Marketing Updates: Medicare Marketing Guidelines; OEV and Surveillance Findings and Areas of Compliance Focus

1. Marketing Updates: Medicare Marketing Guidelines; OEV and Surveillance Findings and Areas of Compliance Focus April 12, 2012 Chevell Thomas Christine Reinhard Division of Surveillance, Compliance, & Marketing Medicare Drug & Health Plan Contract Administration Group

2. Overview of Presentation • Medicare Marketing Guidelines (MMG) • Outbound Enrollment Verification Calls • Surveillance Results • Compliance Focus for 2012

3. MEDICARE MARKETING GUIDELINES (MMG) UPDATE • Medicare Marketing Guidelines Streamlining Project • Began Fall 2011 • Focus • Marketing requirements (Subpart V) • Eliminating redundancy • Consolidating requirements • Reducing prescriptiveness • Cut ~70 pages

4. MMG Guiding Principles • Plan sponsors are responsible for: • Compliance with CMS’ current marketing regulations and guidance • Full disclosure when providing information to beneficiaries about plan benefits, policies and procedures • Documenting compliance with all applicable MMG requirements

5. First Principle • Compliance with CMS’ current marketing regulations and guidance, including monitoring and overseeing the activities of their subcontractors, downstream entities and/or delegated entities • Agents, Brokers, Third-party Marketing Organizations (TMOs), Providers, Pharmacy Benefit Managers (PBMs), etc. • Materials, activities, and information

6. Second Principle • Full disclosure when providing information to beneficiaries about plan benefits, policies, and procedures • Materials are accurate, do not mislead and do not misrepresent the sponsor or plan products • Beneficiaries must have the information complete to make their own choices

7. Third Principle • Documenting compliance with all applicable MMG requirements • Plan sponsors are responsible for developing systems to monitor and document compliance with all aspects of their marketing program • Calls, appointments, material dissemination, use of personal information • Oversight • Processes

8. Marketing Changes for 2013 • Health Plan ID cards • Agent/Broker Fair Market Value Cut-off Amounts • Materials Not Subject to Review • OMB forms • Ad hoc Enrollee Communication Materials • Materials Eligible for File & Use • Scripts • Summary of Benefits (SBs) • Other marketing materials (considering) • Agent/Broker Reporting Requirements (considering)

9. Outbound Enrollment Verification (OEV)

10. Outbound Enrollment Verification Call Audit Findings • Significant number of benefit related questions • Didn’t know premium • Didn’t know cost sharing • Plan processed cancellations as disenrollments • Plan unable to process cancellations • Plan failed to address beneficiary questions

11. Outbound Enrollment Verification – Suggestions for Improvement • Listen to your OEV calls • Ensure your disenrollment department understand cancellation requirements • Address beneficiary questions • Provide CSRs with training and tools to answer questions • CSRs did not know their plan’s premium • Beneficiaries did not understand plan rules • CSRs did not explain the plan rules

12. Benefits of Reviewing OEV Calls • You will have a better understanding of how agents/brokers are marketing • You can use information to update training • You should see a decrease in complaints

13. Surveillance Results

14. 2012 Surveillance Activities • Secret Shopping of Formal Events • Surveillance Marketing Allegation Response Team (SMART) Activity • Tracking of Unreported Marketing Events

15. Secret Shopping Preliminary Results • Over 1650 formal events shopped • CMS Regional Offices • CMS contractors • State Departments of Insurance • We continue to see improvements

16. Top Deficiencies Found In Secret Shopping • Events not taking place • Approximately 5% of events CMS attempted to shop did not occur • Remember to cancel events in HPMS at least 48 hours in advance • If timely cancellation in HPMS is not possible, a plan representative should be at the site

17. Top Deficiencies Found in Secret Shopping • Absolute marketing statements • Inaccurate statements • Inappropriate statements • Scare tactics

18. Top Deficiencies Found In Secret Shopping • Absolute marketing statements – not permissible • Certain plan is the best • Most recognizable name in market • Largest enrollment growth • Lowest annual out of pocket costs • Largest Medicare provider network • We have more drugs on our formulary than anyone else

19. Top Deficiencies Found In Secret Shopping • Inaccurate statements • “A 3.5 rating is excellent” • “There are no 5 star plans” • “The government allows you to test drive for a year” • “We have 3.5 stars but most plans only have 2 stars”

20. Top Deficiencies in Secret Shopping • Inappropriate statements • “I don’t know how long you’ll have a choice” • “CMS will penalize you if you don’t enroll in a Medicare plan or a stand-alone prescription drug plan” • “Original Medicare is a disaster” • “Original Medicare won’t be around” • “You can’t win with CMS”

21. Top Deficiencies Found In Secret Shopping • Scare tactics • “By 2012 all plans would require deductibles, co-pays and/or coinsurance…take advantage…zeros while they can” • “If other plans have a $0 copay, they will get their money somewhere…cut the number of hospitals…authorization for all medical tests…not letting your doctor make the decision”

22. Top Deficiencies in Secret Shopping • Failure to ensure contact information optional • Form may state optional, but agent/broker pressure • Failure to adequately explain drug coverage • Which drugs are covered • Failure to adequately explain Special Needs Plans • Disenrollment and eligibility • Prescription drug coverage

23. Secret Shopping Observations • Presenter did not cover the entire presentation • Insufficient number of copies of materials • Inadequate explanation of rules • Use of contracted pharmacies • Late Enrollment Penalty

24. Addressing Specific Agent Issue - Surveillance • Monitor data for trends • Deficiencies per agent • Geographic differences • Provide necessary training • Take appropriate disciplinary action • Document actions taken against agents/brokers

25. Unreported Marketing Events • Reviewed advertisements to ensure parent organizations are reporting scheduled marketing events to CMS • Reviewed over 2100 advertisements • The 2100 advertisements listed over 9700 events • No decrease in unreported events between 2011 and 2012 • Approximately 4% of advertisements reviewed were not submitted to HPMS

26. Surveillance Marketing Allegation Response Team (SMART) • Received and investigated referrals of potential marketing misrepresentation from numerous sources • Senior Medicare Patrol • Beneficiaries • CMS staff • Plan sponsors • State Departments of Insurance • SHIPs

27. SMART Referrals • Types of referrals/allegations received • Door to door solicitation • Inaccurate statements made by agents/brokers • Third party marketing • Unapproved marketing materials • General inquiries

28. SMART Actions • Referred issue to Account Manager • Follow up by sponsor • Performed secret shop • Referred to Medic • No action

29. Plan Sponsor Secret Shopping • CMS to inquire about Sponsor’s secret shopping programs • Tool development • Resources used to shop • Risk assessment for shopping • Shopping findings

30. Areas of Compliance Review

31. Bids and Benefits • Bids • Failure to include supporting documentation that describes how the findings and observations have been addressed • Failure to follow Actuarial Standards of Practice (ASOP) • Basing Part D worksheet risk scores on the wrong risk model • Benefits • Plan corrections

32. ANOC/EOC Documents • Inaccurate information • Untimely distribution of ANOC/EOC documents

33. Agent/Broker Compensation • Submission of compensation information • Attesting to compensation information • Attesting timely

34. File and Use – Retrospective Review • Review of existing File and Use documents • Moving more document types to File and Use • More systematic retroactive review • National effort • Consistency • Compliance letters based on national findings

35. Risk Adjustment and Encounter Data • Development of compliance process • Timeliness • Accuracy • Completeness of submission • Compliance letters release for Encounter Data certification process

36. Reminders

37. Sponsors and the CTM • Think “beneficiaries first” • Work cases thoroughly and expeditiously • Perform trend analysis • Areas where issues could be resolved at sponsor level • Notify CMS of trends and significant issues • Conduct root cause analysis • Implement processes to address findings • Implement corrective actions

38. CMS and the CTM • We perform regular review of issues • We identify and notify sponsors of our findings • Sponsors should have already identified the same findings • Tracking and trending • Investigations • Enforcement

39. Questions? marketing@cms.hhs.gov surveillance@cms.hhs.gov Chevell Thomas chevell.thomas@cms.hhs.gov 410-786-1387 Christine Reinhard christine.reinhard@cms.hhs.gov 410-786-2987