4 Tips to Stay Compliant During AEP

As the annual election period (AEP) continues, it’s imperative the regulations established by the Centers for Medicare & Medicaid Services (CMS) for 2017 are thoroughly understood. After all, your bottom line is meaningless if it’s not compliant.

Below are four essential components to remember during AEP.

Consent to Contact (C2C)

CMS regulations prohibit agents from marketing or promoting plans prior to receiving consent to contact (C2C) or a Business Reply Card (BRC). That sounds straightforward enough, but make sure you know the particulars.

Below are activities that violate consent to contact regulations:

  • Door-to-door solicitation
  • Outbound telemarketing calls including calling referrals provided by members
  • Approaching a beneficiary in a public space
  • Follow-up calls about mailings prior to receiving a response

Keep in mind that consent to contact agreements are temporary and do not give an agency permanent rights to market to that individual. The permission to call ends when that specific product is no longer available during AEP. However, an agent does not need C2C for members the agent personally enrolled if that individual is still an active member under that plan.

Scope of Appointment (SOA)

The SOA ensures that agents are following CMS guidelines during appointments with beneficiaries. SOAs should be obtained at least 48 hours prior to the scheduled appointment time. In the event this is not possible, the reason must be sited on the form or within the recorded oral agreement.  One exception is a beneficiary can meet with an agent immediately after a marketing presentation if the beneficiary completes a SOA form before the meeting.

Take the SOA seriously; many times the SOA is the only evidence that indicates your sales meeting was compliant. When conducting an appointment, here are the things an agent is permitted to do:

  • Discuss plan options and provide plan materials that the beneficiary agreed to hear about
  • Inform where information about the plan can be found online or over the phone
  • Provide educational materials
  • Collect enrollment forms
  • Leave business cards for the beneficiary to give to friends and family

Discussing products that are not outlined in the scope of appointment (SOA) is considered cold-calling.

Approved Scripts

Providing agents a sales script ensures all information given to beneficiaries falls within CMS guidelines. All enrollment scripts must be submitted into Health Plan Management System (HPMS) verbatim even those that are used by downline agents on behalf of the plan. All scripts must include the following:

  • Follow requirements established in the CMS Eligibility and Enrollments Guidelines
  • Beneficiaries must be clearly informed when a call transitions from a sales presentation to enrollment in the form of a yes or no question.
  • State that the individual is requesting enrollment into the plan name and plan type
  • Acknowledge the person will receive a receipt of the enrollment
  • Provide contact information including a 1-800 number for further questions

Call recording protects agents and the agency from liability if a complaint is received after a telephonic enrollment was made. If complaints are filed, the recording is used to ensure the agent provided the required information in a non-misleading way.

No Outbound Enrollment

Agents cannot enroll a beneficiary in a Medicare Advantage plan through an outbound call. Outbound sales calls can only be used to reach out to a beneficiary that has requested information, a call back or the outbound call is for an enrollment verification.

When making an outbound sales call, always adhere to the below:

  • A privacy statement clarifying that the beneficiary is not required to provide any health related information to the sales agent unless the information will be used to determine enrollment eligibility.
  • If a beneficiary requests enrollment over the telephone via an outbound call, the agent can provide information as to how the beneficiary can enroll in the plan telephonically.
  • Do not transfer an outbound call to an inbound call flow (this includes your warm transfer leads)

It’s recommended to include your enrollment verification into your welcome call workflow to free up licensed agents to sell.

In addition to these four key components, there are other critical compliance requirements an agency must consider when structuring Medicare sales. It’s important to review any changes from CMS in real time and update internal processes to ensure adherence to guidelines. Contact AgentCubed to see why we are considered the leader in Medicare sales solutions.