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).