Drawing within the lines during Medicare Advantage sales presentations

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Prevent marketing complaints by helping your sales force understand which materials are required during sales discussions.

Your organization has spent tireless months finalizing a plethora of materials to promote next year’s plan offerings, and the Annual Enrollment Period (AEP). With captive and independent agents competing for enrollments, the significance of how those materials is required for use in sales appointments and presentations can impact your sales and renewals. Whether in classroom-style or individual appointments for selling Medicare Advantage and Part D plans (MAPD), we want to provide some insights for how their proper use can help avoid dreaded sales complaints.

Challenges in providing consistent sales presentations

Why can this be such a challenge? The Centers for Medicare & Medicaid Services (CMS) previously published a sales event checklist for scoring an agents’ presentations, as part of CMS’ retired “secret shopper” surveillance activities. However, the checklists which were heavily relied-upon by organizations to plan compliant presentations, went away with CMS’ surveillance program years ago. Medicare Advantage Organizations (MAOs) have missed this “cheat sheet” of sorts. To achieve compliant presentations, MAOs and their agencies must revert to pared-down marketing guidelines, navigating the Code of Federal Regulations, and lessons learned from past audits – if those are shared with the sales force.  

As part of those sales presentations, agents should understand which materials to have on-site and which to reference during sales discussions, to help avoid enrollment errors and eventual complaints to CMS. MAO(s) may opt for other non-required staples for agents to include, such as information on diabetes or other educational services available, along with specifically approved presentations. CMS’ expectations hold steady, that certain materials remain essential while others are considered a best practice.

Avoid claims of “Marketing Misrepresentation”

If your organization hasn’t experienced a sales-related inquiry for a while, it pays to remember there’s a certain path for CMS allowing beneficiaries to change plans without enduring special circumstances: an enrollee’s claim of “marketing misrepresentation.” Typically, before the claim is researched, the enrollee will be allowed to change plans no matter the outcome of follow-up research. However, the fallout for the selling agent and the plan they represent will most certainly result in a case being opened by CMS for investigation. If your agents are left holding the bag to evidence their position, let it be full of documentation showing the right tools were presented and thoroughly explained. Note-taking can be helpful, however documentation of proper materials and how they were used, will support the case when the sale is investigated (CMS requires this).

A best practice for your plan’s sales agents, is for each agent to keep their own folder of all materials routinely presented for each plan, in the event of a beneficiary complaint. If CMS opens a case, they may ask for enrollment and sales appointment details right down to the CMS marketing material identification number found on the materials used, in order to confirm the correct materials were shown to the plan seeker. Make sure your prospective enrollees are provided the same version of the materials and presentations for each plan, as CMS may even call new enrollees asking for the material identification numbers on any documents kept from the sales discussion.

Sales presentation materials

Below we’ve noted some of the CMS-required, and other materials which also can support a plan’s sales processes. In recent years, CMS re-classified some of these documents between two material types, so we’ll note that as well.

Pre-Enrollment Checklist: (Type: Communication) This document needs to be provided to potential enrollees with the Summary of Benefits, and enrollment form. This is a beneficiary-facing piece that the agent reviews with the individual, to support required documents and talking points are covered before a plan decision is made.

Scope of Appointment (SOA): (Type: Communication) A form presented by agents prior to the beginning of a sales discussion, for the beneficiary to confirm which plan types will be reviewed. The goal of populating the SOA form is to avoid confusion on the prospect’s part as to which plans are being discussed. A new form needs to be filled out if the discussion turns to additional plan types. The SOA form is documented for all sales meetings whether in-person, telephonic, and includes walk-ins to plan or agent offices. The SOA becomes particularly important for validating the sales discussion, should an enrollee claim they found themselves in an unexpected plan. If the complaint passes through CMS, CMS will likely request a copy of the SOA form.

Summary of Benefits (SB): (Type: Marketing) A comprehensive (but not all-inclusive) document outlining a plan’s benefits based on those CMS requires to be displayed, and any additional benefits the MAO wishes to feature. This is a simpler arrangement over the EOC providing a snapshot view of the benefits provided under a plan and can include multiple plans of similar type displayed side-by-side for a quick comparison of features.

Enrollment/Election Form: (Type: Communications) This form can be provided in paper, or electronic formats. Don’t forget to include the pre-enrollment checklist and the SB with this form!

Event Signage: (Type: Marketing) A best practice is to provide signage at sales events indicating the carrier and plan types being presented. Signage should be approved by the plans represented who may file them with CMS and can provide another line of defense against any claims of plan misrepresentation following the event.

Sales Presentation Formats/PowerPoint or Flipchart: (Type: Marketing) Having a formal presentation for both classroom and individual sales events will provide its own sort of checklist for an agent’s talking points, and help the audience track through the discussion. Sales presentations need to be filed with CMS by the carrier and can be provided as a table-top flip chart, viewed on a tablet or a PowerPoint projected onto a screen. The font size will still need to appear at no less than 12-point Times New Roman per CMS requirements (which may vary depending on electronic display). 

Annual Notice of Changes (ANOC): (Type: Marketing) All changes to existing plans for the upcoming year’s benefits, are listed on the ANOC document. Did the monthly premium change? Does the plan no longer use the same pharmacy network? These are often deciding factors for enrollees deciding whether to stick with their same plan or make a change. If office copays go down, that can be a great sales feature. However, if the number of covered chiropractic visits are reduced (for example), others relying on their chiropractor may want to switch. The ANOC is important to share during sales discussions particularly for current enrollees, who may switch plans based on the ANOC’s details.

Evidence of Coverage (EOC): (Type: Communications) Neither the Summary of Benefits or the Annual Notice of Change will hold all the fine print for things such as what’s completely excluded from coverage or the “fine print” of benefit details. As a best practice, your sales agents should keep an EOC handy for each MA or Part D plan being presented, so follow-up questions can be answered in detail.

Formulary: (Type: Communication) This is the drug list for the plan, showing the medications covered under the plan, at what tier and cost. “Access to care” can be another issue resulting in complaints, if an individual is advised into a plan that ultimately doesn’t cover their medications. A best practice is to look up all current medications used by the individual and confirm what is/isn’t covered, and if the change in plans prompts an increase for out-of-pocket costs.

Provider and/or Pharmacy Directories: (Type: Communication) A frequent complaint received by CMS following enrollment, is that a beneficiary learns their provider is not in their new plan’s network and felt they were misled during the sales process, that the provider was in fact, in-network. Pharmacy and provider status can change monthly. Often upon investigating, a provider’s network status changed after the enrollment discussion but had been in-network at the time the plan was selected. Ensuring the most current directories are available, and keeping detailed notes from the appointment can help avoid complaints about access to care or misleading sales activities.

How Toppan Merrill can help

Toppan Merrill helps MAOs prepare their annual member-facing and marketing materials each year, so your sales force and membership have the resources they need. From document creation and management, sales enablement, omnichannel communications, printing services, and more, we deliver best-in-class solutions that help you respond quickly to changes in regulations, member needs, and markets. 

Learn more about how Toppan Merrill can help with your health plans member communications.

Summer Beach – Associate Director, Medicare Compliance Solutions

With more than 30 years of insurance industry experience, Summer Beach is an industry thought leader and expert on Medicare-related compliance. Her background includes past roles as Regulatory Compliance Manager and Compliance Director for state, regional and national insurers. Her areas of expertise include CMS-regulated documents and guidelines, agent/broker and sales compliance, designing CMS-approved investigation processes, audits, Corrective Action Plans, and training with re-education formats following CMS disciplines. Summer brings expertise on policies and procedures, auditing compliance programs and has measurably reduced plan member complaints to CMS through remedial initiative.

Summer Beach – Associate Director, Medicare Compliance Solutions's Photo

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