Policy Number: SLS-001
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
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.
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.
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.