CMS has proposed new regulations in hopes of protecting beneficiaries enrolled in Medicare Advantage (MA) and special needs plans (SNP).
The proposed plan would prohibit cold calling and expand the current prohibition on door-to-door solicitations, prohibit sales activities at educational events, require state-licensed agents for MA organizations that use independent agents to market MA and Part D plans, and require MA organizations to use commission structures for agents and brokers. (See the sidebar on MDM below.)
The proposed rules also look to protect beneficiaries of SNPs, which provide coordinated care to individuals in institutions such as nursing homes. These provisions include a requirement that 90% of new SNP enrollees have special needs and a provision that protects beneficiaries from being billed for cost-sharing that is not their responsibility. The proposal would also give CMS greater flexibility in determining penalty amounts, which could be as much as $25,000 for each enrollee affected by the violation.
“These proposed changes will have a direct, positive impact on people with Medicare,” Kerry Weems, acting administrator of CMS, said in a statement. “The Medicare Advantage program is a valuable source of enhanced benefits and coordinated care for beneficiaries, and it should not be undermined by the actions of a limited number of unscrupulous sales agents.”
XLHealth, the owner and operator of the largest chronic condition SNP (C-SNP), with a total of 65,000 beneficiaries, supports the proposals.
XLHealth runs C-SNPs in Texas, Arkansas, Missouri, Maryland, South Carolina, and Georgia for beneficiaries with HF, diabetes, COPD, and/or end-stage renal disease. The new rules will raise the bar for companies offering MA and SNPs, says Paul Serini, executive vice president of XLHealth, adding that inappropriate broker activity affects the companies offering MA plans and can cause beneficiaries to feel wronged.
XLHealth supports the new proposed regulations, but if there is a downside, it’s that the proposed changes represent the difficult nature of offering SNPs, Serini says, noting that there are many shifting regulations, which makes managing the programs difficult. “We are running as fast we can, and if the rules keep changing every six months, it makes it very difficult to set business policies that are understood throughout the organization and at the broker community level,” Serini says.
New proposed MA, SNP regulations
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 nonhealthcare-related products to a prospective Medicare Advantage (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, where they are using those agents.
Require MA organizations to establish commission structures for sales agents and brokers that are level across all years and MA plan product types (e.g., HMOs, PPOs, and private fee-for-service plans). Commission structures established for prescription drug plans would have to be level across the sponsors’ plans as well.
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.
The rule also proposes new protections for beneficiaries enrolled in special needs plans (SNP), which would:
Require that 90% of new enrollees in SNPs be special needs individuals to ensure that SNPs focus on the population for which these MA plans are designed.
More clearly establish delivery-of-care standards for SNPs.
Protect beneficiaries from being billed for cost-sharing that is not their responsibility. For SNPs that target beneficiaries who are eligible for both Medicare and Medicaid, the rule would establish standards designed to ensure that those beneficiaries are able to access essential services that are available through Medicaid in addition to those benefits available through the SNP.