Lesson 4: Medicare Marketing Regulations

1. Lesson 4:Medicare Marketing Regulations 2011 MIPPA Agent Training

2. Marketing Materials:Overview • Marketing materials are designed for Medicare beneficiaries to: • Promote a health or drug plan • Provide enrollment information • Explain benefits and how services are provided • Marketing materials not only include advertising materials but also include enrollment and disenrollment forms and letters.

3. Marketing Materials:Overview (cont’d) • Only CMS-approved marketing materials may be used to market health and drug plans • Forbidden to use words or symbols including Medicare, Centers for Medicare & Medicaid Services, Department of Health and Human Services that would convey the impression that the product is approved, endorsed or authorized by Medicare • Medicare Marketing Guidelines may be found: www.cms.hhs.gov/prescriptiondrugcovcontra/downloads/finalmarketingguidelines.pdf

4. Advertising Materials:Examples • Television ads • Radio ads • Internet advertising • Window stickers • Outdoor advertising (billboards, signs attached to transportation vehicles) • Banner and banner-like ads • Event signage • Counter tents • Print ads (newspaper, magazine, flyers, brochures, posters, church bulletins) • Post stands and free-standing inserts (newspapers or magazines) • Pharmacist’s promotional buttons

5. Explanatory Materials:Overview • A subset of marketing materials • Applies to Medicare Part C and Part D • Explains benefits, operational procedures, cost sharing, and/or other features of a health or drug plan to current members or those considering enrolling • Two types of explanatory materials: • Pre-enrollment materials • Post-enrollment materials

6. Explanatory Materials:Pre-enrollment • Pre-enrollment materials provide more detail on the plan than what is provided in an advertisement • Generally used by prospective enrollees to decide whether or not to enroll in a plan • Plan rules and organization benefits are among the information included in pre-enrollment materials • Examples: • Sales scripts or sales presentations • Direct mail that includes enrollment forms or letters • Product descriptions or sales kits used by sales agents

7. Explanatory Materials:Required pre-enrolment materials • Required pre-enrollment materials are used to assist potential enrollees in making an informed decision and must include:

8. Explanatory Materials:Post-enrollment • Conveys benefits or operational information to enrolled plan members • Includes all notification forms and letters that are used to communicate membership policies, rules and procedures • Examples: • Annual Notice of Change/Evidence of Coverage • Pharmacy Directory • Provider Directory • Disenrollment forms and letters • Member ID card • Grievance, coverage determinations and appeal letters.

9. Explanatory Materials:Required post-enrollment materials • Required post-enrollment materials include:

10. New Marketing Guidelines • Standardized plan types (HMO, PPO, PFFS, PDP) • Plan type must be included in plan logo • A series of disclaimers have been released that must be included on advertising and plan materials.

11. New Marketing Guidelines (continued) • Unsolicited e-mails, no purchasing of e-mail lists. Beneficiary must provide their e-mail address. Plan must provide an “opt out” method for beneficiaries who no longer wish to receive e-mails. • No “cold calling” via phone or e-mail. • Once a beneficiary has provided permission for contact, plans cannot request social security numbers, bank account or credit card numbers or HICN numbers.

12. CMS Approval • CMS approval is required for: • All advertising • Plan documents • Envelopes with required outside designation of: • Important Plan Information • This is an advertisement • Health or wellness or prevention information • Non-health or non-plan related information • Envelopes cannot be designed with flags or other designs implying they are from a government entity

13. Outbound Verification Calls (OVC) • Purpose is to assure that beneficiary understands the plan on which they enrolled • Calls must be made for every enrollment or change within a plan to a different type of product (PDP to HMO) • They must be conducted after the sale not at the time and must not be done by the sales agent.

14. Educational Events • No sales activity; cannot discuss plans or benefits • No distribution of marketing materials • Cannot distribute business cards or have sign-up sheets • A business card may be provided only upon request of the beneficiary • May not set up appointments or get permission for an outbound call.

15. Sales Activities in a Health Care Setting • Plans may not conduct sales activities in health care settings except in common areas such as cafeterias or conference rooms. • Upon request of a beneficiary plans are permitted to schedule an appointment with a resident in a long-term facility or assisted living. • Providers may not be involved in: • Accepting enrollments, • Directing/steering a beneficiary to a particular plan • Mailing marketing materials on behalf of a plan • Accepting compensation from the plan for beneficiary enrollment activities

16. Sample of Disclaimers • A Medicare Advantage organization with a Medicare contract • This event is only for education purposes and no plan specific benefits or details will be shared. • A Sales person will be present with information and applications. • The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. • You must continue to pay your Medicare Part B premium.

17. Sales Events • Date/time/location must be reported to CMS the month prior to the event. • Can only provide gifts of nominal value, defined as $15 or less based on the retail value of the item. This is an annual maximum. • The gift must be offered to all attendees with no obligation.

18. Marketing Surveillance CMS will conduct “secret shopper” activities • call centers for existing members • Sales departments for prospective members • Sales events, including individual appointments • Educational events • Newspaper clipping of ads and events

19. Scope of Appointment • The scope of appointment must be agreed to by the beneficiary prior to any face-to-face individual marketing appointment. The scope of appointment must be documented in writing or by recorded telephone call. • The scope of appointment must detail the products to be discussed during the appointment. Any deviation will require a second scope of appointment. • A “walk-in” by a beneficiary requires a scope of appointment signed by the beneficiary before discussion of plan products.

20. Customer Call Center Requirements • Hours of operation, seven days a week from 8:00 am to 8:00 pm during Annual Election Period and sixty (60) days beyond. • Beyond the sixty (60) day period, calls centers are permitted on Saturday, Sundays and holidays to have members leave messages and return the call on the first following business day.

21. Call Center Requirements (continued) • Provide service to all non-English speaking and hearing impaired beneficiaries • Follow a documented process for handling complaints • Understand CMS policy on Best Available Evidence (BAE)

22. Best Available Evidence (BAE) • Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. • To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate

23. Use of Medicare Mark