A Complete Guide to Medicare Compliance Training

Written by Matthew King, time it takes to read this article is  minute(s).

Medicare is a lucrative career for insurance salespeople. This applies whether it’s the only insurance you sell or in addition to other medical options.

The number of people enrolling in Medicare has doubled since 2010. This is because of the over-65 demographic growing rapidly as baby boomers age into retirement.

More than 3,500 Medicare Advantage (MA) plans are available throughout the United States. The 2021 projection is that Medicare Advantage will gain 2 million members this year, totaling 26.5 million beneficiaries. This is an ever-expanding combination of client growth and plan options.

Medicare compliance training is a requirement when selling these policies. This is because your actions impact the Medicare enrollee, the Medicare Program, and the Medicare Trust Fund. The goal is to avoid fraud, waste, and abuse of the system.

If you want to add Medicare to your insurance offerings or make sure you are current, keep reading. We will provide you with Medicare compliance training information and how to become a Medicare salesperson.

What Is Medicare Compliance Training?

The Center for Medicaid and Medicare Services (CMS) has annual compliance training standards. These are a requirement for agents and brokers who sell Medicare insurance.

The agent and broker Medicare compliance training guide is established in the:

  • CMS Medicare Managed Care Manual (MMCM)
  • CMS Medicare Prescription Drug Benefit Manual (MPDBM)
  • Medicare Communications and Marketing Guidelines (MCMG)
  • Title 42 of the Code of Federal Regulations, Parts 417, 422, 423

Agents current on compliance issues lower their risk of giving inaccurate information to clients. They must be compliant with all ethical and legal standards.

Ethical standards include acting honestly and fairly. You are to follow all laws, regulations, and CMS requirements and report any suspected violations.

Agent Broker and Third-Party Requirements

Requirements are set forth in Title 42 CFR § 422.2274. The law applies to agents, brokers, public entities, and private entities licensed to sell Medicare plans. They must all follow the compliance standards shown below.

These standards apply to anyone who contacts existing or potential beneficiaries. Even if only answering Medicare questions, the person must:

  • Must be licensed and appointed under state law
  • Be trained and tested annually in accordance with MA organization oversight, passing with an 90% or higher score
  • Secure and document a Scope of Appointment prior to meeting with potential enrollees

MA organizations must oversee downstream, first-tier, and other related entities. They must ensure compliance with all state and federal laws.

Brokers and agents must receive annual training and testing regarding:

  • Medicare rules and regulations
  • Plan Products agents and brokers will sell
  • Details specific to each product being sold
  • State and Federal requirements

MA organizations must report to CMS no later than the last Friday in July. This report must state whether they will be using agents who are captive, employed, or independent. It must also include the rate of pay the plans will pay agents and brokers.

This law also provides details regarding various levels of compensation. This includes compensation for the initial enrollment year, renewals, and compensation recovery.

Agent and Broker Training and Testing Guidelines

CMS issues training and testing requirements every year that agents and brokers must complete. The training must include general training plus training specific to the products they are selling (Part C, Part D, Cost Plans, Advantage, etc.). Suggested topics for the training are:

  • Medicare Basics—overview of Medicare, including eligibility, premiums, options, and high-level descriptions of each plan type
  • Enrollment and Disenrollment for Part C, Part D, and Section 1876 cost plans
  • Marketing and communication requirements and other regulations for Part C, Part D, and Section 1876 cost plans

The guidelines include a sample agent and broker test.

Because of the yearly changes to the guidelines, Medicare Training 101 is beneficial. In addition to all information necessary to maintain and keep compliant, you will be privy to excellent sales tools.

You gain medicare compliance training benefits by signing up. This includes access to Medicare training videos, case studies, and one-on-one coaching sessions.

You will learn techniques for prospecting clients, case design, underwriting, and audience targeting. You will also receive insurance agent discounts that help you close sales.

Medicare Compliance Training Tips

You will experience a flurry of contracting and certifying prior to the Medicare annual enrollment period. You must make sure you follow all compliance regulations during that time.

The Medicare Communications and Marketing Guidelines (MCMG) have undergone changes. You can refer to the Federal Register if you have questions about compliance with communication rules. Enter the compliance issue you need to review into the search box and gain access to all documents written since 1994.

Permission to Contact

Communication requirement changes took place in 2019. These changes allow agents to make unsolicited direct contact with potential enrollees by email. The email must include an opt-out option to be in compliance.

The email can promote your services. It cannot contain content that directs a client to select or keep a specific plan.

Restrictions remain preventing you from approaching potential enrollees in common areas. Unsolicited phone calls are also prohibited.

The best way to make sure you are compliant is to use direct mail providers to obtain permission to contact. You can also use lists from lead providers, then mail out a business reply card or flyer to obtain permission to contact.

Using social media opens up a potential area of non-compliance. If viewers “like” or “share” your posts, this does not constitute permission to contact.

Scope of Appointment (SOA)

This is a form that outlines what you will present to a client when you meet. It is a guarantee you will not promote plans other than those the client requests.

The requirement for SOAs to be filed 48 hours prior to the appointment was removed in 2018. This makes it easier to schedule appointments quickly, as same-day scopes are now compliant.

Every appointment must include a Scope of Appointment form. This applies to in-person, video/skype, and telephone appointments. You have an obligation to maintain your SOA forms for a minimum of 10 years, even if you did not obtain a sale.

A client may request information not shown on your Scope during the meeting. If this happens you must fill out a second Scope covering the new information.

If their request is about non-health products you must schedule a separate appointment.

Marketing Rules

CMS requires that agents wait until October 1st to begin marketing. Agents may not enroll anyone until October 15th. The difference between marketing and non-marketing material depends on the information it contains.

Non-marketing items are general and non-specific information sent to current and prospective clients.

Marketing piece content is designed to influence people into retaining a plan or enrolling in a new plan. Marketing content includes plan-specific information, including premiums, benefits, and plan comparisons.

CMS also puts restrictions on the presentation of one plan or several plans to a client.

You may not attempt to sway them toward one particular product. If they are interested in just one plan, you still have an obligation to advise them they have other options.

You must also be careful of the terminology you use in marketing plans. For instance, you may not use the term “free” when showing plans that have $0 premiums. This implies there is no cost to the plan when it probably has higher co-pay amounts.

Beware of Secret Shoppers

CMS uses secret shoppers to check agent compliance and quality of service. These secret shoppers will appear to be potential clients.

Their goal is to make sure your presentations and practices follow marketing appointment rules. This prevents Medicare fraud and abuse.

Things they will watch for include:

  • Only speak about the products you were asked to discuss
  • Complete a Scope of Appointment form prior to the appointment
  • Don’t discuss anything, not on the Scope of Appointment form
  • Complete an additional Scope of Appointment form if they ask you to discuss products not previously requested
  • Marketing of non-health-related products
  • Asking for referrals
  • Accepting enrollment applications outside the enrollment period

During the appointment, you are allowed to provide materials on the plan. This includes educational materials and the enrollment kit.

You may discuss different plan options and collect enrollment forms if you have the authorization to enroll clients.

Becoming a Medicare Insurance Agent

When you sell Medicare insurance there are three groups of people you will target.

Your main market is people who are turning 65 and above and are eligible for Medicare health benefits. The second group is people with disabilities under 65 and eligible for Medicare. The third group is people 67+ looking to save money.

The steps to becoming a Medicare insurance agent are simple:

  • Get your license to sell health insurance
  • Complete your America’s Health Insurance Plans (AHIP) Certification—proof that you have completed a series of Medicare training
  • Purchase errors and omissions (E&O insurance)
  • Contract with a Field Marketing Organization (FMO)
  • Become contracted and appointed with several Medicare companies
  • Complete annual certifications
  • Maintain your health insurance license and continuing education requirements.

Your state establishes the requirements for classroom training to obtain a license to sell insurance. Once you complete your course of study you may take the licensing exam. Passing the exam is how you become officially licensed.

To sell Medicare products you need to obtain special certification. This requirement is set forth by the Center for Medicare and Medicaid Services (CMS). This organization regulates Medicare plans and those that sell them.

There are many advantages to becoming a Medicare agent. The first is the abundance of clients.

More than 10,000 people turn 65 every day. When you couple this with the longevity of people, you have a huge client pool to serve.

This gives you a lot of earning potential in a field that has room for advancement. You have the opportunity to expand your business in a rewarding career with flexible work hours.

Medicare Compliance Training

Because Medicare compliance training is a yearly obligation, becoming a customer of an agent training program is a financially sound career move. InsuranceSales101 provides the education you need to take your career to the next level.

As an InsuranceSales101 customer, you will learn advanced sales and prospecting techniques, case design, underwriting, audience targeting, and more. You will have access to one-on-one coaching sessions and support. There are no contracts or needs to tie yourself to an upline.

Our self-paced training program provides you with all materials necessary and includes free tools and resources. This includes CRM quoting tool recommendations, spreadsheets, planners, worksheets, and actionable guides for increasing sales.

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