How to Stay Compliant During AEP

Written by Shelby Hudson

October 28, 2021

How to Stay Compliant During AEP

As we continue through the Medicare Advantage Annual Enrollment Period (AEP), it is crucial that agents thoroughly understand and follow the regulations set by CMS (Centers for Medicare and Medicaid Services). Simply put, your bottom line means nothing if it was non-compliant. We know compliance can be tricky, so here are some essential tips to staying compliant this AEP.

Permission to Contact

It is prohibited for agents to market or promote any plans to prospects without receiving permission to contact (P2C, also known as consent to contact, or C2C) or a business reply card (BRC). However straightforward this may seem to you, make sure you take note of the details.

For example, these activities violate P2C regulations:

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

It is also important to note that P2C agreements do not give an agent or agency permanents rights to market to an individual; the arrangements end when that product is no longer available during AEP. On the other hand, an agent does not need a P2C for clients that an agent personally enrolled if the individual is still an active member under the plan.

Scope of Appointment (SOA)

The SOA ensures agents follow CMS guidelines during their appointments with beneficiaries. SOAs need to be obtained at least 48 hours before the scheduled appointment time. Reason must be cited on the formed or within a recorded oral agreement if this is not possible. An exception to this rule is that an agent can meet with a beneficiary immediately after a marketing presentation if the beneficiary completes an SOA before the meeting.

SOAs should be taken seriously, as, in many instances, the SOA is the only evidence that your sale meeting was compliant. Agents are permitted to do the following when conducting an appointment:

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

Discussing any products not mentioned in the SOA is non-compliant and considered cold-calling.

Approved Scripts

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

  • Follow requirements set by CMS
  • Beneficiaries must be informed when a call transitions from a sales presentation to the enrollment by a yes or no question
  • State the individual is requesting enrollment into the plan name and play type
  • Acknowledge that the person will receive receipts of enrollment
  • The agent should provide their contact info, including a 1-800 number for any questions

Call recording protects agents from liability if a complaint is received after a telephonic enrollment. If complaints are filed, the recording ensures the agent provides the required information in a non-misleading way.

No Outbound Enrollment

Agents cannot enroll beneficiaries in a Medicare Advantage plan during outbound calls. Outbound sales calls can only be used if a beneficiary has requested information. A callback or the outbound call is for enrollment verification.

Here are rules to always follow when making an outbound sales call:

  • Agent must provide a privacy statement that clarifies that the beneficiary is not required to provide any health-related information to the sales agent unless the information is used to determine enrollment eligibility.
  • If a beneficiary requests enrollment over the phone via an outbound call, the agent can provide information on how the beneficiary can telephonically enroll in the plan.
  • Agents cannot transfer an outbound call to an inbound call flow (including warm transfer leads)

Including your enrollment verification into your welcome call workflow is recommended to free up licensed agents to sell.

Ensure your Marketing is Compliant

CMS also sets guidelines on marketing materials such as direct mail, websites, social media, etc. You must make sure anything you create and use to market your business is compliant. Agent Pipeline’s compliance team ensures our agents are notified of current rules, regulations, and marketing guidelines. Our team can review your marketing pieces or website for compliance, and our marketing team can provide you with pre-approved marketing pieces customized with your information – contact your marketer for more details.

To learn more about how Agent Pipeline can help you stay compliant and avoid any sales allegations – contact us today at 800.962.4693


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