compliance quick reference guide and FAQ's, or Here for our comprehensive archive of compliance information.

Specific questions or concerns regarding compliance? Send an email to [email protected]. We'll respond within 24 hours to your request.