Compliance

Medicare Market Conduct Addendum

This Addendum describes certain guidelines regarding the marketing, soliciting, and facilitating of enrollments for the Company’s Medicare MA and MA-PD plans. Agent shall comply with all Company and CMS policies, and other applicable laws, regulations, and guidelines, including but not limited to those in this Exhibit.

With any conflict of statement between this Addendum and the published and applicable regulations from CMS, North Carolina and/or Texas Insurance Departments or any other regulatory agency or entity of competent jurisdiction, this Addendum shall be considered amended as to properly reflect the official guidance or rule.

This Addendum may be amended from time to time by the Company in its sole discretion, and such amendments shall be provided to Agent.

1. Agent understands that in marketing, soliciting, and facilitating enrollments for MA and MA-PD membership, Agent is not permitted to, and will not:

  • engage in any marketing and solicitation of enrollments or distribution of any marketing materials prior to such date(s) as may be specified by CMS;
  • engage in door-to-door canvassing or approaching prospects in common areas, and only visit prospects when invited to do so, consistent with CMS scope of appointment requirements;
  • engage in marketing of non-healthcare related products (such as annuities and life insurance) to prospective enrollees during any MA or Part D sales activity or presentation (as defined in CMS guidelines), except to the extent consistent with CMS marketing guidelines for selling of non-health related products on inbound telephone calls when a beneficiary requests information on other non- health products;
  • engage in cold calling or other unsolicited telephone or electronic contacts, provided that:
    • if a beneficiary contacts Agent or the Company to grant permission for a solicitation, such permission shall be considered short-term and event- specific and not treated as open-ended permission for future contacts;
    • permission for a solicitation applies only to the scope of product (MA or MA-PD) previously discussed or indicated by the beneficiary, on a completed scope of appointment form, except to the extent CMS may otherwise permit, and subject to CMS scope of appointment requirements;
    • if a beneficiary grants such permission for a contact, Agent will utilize only telephone scripts or electronic messages approved in writing by the Company and CMS if applicable prior to the utilization of any such script or message;
    • Agent is permitted to contact a beneficiary enrolled in a Company MA or MA-PD plan, if Agent had enrolled the individual into such plan, or initiate a phone call to confirm an appointment that has already been agreed to by a beneficiary via completed scope of appointment documentation, provided that any such contact complies (to the extent applicable) with Federal Trade Commission’s Requirements for Sellers and Telemarketers, Federal Communications Commission rules and applicable State law, National-Do-Not-Call Registry, any individual’s “Do not call again” request, and Federal and State calling hours; and
    • E-mails may be sent to a beneficiary who agrees to receive e-mails and has provided his/her e-mail address, provided that Agent complies with CMS restrictions relating to e-mails, including providing an opt-out process for beneficiaries who no longer wish to receive e-mail communications;
  • Agent shall not, in any event (including, without limitation, nonpayment of any compensation make any inquiry as to the health of the prospective member, unless inquiring if MA and MA-PD enrollee has End Stage Renal Disease (ESRD) – or as CMS may otherwise permit (e.g., in connection with special needs plans), and in no event shall any such inquiry be a health screening or other like activity that could give the impression of impermissible “cherry picking” of individuals based on their health status;
  • in any way seek to limit Agent’s MA or MA-PD marketing, solicitation or enrollment by reason of the health condition or health history of the prospective member, except as noted in 1(e);
  • use any marketing material – including brochures; illustrations; examples; flip charts; handouts; scripts; radio, television and print ads; internet advertising; and any other material primarily intended to attract or appeal to prospective members for MA or MA-PD membership – other than marketing material supplied by, or approved in writing by the Company (and as applicable, CMS) for use in marketing, soliciting, and facilitating enrollments for MA or MA-PD products;
  • alter, modify, waive or change any of the terms, rates or conditions of any advertisement, marketing materials, scripts (including, but not limited to, telephone scripts and other sales scripts), receipts, policies or contracts of the Company, in any respect, including making verbal statements in conflict with information in written materials;
  • discriminate based on race, ethnicity, religion, gender, sexual orientation, disability, health status or geographic location, including targeting marketing to beneficiaries from higher income areas or stating or otherwise implying that plans are available only to seniors rather than all Medicare beneficiaries;
  • offer or give to any prospective member any gift or premium except in compliance with the rules, guidelines and regulations of CMS and other applicable healthcare laws, including restrictions on cash inducements of any kind, on gifts of more than nominal value, on meals at events at which plan benefits are being discussed and/or plan materials are being distributed;
  • market, solicit, or sell for the Company in any state:
    • where Agent is not duly authorized by the Company;
    • where Agent does not have the required licenses; or,
    • until Agent’s authority to represent the Company is confirmed by the Company;
  • require beneficiaries to provide any contact information as a prerequisite for attending an event (sign-in sheets must clearly indicate that completion of any contact information is optional) or for participating in a raffle or drawing;
  • schedule a one-on -one meeting with an individual without complying with CMS scope of appointment requirements;
  • ask a beneficiary for referrals;
  • sign an enrollment form for a beneficiary when agent was not involved in the enrollment process for such beneficiary; or
  • make any statements that convey the impression that the business or product is approved, endorsed, or authorized by Medicare or any other government agency, or any other statements that are prohibited under CMS guidance.

2. Agent shall notify Company in accordance with Company policies and otherwise assist Company in ensuring compliance with CMS guidelines regarding the timely scheduling, registration, notification, and cancellation of marketing/sales events.

3. Agent shall not conduct sales activities in healthcare settings except in common areas, in accordance with CMS guidelines.

4. Agent must participate in all required training programs (including annual training) and review in detail training material established by the Company regarding the MA or MA-PD marketing guidelines and other applicable laws and the details specific to the Company’s products. In order to sell Medicare products for Company, an Agent is required to receive a passing score of at least eighty-five (85) percent. If an Agent fails to meet the passing score for one training examination, the Agent shall have one additional opportunity to take the test and achieve a passing score. Agents will not use MA or MA-PD certification as a marketing tool.

5. If Agent or its sub-agents engages in marketing/sales activities in a retail pharmacy, such Agent/sub-agent shall comply with all Company policies relating to such assignment and shall defend, indemnify and hold the pharmacy harmless in the event of a claim, loss or expense arising out of the Agent or sub-agent’s acts or omissions.

6. In accordance with the requirements of CMS for disenrollment and/or Company-applied guidelines, if a MA or MA-PD member disenrolls within the first three months after the effective date of the enrollment, or at any other time a beneficiary is not enrolled, all commissions paid, credited, or advanced for such membership shall be charged back.

7. Agent shall not, in any event (including, without limitation, nonpayment of any compensation provided for by this Agreement) bill, charge, seek compensation or remuneration or reimbursement from, hold responsible, or otherwise have any recourse against any Medicare beneficiary (whether an actual or prospective enrollee) for any amounts otherwise payable by the Company.

8. Agent must make the following disclosure, prior to enrollment or at the time of enrollment, in writing, to a potential enrollee: “The person that is discussing plan options with you is contracted with the Company. The person may be compensated based on your enrollment in a plan.” In addition, Agent must make all disclosures required under CMS guidelines at marketing/sales events, including an announcement at the beginning of the presentation regarding all products/plan types that will be covered during the presentation and specific disclosures relating to private-fee-for service products and special needs plans, as applicable.

9. Agent shall be responsible for complying with all applicable state and federal privacy and security requirements. Accordingly, Agent shall comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended, relating to the privacy and security of individually identifiable health information and all regulations adopted in connection therewith. Consistent with these obligations and as evidenced by Agent’s signature to this Agreement, Agent hereby agrees to comply with the terms and conditions set forth in the HIPAA Business Associate Contract Privacy Addendum attached hereto as an Addendum and incorporated herein by reference to address the handling of protected health information. In addition, Agent shall comply with all CMS guidelines relating to the allowable use of Medicare beneficiary information.

10. Agent shall immediately notify company of:

  • any and all disciplinary actions taken against Agent; and
  • any evidence of noncompliance with any state or federal law or regulation that is related to Agent’s obligations under this agreement.

11. Agent shall comply with any restrictions that the Company may impose, as permitted by CMS, on marketing or sales of MA or MA-PD products to specific group(s) of Medicare beneficiaries.

12. Agent shall provide approved materials with respect to non-English speaking populations and populations with special needs to the extent required by CMS or Company policies.

Last Updated on September 8, 2020 by marketing