Sales Agent Training Process

Policy Number: SLS-021

PURPOSE:

The intent of this operational policy is to document the sales training, certification requirements, and identify business owners and other participants related to training development, execution, and documentation for both employed and contracted Sales Agents.

DEFINITIONS:

America’s Health Insurance Plans (AHIP):  National association representing member companies providing health insurance coverage.

Annual Enrollment Period (AEP):  Time period each calendar year from October 15 to December 7. This time period is when Medicare beneficiaries can make changes to their coverage to take effect on January 1 of the following calendar year.

Centers for Medicare and Medicaid Services (CMS):  The federal agency within the Department of Health and Human Services that administers the Medicare program.

Field Marketing Organization (FMO):  An FMO is an agency contracted to provide broad  coverage for the marketing and sales of a health plan.  Areas of support will include, but are not limited to Marketing/ Lead Generation, Call Center capabilities, and Administrative functions.

Gorman Health Group (GHG):  Company contracted by CNC to administer the CNC Sales Agent certification program, including collection of required documentation (i.e. daily state licensing, AHIP certification, background checks) and facilitation of online sales certification training and examination.

Medicare:   The Federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End Stage Renal Disease (ESRD) or Lou Gehrig’s Disease (ALS).

Medicare Advantage (MA):  A Medicare program that allows for more choices among Medicare         health plans.  Everyone who has Medicare Parts A & B and resides in the plan’s approved service area is eligible, except those who have End-Stage Renal Disease (ESRD).

Medicare Advantage (MA) Organization:  A public or private entity organized and licensed by a state as  risk-bearing entity (with the exception of provider sponsored organization receiving waivers) that is certified by CMS as meeting the Medicare Advantage contract requirements.

Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines:  Manual written and published by CMS for use by Medicare Health Plans and Agents to use to ensure compliance in regards to marketing to potential plan enrollees. It sets guidelines for communication and enrollment for these entities.

Sales Agent:  Licensed insurance agents that are employed by CNC and/or external agents  who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

POLICY:

Care N’ Care (CNC) follows the Centers for Medicare & Medicaid’s Services (CMS) requirements contained in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines, and in the applicable regulations, in regard to Sales Agent training.

CMS requires that Medicare Advantage (MA) plans have effective training programs for all Sales Agents that sell Medicare products.  In addition, CMS requires that all Sales Agents pass a regulated written test and take an agent training course to demonstrate their knowledge of the Medicare program and the plan specific products they intend to sell.

CNC believes that each Medicare beneficiary should be able to understand the benefits of the Medicare plans they are reviewing and be able to select the Medicare plan with the right health care coverage that appropriately meets their personal needs.  CNC recognizes that Sales Agents play a significant role in helping Medicare beneficiaries with their coverage choices.  Accordingly, CNC’s policy states that each Sales Agent selling our plans should be highly qualified and properly trained according to the company’s philosophy, policies and processes.

It is CNC’s direct policy that Sales Agents will not be authorized/certified to sell our Medicare health plans until all of CNC’s training requirements are completed and documented.

Our policy is that any appointed CNC Sales Agent who wishes to continue selling our Medicare products must go through annual recertification.

CNC does not recognize the certification status of any other Medicare Advantage organization.  CNC recognizes AHIP as the CMS approved on-line training site.  Agents who have already taken and passed the AHIP training test for the certification year will not be required to take the certification exam again.  They will need to register on the Gorman Health Group site and provide their AHIP certification information and acknowledge that all required documentation related to selling CNC plans has been read and understood.   The AHIP information once submitted by the agent, is queued up on Gorman’s site and reviewed one-by-one by a member of their team for authenticity, matching name and a current plan year completion date.  Once reviewed, the agent will receive an email stating that the AHIP was approved or rejected.  If rejected, an explanation as to why it rejected is provided to the agent allowing them the opportunity to resolve the issue.

CNC is committed to ensuring that only qualified agents sell CNC Medicare products and has created this P&P to outline the training and certification requirements for Sales Agents.

This policy and the related procedures apply to all Sales Agents employed, contracted, or otherwise representing Care N’ Care Company, Inc., and its subsidiaries who represent and are authorized to sell CNC Medicare Health Plans.  This includes, but is not limited to all internal Sales Agents and External Sales Agents contracted by CNC, including independent Agents, and Sales Entity (Agency, General Agency (GA) or Field Marketing Organization (FMO)).

PROCEDURE:

Sequence of CNC’s Certification Policy

CNC’s Medicare certification process means that all Sales Agents will be required to complete the following training program annually, in addition to any other on-boarding requirements/state appointment:

  1. All Sales Agents will be required to begin the certification registration process by contacting the Senior Manager of Sales, Agent Concierge, or their immediate upline if applicable who will provide instructions on accessing the CNC Gorman Group certification code.
  2. All Sales Agents are required to have an America’s Health Insurance Plans (AHIP) Medicare certification to sell Care N’ Care health plans. Sales Agents are not required to re-take an already completed and passed AHIP Medicare exam. During the online training, you will be prompted to enter your AHIP information.  Sales Agents who have not yet completed their  AHIP Medicare certification may do so by going to the AHIP training site: https://www.ahipmedicaretraining.com.
  3. In addition to AHIP certification, Care N’ Care has partnered with Gorman Health Group to provide our Sales Agents the Care N’ Care Certification and Training course. This online program will provide an overview of the Care N’ Care health plans, coverage changes, and additional health plan benefits. All Sales Agents must complete the course with a minimum score of 85%.
  4. On the CNC Training and Certification page of the Gorman Group website, there will be documentation that all Sales Agents will be required to read and acknowledge before they can proceed to the next step. The documentation includes the CNC’s Introduction & Attestations of Required Certification, Agent Agreement, Code of Ethics, P & P Attestation, Acknowledgement & Authorization for Consumer Reports, W9, Electronic Signature, License Verification, Proof of E & O, Background Check, AHIP upload, CMS FWA, CMS Complaince Training, FWA Information Sheet, Product Final Exam, and then the last step is Appointment by the state.
  5. All Sales Agents must complete the CMS Compliance Training and CMS Fraud, Waste & Abuse training.
  6. Upon completion of the required steps, Sales Agents will be authorized to represent CNC Medicare plans for the selling season.

Training Modules and the Certification Exam(s)

  1. AHIP Medicare Exam: Beginning with the Medicare Annual Enrollment Period, CNC requires all Sales Agents must pass the AHIP Medicare exam each year with a score of 90% or greater before they will be permitted to sell CNC Medicare products.
    1. Each Sales Agent will be allowed three (3) attempts to successfully pass the AHIP certification exam. If the Sales Agent is unable to pass with a satisfactory score after three (3) attempts, they must meet with the Senior Manager of Sales to determine if they will be allowed to continue to attempt to contract with CNC.
    2. Sales Agents are strongly encouraged to study all modules prior to completing all random questions for the exam.
  1. CNC Certification Period: Sales Agents must be certified for the plan year in which they are selling.  Additionally, Sales Agents must be product trained for the plan year of the products they are selling.
    1. EXAMPLE: A Sales Agent first becomes certified on March 18, 2016 to sell the current year’s CNC Medicare products.  The certification will remain valid to sell through December 31, 2016 member effective dates.
    2. EXAMPLE: A Sales Agent first becomes certified to sell CNC Medicare products on August 22, 2016 by passing the 2016-2017 AHIP online training.  The certification is accepted as valid for the remainder of 2016, and to sell through December 1, 2017 member effective dates.
  2. CNC Product Training Module and Exam: Sales Agents will learn specific information about the company, plan benefits and the enrollment process.  Sales Agents must complete the Sales Training Module and pass the Module Exam with a minimum passing score of 85%.  Each Sales Agent will be allowed three (3) attempts to successfully pass the CNC certification exam.  If the Sales Agent is unable to pass with a satisfactory score after three (3) attempts, the Sales Agent will not be certified to sell CNC Medicare Advantage products for that Medicare selling season.
  3. Seminar Preparation and Training Requirements: Sales Agents will learn specific procedures to effectively and compliantly hold sales and educational events prior to being able to hold any said event. Each Sales Agent will be provided an Optional Sign In Sheet and a Seminar Report that will need filled out or referenced for every event.  The expectations prior to holding an event will include but are not limited to the following processes:
    1. Attend two (2) scheduled events given by an approved sales agent or manager.
    2. Demonstrate Comprehension by performing two (1) trial sales events in a controlled environment.

Additional training available by Sales Management as needed.

  1. Sales Agents are monitored via ride-alongs with sales management or FMO Management to ensure compliant sales and marketing activities. In an effort to prevent non-compliant activities, CNC has developed a Medicare Sales Compliance Training module to ensure compliance with the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines.
  2. Upon successful completion of all CNC Sales Certification requirements, the Agent will be deemed Certified to sell CNC Medicare Advantage plans.

Documentation and Record-Keeping

The CNC Sales department will document the completion of the Sales Agent certification training requirements through the Gorman Health Group.  CNC has contracted with the Gorman Health Group to track and record that the Sales Agent has read all the required documentation plus verifying certification exam scores (in addition to other demographic information).  In addition, the Gorman Health Group will maintain a database for CNC that will house information about CNC Sales Agent including but not limited to:

  • AHIP certification
  • CNC product specific certification exam results
  • Signed agreement
  • Copy of the appropriate and current state license(s) required to solicit and sell CNC Medicare Advantage products
  • W9 (if directly contracted or affiliated with a contracted sales entity)
  • Verification of completion of CNC Compliance Fraud, Waste & Abuse Module

On-Boarding External Sales Agents

Policy Number: SLS-011

PURPOSE:

To certify external agents with Care N’ Care.

DEFINITIONS:

CNC: Care N’ Care

Direct Agent: Independent agent that receives commissions directly from Care N’ Care

Field Marketing Organization (FMO): An FMO is an agency contracted to provide broad coverage for the marketing and sales of a health plan. Areas of support will include, but are not limited to, Marketing/ lead Generation, Call Center capabilities, and Administrative functions

FMO Sub-Agent: Downline of an FMO company

GHG (Gorman Health Group): Company contracted by CNC to administer the CNC Sales Agent certification program, including collection of required documentation (i.e. daily state licensing, AHIP certification, background checks) and facilitation of on line sales certification training and examination

Salesforce: Lead Management Database

POLICY:

To ensure on-boarding agents receive registration code and complete Gorman Sentinel Elite training and certification to become certified to sell CNC health plans. CNC’s training and certification completion criteria is 85%. Agents that meet the completion criteria, can begin selling CNC Medicare health plans. If Sales Agent is unable to achieve 85% in order to pass, additional tries are at the discretion of the Senior Manager Of Sales.

PROCEDURE:

Provide interested external agent with required registration code and user guide depending on type of agent.

Agent Oversight Committee

Policy Number: SLS-013

PURPOSE:

To ensure Care N’ Care (CNC) is compliant with all Centers for Medicare & Medicaid’s (CMS) rules and guidance regarding consistent oversight of CNC Sales Agents/Entities with the creation of an agent oversight committee.  Furthermore, this policy helps establish adequate oversight of sales and marketing activities conducted by CNC Sales Agents/Sales Entities and furthering CNC’s adherence to all federal and state laws, regulations and guidance.

DEFINITIONS:

Centers for Medicare and Medicaid Services (CMS):  The federal agency within the Department of Health and Human Services that administers the Medicare program.

Sales Agent – Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Allegation:  A beneficiary complaint of a potential marketing problem.  A beneficiary,      family beneficiary, advocate, Power of Attorney, provider or CMS may initiate sales allegations either verbally or in writing.  Sales allegations may originate from communication obtained during an outbound verification call, inbound telephone calls, as well as outbound quality control calls.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

POLICY:

CNC Sales Agents/Sales Entities are subject to a continuous oversight program, conducted by CNC Sales Leadership and CNC Compliance, to ensure the agents are marketing and selling CNC products in accordance with all applicable federal and state laws, as well as Centers for Medicare and Medicaid Services (CMS) regulations, policies, and marketing guidelines.

To ensure consistent and measurable oversight, the Agent Oversight Committee will oversee these matters. The Agent Oversight Committee will be responsible for review of adherence to various statutory and regulatory requirements as well as CMS Marketing guidelines of Agent activities for Medicare health plans; institutes needed actions and ensures follow-up, as appropriate. This committee will:

  • Provide performance monitoring and oversight of the Agents
  • Provide a mechanism for interdepartmental participation and collaboration in agent activities
  • Demonstrate quantifiable improvement in care and services
  • Afford Care N’ Care the opportunity to ensure that agents are not engaging in coercive or aggressive marketing tactics

The Agent Oversight Committee will be comprised of both voting and non-voting members. There will be five voting members and a majority quorum will be necessary for meetings to be held and any decisions to be made.

Non-voting members are permitted to participate in these meetings as well as provide additional background information that may be relevant to the issue being discussed.

PROCEDURE:

Compliance will facilitate quarterly meetings in regards to agent oversight. If there is an urgent issue then Compliance will schedule an ad-hoc meeting.

The following rating scale assigns points for violations on a scale of 1-7 with the points being assigned in the following manner:

  • 1 point – A sales allegation is filed that results in evidence of no wrongdoing by the agent. This category is also used for any deficiency noted by a CMS Secret Shopper as well
  • 3 points – This is a sales allegation where it is a “he said/she said” situation where no harm or malice to the client was found
  • 5 points – This is a sales allegation where the agent did not act in the best interest of the beneficiary, including lack of due diligence or misrepresentation. Some form of harm was place upon the beneficiary
  • 7 points – A sales allegation that resulted in proof of some form of fraud

Once a Sales Agent accumulates 6 points, the Director of Product Management will be responsible for presenting the Sales Agent to the Agent Oversight Committee.

In addition, all sales agents will be placed on a probationary period that will continue from their date of contract through the last day of December of the year they contract the first time. In this probationary period, any sales agent that accumulates three (3) points will be presented to the committee.

Ex: Sales Agent Smith contracts with CNC on June 18, 2013, his/her probationary period would end on December 31, 2013. 

These points do not reset over a period of time, however, if a sales agent is brought to the committee and the committee votes to allow the agent to continue to market Care N’ Care products, their point total will be reset.

QUALITY ASSURANCE:

Overall responsibility for monitoring and oversight process of Care N’ Care Sales Agents rests with the Director of Product Management.

Dos and Don’ts of Seminars

Policy Number: SLS-026

PURPOSE:

This policy exists to ensure Care N’ Care (CNC) seminars are compliant with the guidelines outlined by the Centers for Medicare & Medicaid Services (CMS) by adhering to the policies outlined herein as well as related policies and procedures.

DEFINITIONS:

Centers for Medicare and Medicaid Services (CMS): The federal agency within the Department of Health and Human Services that administers the Medicare program.

Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines –  Manual written and published by CMS for use by Medicare Health Plans and Agents to use to ensure compliance in regards to marketing to potential plan enrollees. It sets guidelines for communication and enrollment for these entities.

Sales Agent – Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

POLICY:

CNC follows the Centers for Medicare & Medicaid’s Services (CMS) requirements contained in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines and in the applicable regulations, in regard to seminar activities, to ensure that they do not mislead, confuse, or misrepresent the organization.

CNC is committed to ensuring that all CNC Seminars follow the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) and in CNC policies when representing CNC plans and products. All CNC employees or sales agents delivering or assisting in the delivery of seminars must follow the do’s and don’ts for seminars. Failure to comply with the do’s and don’ts will result in re-training and/or removal of employee(s) or sales agent(s) from seminar participation.

PROCEDURE:

Seminar participants must review the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines and related content for the execution and delivery of seminars. In addition, CNC staff must review related Policies and Procedures (P&P) to ensure associated P&Ps are adhered to within the delivery of seminars.

  1. Sales Agents must review Do’s and Don’ts.
    Do:
    • Understand roles and responsibilities
    • Work with sales support to adequately prepare materials and presentations in advance of the meeting
    • Complete required CNC compliance, sales training and certifications before conducting seminars
    • Report any issues and results to Senior Manager of Sales
    • Complete required seminar documentation
    • Comply with the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines
    • Provide proper support to ensure all attendees understand the purpose of the seminar

Don’t:

    • Deviate from prepared materials
    • Offer opinions or personal beliefs that may sway attendees
    • Present content using scare tactics
    • Misrepresent CNC or the content provided by CNC
    • Offer other programs or services not approved
    • Speak of other plans or agents in a negative light
    • Misrepresent plan’s Star Rating
    • Sign up members outside of the appropriate enrollment periods
    • Use Superlatives such as “best” or “only” when describing the plan
  1. Senior Manager of Sales or other sales staff to conduct an internal secret shopping exercise for each Sales Agent conducting seminars
  2. If Sales Agent is not adhering to do’s and don’ts, he/she is removed from presenting at seminars until retraining is completed.
  3. If a Sales Agent must complete retraining more than two (2) times within a selling season, they are removed from presenting at seminars for the remaining season.
  4. Each Sales Agent will be provided an Optional Sign In Sheet or will have to furnish one as well as a Seminar Report that will need to be filled out or referenced for every event.

QUALITY ASSURANCE:

  • Sales Leadership to promptly review any deficiencies identified
  • Retraining conducted with sales agent prior to conducting the next seminar
  • Adhere to cross-referenced policies and procedures
  • Required documentation must be complete within 48 hours of retraining

Responding to Sales Allegations

Policy Number: SLS-100

PURPOSE:

To ensure Care N’ Care (CNC) is compliant with all Centers for Medicare & Medicaid’s Services (CMS) rules and guidance regarding sales allegations filed against CNC Sales Representatives and create the framework by which sales allegations are properly investigated and corrective action taken as warranted.

DEFINITIONS:

Agency:  An individual/company that allows Agents to write underneath them.

Centers for Medicare and Medicaid Services (CMS):  The federal agency within the Department            of Health and Human Services that administers the Medicare program.

Field Marketing Organization (FMO):  An FMO is an agency contracted to provide broad  coverage for the marketing and sales of a health plan. Areas of support will include, but are not limited to, Marketing / Lead Generation, Call Center capabilities, and Administrative functions.

General Agency (GA):  A GA is an agency contracted to provide sales of a health plan.  Typically  its focus is on Agent recruitment and sales.  Areas of support will include, but are not limited to, Agent Certification, Sales Training, Product Training and Compliance Oversight.

Gorman Health Group (GHG):  Company contracted by CNC to administer the CNC Sales Agent certification program, including collection of required documentation (i.e. state licensing, AHIP certification, background checks) and facilitation of online sales certification training and examination.

Medicare Managed Care Manual:  Chapter 3 Medicare Marketing Guidelines:  Manual written and published by CMS for use by Medicare Health Plans and Agents to use to ensure compliance in regards to marketing to potential plan enrollees. It sets guidelines for communication and enrollment for these entities.

Sales Agent:  Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Allegation:  A beneficiary complaint of a potential marketing problem.  A beneficiary,      family beneficiary, advocate, Power of Attorney, provider or CMS may initiate sales allegations either verbally or in writing.  Sales allegations may originate from communication obtained during an outbound verification call, inbound telephone calls, as well as outbound quality control calls.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

POLICY:

CNC follows the Centers for Medicare & Medicaid’s Services (CMS) requirements contained in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines and in the applicable regulations, in regard to the activities of Sales Agents, to ensure that they do not mislead, confuse, or misrepresent the organization.

CNC is committed to ensuring that all CNC Sales Agents follow the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) and in CNC policies when representing CNC plans and products.  When CNC is informed of a possible allegation of inaccurate or improper sales activity or inappropriate conduct by a CNC Sales Agent, the issue is investigated thoroughly and reviewed through the grievance process with oversight on each case through Sales Management.

Sales Agents may NOT engage in any of the following activities when conducting marketing activities (please see the Care N’ Care Sales and Marketing Code of Ethics Career and Delegated Agents) on the Gorman Health Group CNC web page for a complete list as well as detailed information on the below activities:

  • Engage in activities which mislead, confuse or misrepresent the plan
  • Engage in discriminatory marketing practices
  • Offer gifts or payments as an inducement to enroll or solicit referrals
  • Solicit door-to-door for Medicare beneficiaries or through other unsolicited means of direct contact, including calling a beneficiary without the beneficiary initiating the contact or giving express permission
  • May not claim recommendation or endorsement by CMS or that CMS recommends that the person enroll in a CNC plan
  • May not make erroneous written or oral statements including any statement, claim or promise that conflict with, materially alters, or erroneously expands upon the information contained in CMS approved materials
  • May not use providers or provider groups to distribute printed information comparing benefits of different health plans, unless the materials have concurrence of all Medicare Advantage (MA) plans involved or the materials have received prior approval from CMS
  • May not cross-sell any non-health care related products (such as annuities, life insurance, etc.) during any sales or marketing activity or presentation conducted with respect to an MA plan or Part D plan
  • May not provide meals of any sort, regardless of value, at any event at which plan benefits are being discussed and/or plan materials are being distributed
  • May not conduct sales or marketing activities at educational events
  • May not conduct sales or marketing activities in areas where patients primarily intend to receive health care services or where health care is delivered

PROCEDURE:

Sales Management will work with Compliance to monitor and track complaints from beneficiaries or their representatives regarding Sales Agents on an ongoing basis. Complaints may come in from, but are not limited to, the following sources:

  • The CMS Complaints Tracking Module (CTM) in HPMS
  • The CMS Regional Office
  • The Member Service call center
  1. Beneficiary sales allegations are received by CNC via the member call centers, member correspondence, CMS correspondence, State Department of Insurance or other communication to anyone within CNC
  2. When a beneficiary sales allegation is received, CNC conducts a thorough investigation of the issue
  3. The Sales Agent is asked to respond to the investigation inquiry within two (2) calendar days. It is critical that Sales Agents respond in a timely manner
  4. Sales Management reviews the sales allegation and the Sales Representative response and makes a determination of whether the agent acted in any manner not in alignment with CNC’s Policies and Procedures or Medicare’s guidelines found in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines
  5. Sales Management will input allegation information into Salesforce and assign a score to the allegation based on the model developed for the Agent Oversight Committee. Refer to SLS-013 on Agent Oversight Committee for point definitions.
  6. Corrective actions will be implemented as needed and could include but are not limited to:
    1. No Action
    2. Coaching/Immediate Need Training
    3. Ride Along
    4. Verbal Discp Action
    5. Written Discp Action
    6. Suspension
    7. Suspension – Discp Action
    8. Termination
    9. Termination – Discp Action
    10. Report to State Department of Insurance

In the event sales allegation is not responded to by the Sales Agent as required, CNC has a right to take any of the above actions.  Note: all Sales Agent/Sales Entity contracts/agreement contain language requiring that all sales allegations require a timely response.

Corrective Action Plan (CAP)

In assessing any corrective action plans for a Sales Agent/Sales Entity, Sales Management will review the Agent/Entity’s Compliance file to verify or determine any patterns in their behavior.

The history of the agent/entity will be taken into account to determine what corrective measures need to be implemented, if any.

The final determination for a Corrective Action Plan will be recorded on the Sales Agent Complaint Resolution Form, signed by the Sales Management Member making the recommendation, and both forwarded to Compliance and filed in the Agent/Entity’s Oversight File.

Fraud

  • Any documented incidence(s) of Sales representative fraud will result in immediate termination and is subject to reporting to the State Department of Insurance

Direct Violation of Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines

  • Immediate termination occurs for a verifiable claim if an agent directly violates any part of the CMS marketing guidelines including, but not limited to:
    • Door to Door sales
    • Unsolicited outbound telemarketing, which violates the CMS regulations

Termination of a Sales Agent

If the Sales Representative’s insurance license is terminated by the State, due to a founded CMS/TDI violation, Care N’ Care will electronically file with NIPR (National Insurance Producers Registry) to terminate the Sales Representative’s Appointment with Care N’ Care.

Sales Agent Corrective Action

Policy Number: SLS-022

PURPOSE:

To ensure Care N’ Care (CNC) addresses and administers appropriate corrective action for Sales Agents.  Corrective action is designed to correct and ensure compliance with all Centers for Medicare & Medicaid’s (CMS) rules and guidance regarding corrective action needed and create the framework by which sales corrective action is taken as warranted.

DEFINITIONS:

Centers for Medicare and Medicaid Services (CMS): The federal agency within the Department of Health and Human Services that administers the Medicare program.

Sales Agent – Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

POLICY:

CNC follows the Centers for Medicare & Medicaid’s (CMS) requirements contained in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines and in the applicable regulations, in regard to the activities of Sales Agents, to ensure that they do not mislead, confuse, or misrepresent the organization.

Care N’ Care has developed policies, rules, and regulations designed to assure compliance with CMS and Company requirements. CNC responds to reported or suspected compliance or deficiency concerns by reviewing the matter to fully understand the issue and by taking appropriate corrective action when warranted. Whenever the CNC Sales Leadership and Compliance Officer determines that an individual has acted in violation of CNC compliance requirements, the Compliance Officer, in conjunction with Sales Leadership, may implement or recommend corrective action designed to address the particular violation and to assure that the violation does not recur. Corrective action will be proportional to the potential risk of harm to CNC. Consequently, corrective action imposed will vary based on the severity of the violation.

  1. Applicability – Each individual is responsible for having knowledge of CNC requirements.
  2. Scope – The CNC Compliance Officer and Sales Leadership will review all potential compliance and deficiency concerns raised, initiate an investigation as appropriate, and when warranted impose corrective action. Sales Leadership authority impose corrective action extends to CNC Sales Agents. The provisions of this Policy supplement existing CNC policies and procedures.

This policy and the related procedures apply to all Sales Agents employed, contracted, or otherwise representing Care N’ Care Company, Inc., and its subsidiaries that represent and are authorized to sell CNC Medicare Health Plans.  This includes, but is not limited to all internal Sales Agents and External Sales Agents contracted by CNC, including independent Agents, and Sales Entity (Agency, General Agency (GA) or Field Marketing Organization (FMO)).

PROCEDURE:

  1. Investigation Process – Sales Leadership will review all potential concerns and follow procedure detailed below:
  2. Corrective Action
    1. Compliance Violation Confirmed – If a compliance violation is confirmed, Sales Leadership may impose one or more of the following corrective actions:
      1. Provide additional education.
      2. Implement a Focused Compliance Review of the Sales Agent’s activity.
      3. Restrict or suspend the Sales Agent’s activity.
      4. Recommend termination of the Sales Agent in accordance with this Policy.
      5. Initiate sanctions against or the termination of a CNC employee.
      6. Other corrective actions as necessary to address the compliance violation and preclude the violation from recurring.
  1. Documentation – Sales Leadership will maintain documentation of corrective action imposed on an individual.
  1. Summary Action During Investigation
    1. Decision to Implement Summary Action – Sales Leadership may implement immediate corrective action when appropriate to avoid continuing violations during the investigation, up to and including the immediate suspension of an individual’s sales activities or authority. Summary action is effective throughout the investigation unless otherwise specified by Sales Leadership.
    2. Notice – If summary action is taken, Sales Leadership will notify the Compliance Officer, and the Sales Agent.
  2. Notice to the Sales Representative – If Sales Leadership imposes corrective action against a Sales Agent, the CNC Compliance Officer will provide written notice to the Sales Agent. Such notice will include the following:
    1. A summary description of the conduct giving rise to the corrective action.
    2. The standard violated;
    3. The date that the corrective action is effective;
    4. A description of how the Sales Agent may request review of the corrective action by Sales Leadership; and, if appropriate
    5. The potential sanctions that may be applied if the Sales Agent fails to comply with CNC Compliance Requirements in the future.
  3. Review of Non-Termination Corrective Action Involving a Sales Agent– The Sales Agent may request review by Sales Leadership when the CNC Compliance Officer imposes non-termination corrective action.
    1. Request for Review – The Sales Agent must submit a written request for review within 15 days of the date on the notice of the corrective action. Requests for review, and all accompanying information, are submitted to Sales Leadership. A Sales Agent may request an in-person meeting with Sales Leadership.
    2. Termination Action
      1. Written Notice – The CNC Compliance Officer will provide written notice of the recommendation for termination to the Sales Agent. The notice will include a summary description of the basis for the recommendation to terminate and may also include conditions for rescinding the termination.
      2. Effective Period – The termination will be effective throughout any review period.

CORRECTIVE ACTION PLANS (CAP):

In assessing any corrective action plans for a Sales Agent/Sales Entity, Sales Management will review the Agent/Entity’s Compliance file to verify or determine any patterns in their behavior.

The history of the agent/entity will be taken in to account to determine what corrective measures need to be implemented, if any.

The final determination for a Corrective Action Plan will be recorded on the Sales Agent Complaint Resolution Form, signed by the Sales Management Member making the recommendation, and both forwarded to Compliance and filed in the Agent/Entity’s Oversight File.

Fraud

  • Any documented incidence(s) of Sales Agent fraud will result in immediate termination and is subject to reporting the State Department of Insurance

Direct Violation of Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines

  • Immediate termination occurs for a verifiable claim if an agent directly violates any part of the CMS marketing guidelines including, but not limited to:
    • Door to Door sales
    • Unsolicited outbound telemarketing, which violates the CMS regulations

Termination of a Sales Agent

If the Sales Representative’s insurance license is terminated by the State, due to a founded CMS/TDI violation, Care N’ Care will electronically file with NIPR (National Insurance Producers Registry) to terminate the Sales Representative’s Appointment with Care N’ Care.

Standards of Professionalism

Policy Number: SLS-003

PURPOSE:

The purpose of this policy is to ensure that Sales Agents adhere to Care N Care’s (CNC) Standards of Professionalism and personal behavior when representing, soliciting and selling CNC Medicare Advantage (MA) products.

In addition, the purpose is to promote the ethical representation of CNC’s Medicare products with the highest level of honesty, integrity, and professionalism.

DEFINITIONS:

Medicare:  The Federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End Stage Renal Disease (ESRD) or Lou Gehrig’s Disease (ALS).

Medicare Advantage (MA):  A Medicare program that allows for more choices among Medicare health plans.  Everyone who has Medicare Parts A & B and resides in the plan’s approved service area is eligible, except those who have End-Stage Renal Disease (ESRD).

Sales Agent:  Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

POLICY:

CNC follows the Centers for Medicare & Medicaid’s (CMS) requirements contained in Chapter 3 – Medicare Marketing Guidelines (MMG) and in the applicable regulations, in regard to the standards of professionalism.  CNC expects that each Sales Agent who sells CNC MA Plans conduct themselves in a professional manner when interacting with Medicare beneficiaries.  CNC expects that each Sales Agent will assist Medicare beneficiaries to obtain Medicare coverage that best meets their needs and provide a high-quality customer solution for them.

PROCEDURE:

Sales Agents are expected to adhere to the following requirements:

  1. Be prompt for appointments and presentations.
  2. Any unsolicited means of direct contact of beneficiaries is prohibited, including door-to-door solicitation, email or any outbound telemarketing without the beneficiary initiating the contact or giving express permission.
  3. Appropriate business attire is required at all times.
  4. If it is not possible to keep an appointment, a call must be made as early as possible to reschedule with the beneficiary or notify CNC Sales Leadership to assist in rescheduling or reassigning the appointment.
  5. Sales Agents unable to attend a scheduled sales seminar presentation must notify CNC Sales Leadership, at least 48 hours prior the scheduled event, to allow ample time for CNC Sales Leadership to coordinate alternate Sales Agent coverage and provide notification to CNC Compliance for CMS scheduled marketing/sales event reporting.
  6. Sales Agents shall not smoke or use tobacco products when representing, soliciting, or selling CNC Medicare products.
  7. Sales Agents shall not be under the influence of illegal drugs when representing, soliciting, or selling CNC‘s Medicare products.
  8. Sales Agents shall not drink alcohol during working hours on days when they are representing, soliciting or selling CNC’s Medicare products or prior to sales meetings/seminars conducted outside of normal business hours.
  9. Sales Agents shall refrain from using inappropriate language while representing, soliciting, and selling CNC Medicare products.
  10. Upon request, Sales Agents shall produce a photo ID to the prospect; driver’s license is acceptable.
  11. Sales Agents shall provide and leave behind a current business card, or at the very least their contact information, to all Medicare beneficiaries prior to all sales presentations and/or meetings. In addition, Sales Agents shall ensure that any beneficiary requesting an enrollment application also receive any required CMS documents as outlined in the CMS Marketing Guidelines.
  12. “Hard Sell” tactics are never to be employed. The goal is to assist the Medicare beneficiary to enroll in a benefit plan that will meet their needs and provide a positive customer experience during the benefit year.
  13. Sales Agents must electronically acknowledge the Sales & Marketing Code of Ethics during their annual CNC Credentialing and Certification Program.
  14. Sales Agents must comply with the most current Medicare Marketing Guidelines when conducting all sales presentations and/or meetings. The following are prohibited marketing and sales activities and in no way represents an all-inclusive list:
    1. Distributing marketing materials and making verbal statements at all sales presentations and/or meetings that are materially inaccurate, misleading, or otherwise make material misrepresentations.
    2. Misrepresenting themselves, their plans, or the benefits and services covered by their plans.
    3. Claim within their marketing materials that they are recommended or endorsed by CMS, Medicare, or the Department of Health & Human Services (DHHS).
    4. Make statements or imply the following: “endorsed or employed by Medicare”, “calling on behalf of Medicare”, “calling for Medicare”, “Medicare certified”, or that “Medicare recommends that beneficiaries enroll in the plan”.
    5. Use of absolute superlative (e.g., “the best”, “highest ranked’, “rated number 1”) unless they are substantiated with supporting data provided to CMS as a part of the marketing review process.

Sales Agents are regularly monitored to ensure compliant sales and marketing activities.  All non-compliant activities reported to CNC will be investigated and appropriate enforcement activities will be taken in accordance with CNC Policies and Procedures.

Introduction to Sales

Policy Number: SLS-001

PURPOSE:

Care N’ Care (CNC) has established the following Policies and Procedures (P&Ps) that will ensure CNC is in compliance with the Centers for Medicare and Medicaid Services (CMS) marketing requirements

DEFINITIONS:

Centers for Medicare and Medicaid Services (CMS): The federal agency within the Department            of Health and Human Services that administers the Medicare program.

Gorman Health Group (GHG):  Company contracted by CNC to administer the CNC Sales Agent certification program, including collection of required documentation (i.e. state licensing, AHIP certification, background checks) and facilitation of online sales certification training and examination.

Sales Agent:  Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Allegation:  A beneficiary complaint of a potential marketing problem.  A beneficiary,       family beneficiary, advocate, power of attorney, provider or CMS may initiate sales allegations either verbally or in writing.  Sales allegations may originate from communication obtained during an outbound verification call, inbound telephone calls, as well as outbound quality control calls.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

POLICY:

PROCEDURE:

Establishing Qualifications for Sales Agents – Initial Certification and Training

CNC has established the qualifications that Sales Agents must meet to market and sell our Medicare Advantage (MA) plans.  CNC has contracted with Gorman Health Group to administer the collection and retention of its Agent Certification Program outlined in Policy and Procedure SLS-021 Sales Agent Training.

Annual Recertification, Targeted Retraining and Ongoing Communication

CNC has established requirements for Sales Agents to achieve minimum passing test scores on annual recertification tests approved by CNC and required product training. Agents must achieve a minimum passing score of 90% for annual AHIP Medicare Certification and a minimum passing score of 85% on the annual CNC Sales Agent Certification. CNC provides updated information through e-mails and direct mail to Sales Agents on an ongoing basis. Updates cover a variety of topics with key emphasis on Compliance and Medicare Marketing Guidelines.

Maintenance of Records

CNC requires maintenance of sales records/files on all Sales Agents in accordance with CMS requirements.  CNC contracts with GHG for the collection and maintenance of Sales Agent certification records.  CNC is responsible for the maintenance of all other required Sales Agent contracts, records and files. Records pertaining to CNC-employed Sales Agents are maintained by CNC Human Resources.

If a recorded Scope of Appointment (SOA) is not available, CNC requires all Sales Agents to acquire and keep a copy that was signed by the Medicare Beneficiary, along with submitted enrollment applications for a period of no less than ten (10) years. The form is retained regardless of appointment outcome and must be readily accessible to CNC upon request.

Monitoring Compliance and Addressing Deficiencies

CNC has instituted processes for tracking and analyzing individual Sales Agent performance in such areas as rapid disenrollments, cancellations and sales allegations.  This ongoing process of evaluation allows CNC to promptly identify sales conduct that merits investigations, such as: provision of incorrect, misleading or inaccurate information; unauthorized contact or home visits; fraudulent enrollment submission; or intimidation.

Complaints will be treated as grievances as required by CMS. CNC Appeals and Grievance will receive referrals and, in conjunction with CNC Sales Leadership, investigate complaints involving alleged fraud or misrepresentation. When complaints are verified, corrective actions will be taken that may include re-qualification, suspension or termination of the Sales Agent agreement with CNC. CNC will make reports of Sales Agent terminations to the Texas Department of Insurance, when warranted. CNC will use rapid disenrollment and cancellation data to identify and correct adverse compliance trends.

Compensation

Sales Agent Compensation arrangements must comply with CMS Medicare Marketing Guidelines and must be documented using CNC’s approved agreements.  CNC will withhold or recover payment according to CMS guidelines (i.e. rapid disenrollments and cancellations).  CMS compensation requirements do not apply to CNC employed Sales Agents.

Updating and Maintaining Policies and Procedures

These P&Ps will be updated annually or when changes are necessary.  The P&Ps will be made available to CNC Sales Agents and internally stored with the M:/CNC/Sales/Policies & Procedures folder.

Qualifications and Primary Duties for Sales Agents

Policy Number: SLS-002

PURPOSE:

The purpose of this policy is to ensure that qualifications are met and that primary duties and responsibilities are understood by each Care N’ Care (CNC)-employed and CNC-contracted Sales Agent, whether independent or affiliated with an Agency or FMO, who will represent and sell CNC Medicare products.

DEFINITIONS:

Agency:  An individual/company that allow Agents to write underneath them.

Centers for Medicare and Medicaid Services (CMS):  The federal agency within the Department of Health and Human Services that administers the Medicare program.

Field Marketing Organization (FMO):  An FMO is an agency contracted to provide broad coverage for the marketing and sales of a health plan.  Areas of support will include, but are not limited to, Marketing/Lead Generation, Call Center capabilities, and Administrative functions

Medicare:  The Federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End Stage Renal Disease (ESRD) or Lou Gehrig’s Disease (ALS).

Medicare Advantage (MA):  A Medicare program that allows for more choices among Medicare health plans.  Everyone who has Medicare Parts A & B and resides in the plan’s approved service area is eligible, except those who have End-Stage Renal Disease (ESRD).

Sales Agent:  Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

Texas Department of Insurance (TDI):  Regulatory body which oversees all Insurance Companies operating within the State of Texas.

POLICY:

CNC follows the Centers for Medicare & Medicaid’s (CMS) requirements contained in Chapter 3 of the Medicare Marketing Guide and in the applicable regulations, in regard to the qualifications and primary duties of Sales Agents.  CMS requires that Medicare Advantage (MA) Plans utilize only state-licensed sales agents to perform marketing.  In addition, the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 requires MA organizations to comply with state appointment laws.

CNC is committed to ensuring that only qualified Sales Agents be allowed to sell CNC Medicare products and has created this Policy & Procedure (P&P) to outline the qualifications for Sales Agents.

PROCEDURE:

A. General Qualifications

The following qualifications are applicable to all CNC Sales Agents, and Sales Entities:

  1. Be appropriately and currently licensed by the Texas Department of Insurance (TDI).
  2. Must be appointed by CNC with TDI.
  3. Not be censured, restricted, or otherwise sanctioned by CMS or TDI within the past two (2) years.
  4. Agencies that are licensed under the state laws must use their associated FEIN # for the agency, not their personal SSN.
  5. Review, acknowledge and agree to abide by CNC’s Introduction & Attestations of Required Certification, Agent Agreement, Code of Ethics, P & P Attestation, Acknowledgement & Authorization for Consumer Reports, W9, Electronic Signature, License Verification, Proof of E & O, Background Check, AHIP upload, CMS FWA, CMS Complaince Training, FWA Information Sheet, Product Final Exam, and Appointment by the state.
  6. Abide by the requirements in the applicable Sales Agent/Sales Entity contract/agreement.

B. Summary of Sales Agent Duties and Responsibilities

The following are applicable to all CNC Sales Agents:

  1. Represent CNC and all CNC’s Medicare products with the highest level of honesty and integrity, always putting the needs of each Medicare beneficiary ahead of any personal consideration.
  2. Offer all available CNC Medicare products to each eligible Medicare beneficiary with whom the Sales Agent meets (non-discrimination). Help the prospect determine the most appropriate product based on their personal needs and situation.
  3. Solicit and sell CNC’s products using only CNC/CMS-approved advertising, sales presentations, and marketing/enrollment materials.
  4. Validate the accuracy and completeness of all applications, prior to submitting to CNC.
  5. Provide CNC with all required and/or requested reports and information within timeframes determined by CNC.
  6. Abide by all applicable federal and state laws, rules, regulations and CNC P&Ps that pertain to the solicitation, sale and administration of any CNC Medicare product, including the prevention of fraud, waste and abuse.
  7. Actively participate with CNC and/or any government agency regarding all inquiries, investigations and audits resulting from member, provider, CMS, and/or regulatory agency concerns or allegations regarding any type of misconduct, fraud, or associated sales and marketing misrepresentation issues. Agent response to such inquiries should occur within two (2) calendar days of receipt.
  8. Annually complete the CNC Medicare re-certification training and pass the re-certification exam(s).
  9. Maintain records for ten (10) years in a secure location.

Application Processing

CNC requires all Sales Agents and Sales Entities to comply with timely application submission timelines.  CNC requires signed, dated, complete enrollment applications to be submitted to CNC no later than two (2) calendar days of receipt from the Medicare beneficiary.  Demonstrated patterns of late enrollment submissions by Sales Agents will be subject to CNC Sales Agent oversight guidelines prescribed in SLS-012, Oversight of Sales Agents.

  1. The preferred submission method is by utilizing our CNC agent web enrollment tool.
  2. Applications may be faxed to the fax number provided no later than two (2) calendar days of receipt from the Medicare beneficiary.
  3. Mailed applications must be sent by overnight mail/delivery of the same day as received from the beneficiary.
  4. Hand-delivered applications must be delivered to CNC Agent Concierge no later than two (2) calendar days of receipt from the Medicare beneficiary.

Affiliated Sales Agents:

Sales Agents affiliated with a Sales Entity may submit applictions to their respective Agency or FMO, and should follow application processes as identified by their Sales Entity in order to reconcile application submissions after faxing to CNC.  In such cases, the Sales Agent and the Sales Entity are responsible for timely submission, ensuring CNC receives the application no later than two (2) calendar days after receipt from the beneficiary.

The following outlines Enrollment Submission responsibilities of Sales Agents:

  1. Responsible for the validity and legibility of the data and for the completeness of each application submitted to CNC.
  2. Sales Agent must sign and date every application received from the Medicare beneficiary as prescribed by CNC per CMS regulation.
    1. Applications received in-hand from the beneficiary should be both signed and dated.
    2. Applications left with the beneficiary for future action should be signed, but not dated by the Sales Agent.
  3. Submit all enrollment applications to CNC no later than two (2) calendar days of receipt from the beneficiary. The completed application can be faxed, hand-delivered, or sent by overnight mail to CNC, although fax is the preferred method of receipt if agent is unable to do an online enrollment.
  4. Failure to follow CNC requirements for submitting applications may result in processing delays, which may then impact enrollees’ requested coverage date and/or Sales entity and Sales Agent commission payments.
  5. All copies of submitted applications must be maintained in a secure location to ensure confidentiality of member Protected Health Information (PHI) and Personally Identifiable Information (PII) pursuant to HIPPA rules.
  6. It is a prohibited practice for storage of member PHI and PII by CNC-employed Sales Agents outside of CNC premises (e.g., home office).

On-Boarding External Sales Agents

Policy Number: SLS-011

PURPOSE:

To certify external agents with Care N’ Care.

DEFINITIONS:

CNC:  Care N’ Care

Direct Agent:  Independent agent that receives commissions directly from Care N’ Care

Field Marketing Organization (FMO):  An FMO is an agency contracted to provide broad  coverage for the marketing and sales of a health plan. Areas of support will include, but are not limited to, Marketing / Lead Generation, Call Center capabilities, and Administrative functions

FMO Sub-Agent:  Downline of an FMO company

GHG (Gorman Health Group):  Company contracted by CNC to administer the CNC Sales Agent certification program, including collection of required documentation (i.e. daily state licensing, AHIP certification, background checks) and facilitation of online sales certification training and examination

Salesforce:  Lead Management Database

POLICY:

To ensure on-boarding agents receive registration code and complete Gorman Sentinel Elite training and certification to become certified to sell CNC health plans. CNC’s training and certification completion criteria is 85%.  Agents that meet the completion criteria, can begin selling CNC Medicare health plans. If Sales Agent is unable to achieve 85% in order to pass, additional tries are at the discretion of the Senior Manager Of Sales.

PROCEDURE:

Provide interested external agent with required registration code and user guide depending on type of agent.

Direct Agent:
Senior Manager of Sales or Agent Concierge will provide on-boarding agent with a GHG certification code for direct agents. Senior Manager of Sales/Agent Concierge to add agent information to Salesforce, Master list of CNC agents, Outlook, Constant Contact for agent communications and EAM for online enrollment purposes.

FMO Sub-Agent:

Senior Manager of Sales or Agent Concierge will provide on-boarding agent with a customized FMO GHG certification code for FMO Sub-Agents. Senior Manager of Sales/Agent Concierge to add agent information to Salesforce, Master list of CNC agents, Outlook, Constant Contact for agent communications and EAM for online enrollment purposes.

Tracking of certified agents:

Senior Manager of Sales and Agent Concierges will receive notification from GHG via electronic communication to confirm agents have either completed all training and requirements or they are still in process.  These reports are received at least weekly and daily during the Annual Enrollment Period.  In addition, a daily report is received of all agents that completed certification the previous day to ensure that all newly certified agents are added to Salesforce, Master list of CNC agents, Outlook, Constant Contact for agent communications and EAM for online enrollment purposes.

GHG provides weekly status reports of agents within the certification process to the Senior Manager of Sales/Agent Concierges for review. Agents with an incomplete status are emailed a reminder to complete the online certification process by CNC staff.

GHG also uses a backup process to maintain consistent data integrity. This process is a daily server back-up to their local storage devices at INETU. (Database server data is first encrypted before transfer). Database server data is then sent to off-site storage in Vienna, VA.

Senior Manager of Sales to randomly spot check licensing status via Texas Department of Insurance web site.  (http://www.tdi.state.tx.us).  Should any discrepancy occur, GHG will be notified immediately to make necessary corrections.  Records of random checks will be stored on local CNC server.