|CMS Proposes Clamp Down On Medicare Advantage And Part D Marketing Abuses
A regulation that would further clamp down on Medicare
Advantage (MA) and Medicare prescription drug plans marketing practices
has been proposed by the Centers for Medicare and Medicaid Services
The proposed regulation is a continuation of CMS’
efforts to enhance compliance and oversight of the MA program over the
past 10 months, CMS said.
The proposed rule would incorporate into regulation a
number of requirements that CMS previously imposed through operational
guidance. It would also introduce several new MA and prescription drug
plan requirements, CMS said.
The new proposed rule specifies prohibitions on
door-to-door marketing and cold-calling as well as new proposed
requirements pertaining to broker/agent commissions that go beyond what
the insurance industry recently endorsed as necessary regulatory
changes to the program for improvement.
Specifically, the proposed plan marketing standards would:
- Prohibit cold-calling and expand the current
prohibition on door-to-door solicitation to cover other unsolicited
circumstances. Any appointment with a beneficiary to market
healthcare-related products would have to be limited to the scope that
the beneficiary agreed to in advance.
- Cross-selling of non-healthcare-related products to a prospective MA or Part D enrollee would also be prohibited.
- Prohibit sales activities at educational events such
as health information fairs and community meetings or in areas such as
waiting rooms where patients primarily intend to receive
healthcare-related services, as well as limit the value and type of
promotional items offered to potential enrollees.
- Require that MA organizations that use independent
agents to market MA and Part D plans use state-licensed agents for such
marketing, and require that MA organizations report to states, in a
manner consistent with state appointment laws, that they are using
- Require MA organizations to establish commission
structures for sales agents and brokers that are level across all years
and across all MA plan product types (for example, HMOs, PPOs and
private fee-for-service plans). Commission structures for prescription
drug plans would have to be level across the sponsors’ plans as
These requirements are designed to discourage "churning"
of beneficiaries from plan to plan each year in a manner that earns
agents and brokers the highest commissions and would ensure that
beneficiaries are receiving the information and counseling necessary to
select the best plan based on their needs, CMS said.
CMS also proposed provisions to streamline eligibility determinations for extra help and limited beneficiary liability would:
- Codify earlier guidance to plan sponsors about using
"best available evidence" to determine an enrollee’s eligibility
for extra help through the low income subsidy program.
- Set other premium and cost sharing protections
related to the Social Security premium withholding and point-of-sale
- The rule would also clarify one approach to
calculating fines, or civil monetary penalties, against MA or Part D
plans that violate Medicare rules in ways that adversely affect
beneficiaries. Under the proposal, CMS would have greater flexibility
in determining penalty amounts and would have clear authority to levy a
penalty of up to $25,000 for each enrollee affected, or likely to be
affected, by the violation.
- The rule also proposes new protections for
beneficiaries enrolled in special needs plans (SNPs). SNPs are a type
of MA plan that provides coordinated care to individuals in certain
institutions such as nursing homes, and those who are eligible for both
the Medicare and Medicaid programs and/or have certain severe or
disabling chronic conditions.
Address: Centers for Medicare and Medicaid Services, 7500 Security Blvd., Baltimore, MD 21244; (877) 267-2323, www.cms.gov.