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Chapter 3 – Medicare Marketing Guidelines

1. Such invitations must also clearly state all of the products that will be discussed during the event i e HMO PDP 50 1 9 Disclaimers Applicable to Advertising that Promotes a Nominal Gift Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 b 423 2268 b Plans must include a written statement on all advertising and explanatory materials promoting drawings prizes or any promise of a free gift that there is no obligation to enroll in the plan For example e Eligible for a free drawing and prizes with no obligation e Free drawing without obligation For additional information on nominal gifts refer to 70 2 50 1 10 Pharmacy Network Limitations Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 120 All plan sponsors offering Part D benefits must include a statement on all explanatory marketing materials that indicates eligible beneficiaries must use network pharmacies to access their prescription drug benefit except under non routine circumstances and quantity limitations and restrictions may apply 50 1 11 Required Access Information Disclaimers Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 One of the following statements is required on all enrollment explanatory materials used by all MA and MA PD plans whose members are locked into a provider network if the member obtains routine care from an out of network p
2. e May not be tied directly or indirectly to the provision of any other covered item or service and e Are subject to disclosure requirements that is the plan must clearly inform the enrollee what target activities are rewarded what limitations if any apply and how to claim the reward items and e Must comply with all relevant fraud and abuse laws including when applicable the anti kickback statute and civil monetary penalty prohibiting inducements to beneficiaries 70 2 Nominal Gifts Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 b 423 2268 b Pursuant to 42 CFR 422 2268 b and 42 CFR 423 2268 b plan sponsors can offer promotional gifts to potential enrollees at all marketing activities as long as such gifts are of nominal value and are provided whether or not the individual enrolls in the plan Nominal value rules also apply to rewards and incentives The definition of nominal value is slightly different for a pre enrollment promotional gift and a post enrollment reward To satisfy the requirements of meeting nominal value for rewards to current enrollees e Each individual item must be worth 15 or less based on the retail value of the item e The annual aggregate value of all items offered by the plan to each person must be 50 or less based on the retail value of the items To satisfy the requirements of meeting nominal value for pre enrollment promotional items
3. 90 6 1 or the materials identified in 90 2 plan sponsors may not distribute or otherwise make available to eligible beneficiaries any marketing materials unless such materials have been submitted to CMS and CMS has rendered a status of approved or deemed The marketing review time period begins on the date of a marketing material s submission to HPMS 90 5 1 45 Day Standard Review Period Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 a i 423 2262 a i The default review period for materials is referred to as a standard review A standard review provides CMS forty five 45 calendar days in which to render a review decision If on the forty sixth 46 day a decision has not been rendered by CMS the material will be deemed approved The forty five 45 day review period applies each time an individual marketing material is submitted to CMS for review For example if a material is submitted to CMS for review and on the thirty second 32 day CMS renders the decision of disapproved upon correcting the material s deficiencies and resubmitting the piece the forty five 45 day clock starts anew The forty five 45 day standard review applies to materials submitted where e No standardized or model language is available e Model language is available and the plan sponsor has chosen to make modifications to the model language 90 5 2 10 Day Model Review Period Rev 93
4. Example Table 1 Enrollment Effective Disenrollment Effective Date Date Beneficiary February 1 April 1 Recovers all payments for this enrollment because it Plan D Pays agent monthly is a rapid disenrollment it amount occurs within the first 3 months of enrollment in the plan Example 2 A beneficiary enrolls in Plan G effective in March 1 Several months later the beneficiary decides to enroll in Plan T with an effective date of November 1 If plan G has paid the agent for March through December then it must recover compensation from the agent for November and December If the beneficiary changes plans in January of the following year the plan sponsor does not recover payments made from November and December because this is not a rapid disenrollment Example Table 2 Enrollment Effective Disenrollment 2 Enrollment Following Date Effective Date Effective Date Contract Year Beneficiary March 1 November 1 November 1 Pays agent a Plan sponsor recovers Plan G prorated amount payments for for March through November through December December Does not Pays agent for Aces Plan T November through payments December from me previous year Makes payments Plan X for the following year Example 3 An agent enrolls a beneficiary in Plan K with an effective date of January 1 The beneficiary is subsequently disenrolled beca
5. e This plan is available to anyone who has both Medical Assistance from the State and Medicare 50 1 19 Radio Advertisements Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 Radio advertisements for a plan sponsor must include the plan sponsor s toll free number and applicable requirements for hours of operation Additionally any radio ads that mention benefit information must state the general advertising disclaimer noted in 50 1 3 The Federal contracting statement is not required Radio advertisements are File amp Use eligible documents 50 1 20 Television Advertisements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Television advertisements for a plan sponsor must include the plan sponsor s toll free number including TTY number and applicable requirements for hours of operation Additionally any television ads that mention benefit information must contain the general advertising disclaimer noted in 50 1 3 This information must be displayed on the crawl or banner The Federal contracting statement is not required however any other required disclaimers e g actor portrayal must be worked into the script and or shown on the screen Television advertisements are File amp Use documents 50 1 21 Online Enrollment Center Disclaimers for Websites Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42
6. 42 CFR 422 2268 k 423 2268 k Plan sponsors may not conduct sales activities in healthcare settings except in common areas Common areas where marketing activities are allowed include areas such as hospital or nursing home cafeterias community or recreational rooms and conference rooms If a pharmacy counter area is located within a retail store common areas would include the space outside of where patients wait for services or interact with pharmacy providers and obtain medications Plan sponsors are prohibited from conducting sales presentations distributing and accepting enrollment applications and soliciting Medicare beneficiaries in areas where patients primarily intend to receive health care services or are waiting to receive health care services These restricted areas generally include but are not limited to waiting rooms exam rooms hospital patient rooms dialysis center treatment areas where patients interact with their clinical team and receive treatment and pharmacy counter areas where patients interact with pharmacy providers and obtain medications The prohibition against conducting marketing activities in health care settings extends to activities planned in health care settings outside of norma business hours upon ae the alec Me are sanity silos to i with np T a ipea ha or to ee melik oe Jor sees oe a hee ie leet do so oe wes mal Ai ma i wale IM om omer Eaa o aani ah wih wiih they wit
7. Disclaimers When Benefits Are Mentioned if applicable 50 1 3 Disclaimers for the Marketing of Educational Events if applicable 50 1 7 Disclaimers on Advertisements and Invitations to Sales Marketing if applicable 50 1 8 Disclaimers on Advertising that Promotes a Nominal Gift if applicable 50 1 9 e Disclaimer for Third Party Marketing Materials if applicable 50 1 13 50 1 1 Guidance and Disclaimers Applicable to Explanatory Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 In general explanatory marketing materials include those materials that are sent to prospective enrollees prior to enrolling enrollment and to current and new members as part of their enrollment post enrollment Explanatory materials include a higher level of detail with regard to plan benefits and costs As a general rule materials that contain a high level of detail such as premiums cost sharing detailed plan brochure and multiple benefits are subject to all explanatory disclaimers and submission requirements The following disclaimers are applicable to explanatory materials It is the responsibility of the plan sponsor to ensure they meet all requirements contained within the referenced sections as well as any additional disclaimer requirements throughout 50 related to specific materials or plan types e g SNP PFFS PPO and co branding materials F
8. Materials for marketing of education events must also include This event is only for educational purposes and no plan specific benefits or details will be shared 50 1 7 Invitations to sales marketing events must also insert A sales person will be present with information and applications For accommodation of persons with special needs at sales meetings call lt insert phone TTY and hours of operation gt 50 1 8 Materials promoting nominal gifts must also insert a written statement on all materials advertising promoting drawings prizes or any promise of a free gift that there is no obligation to enroll in the plan 50 1 9 Part D sponsor materials mentioning Part D benefits must also include a statement indicating that in general beneficiaries must use network pharmacies to access their prescription drug benefit except in non routine circumstances and quantity limitations and restrictions may apply 50 1 10 MA and MA PD plans whose members are locked into a provider network must also insert information that the member must receive all routine care from plan providers 50 1 11 Materials that are co branded with providers must also insert Other lt pharmacies physicians providers gt are available in our network 50 1 12 Third party materials must also include a disclaimer noting Medicare has neither reviewed nor endorsed this information 50 1 13 PPO plans must also insert
9. s secure Internet website using materials and web pages that have been submitted to CMS for review and received approval refer to Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Prescription Drug Benefit Manual for the appropriate enrollment guidance on what plan types are allowed to utilize enrollment internet mechanisms The following information applies to Internet enrollment conducted by a plan sponsor directly PDP organization enrollment forms and screens must follow the guidance provided in 40 1 2 of Chapter 3 of the Medicare Prescription Drug Benefit Manual MA and MA PD organization enrollment forms and screens must follow the guidance provided in 40 1 2 of Chapter 2 of the Medicare Managed Care Manual Plan sponsors are not permitted to market or enroll beneficiaries in other lines of business products as part of the online enrollment process In developing and submitting online enrollment screens plan sponsors must include all elements from the applicable model enrollment form and provide contact information for questions including toll free telephone and TTY numbers as well as requirements in Chapters 2 and 3 respectively of the Medicare Managed Care Manual and the Medicare Prescription Drug Benefit Manual Following the acceptance of an online enrollment request the plan sponsor must have a tracking mechanism to provide the individual with evidence that the internet enrollment request was received a
10. 06 04 10 42 CFR 422 2262 423 2262 If CMS approves a material submission the material submission has been determined to be compliant with this chapter and any other applicable regulations laws or relevant guidance The material submission is approved for use in the format in which it was submitted and may be distributed by a plan sponsor Marketing materials once approved remain approved until either the material is altered by the plan sponsor or conditions change such that the material is no longer accurate However CMS may at any time require a plan sponsor to change any previously approved marketing materials if found to be inaccurate even if the original submission was accurate at the time of approval NOTE Prior to having an executed contract with CMS plan sponsors marketing material dispositions will be considered conditionally approved 90 3 2 Disapproved Disposition Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 If CMS disapproves a material submission the material submission has been determined to be not compliant with these Medicare Marketing Guidelines or with applicable regulations laws or other relevant guidance CMS will provide a specific reason for disapproval and provide an explanation for the disapproval generated by HPMS CMS will provide citations to the requirement with which the material was found to be non compliant 90 3 3 Deemed Disposition Rev 93
11. 150 6 7 Mark Guidelines on Incorrect Use Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act Following are rules for preventing incorrect use of the Medicare Prescription Drug Benefit Program Mark e Do not alter the position of the mark elements e Do not alter the aspect ratio of the certification mark Do not stretch or distort the mark e Always use the mark as provided e Do not rotate the mark or any of its elements e Do not alter or change the typeface of the mark e Do not alter the color of any of the mark elements e Do not position the mark near other items or images Maintain the clear space allocation e Do not position the mark to bleed off any edge Maintain one eight 1 8 inch safety from any edge e Do not use any of the mark elements to create a new mark or graphic e Do not use the mark on background colors images or other artwork that interfere with the legibility of the mark 150 7 Part D Standard Pharmacy ID Card Design Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act Usage of the Medicare Prescription Drug Benefit Program Mark on any item must be consistent with 60 2 of this chapter Part D Plan Sponsor Name Logo sponsor logo place holder RxBin 999999 RxPCN ABC1234567 RxGrp ABC123456789 Issuer 80840 ID 12345678901 Name JOHN Q PUBLIC CMS S5555 XXXX _Medicare
12. Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 d 423 2268 d As reflected in 42 CFR 422 2268 d and 42 CFR 423 2268 d there is a general prohibition on marketing through unsolicited contacts In general this prohibition includes the following and may extend to other instances of unsolicited contact that may occur outside of advertised sales or educational events Some examples include e Door to door solicitation including leaving information such as a leaflet flyer or door hanger at a residence or leaving information such as a leaflet or flyer on someone s car e Approaching beneficiaries in common areas e g parking lots hallways lobbies sidewalks etc e Telephonic or electronic solicitation including leaving electronic voicemail messages text messaging or sending unsolicited e mail messages NOTE Agents brokers who have a pre scheduled appointment which becomes a no show may leave information at the no show beneficiary s residence The prohibition on marketing through unsolicited contacts does not extend to mail and other print media e g advertisements direct mail provided they are constructed and approved in accordance with the information set forth in these Medicare Marketing Guidelines Leads may still be generated through mailings websites advertising and public sales events Refer to 70 3 regarding email policy Plan sponsors will be held accountable for all
13. Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 a i 423 2262 a i When a plan sponsor follows CMS model language without modification CMS must render a decision within ten 10 calendar days If on the eleventh 1 12 day a decision has not been rendered by CMS the material will be deemed approved As with the standard review period when a material is resubmitted for a ten 10 day review CMS is provided with a new ten 10 day review period to render its decision The ten 10 day review period only applies when the plan sponsor has followed the CMS model without modification Without modification means the plan sponsor used CMS model language verbatim except where indicated and allowed by CMS for example variable fields NOTE The without modification exception will be allowed for grammatical errors only e g if the model has grammatical errors then the plan sponsor may correct the model s grammatical errors It also means that the plan sponsor has followed the same sequence as provided in the model See 90 7 3 for additional information on model materials To facilitate reviews plan sponsors should indicate the model exhibit title and applicable CMS chapter manual or HPMS memoranda date within the comments section of HPMS Plan sponsors must indicate that a marketing material qualifies for model review when that material is uploaded into HPMS This feature will only be present when a m
14. advertis ing SB formulary pharmacy provider directory and EOC Plan sponsors may provide this 1 iks fr however the navigational icons used to access these links must clearly deseribe the information contained on each informational link Links can consist of numerous pages as long as the navigational icons used within the linked pages clearly describe the information being accessed For specific guidance on submission of website reviews refer to 90 18 CMS expects that up to date versions of marketing materials will be available on the website As an example when a plan updates their pharmacy provider directory the directories on the website must reflect the most up to date version Similarly if a plan issues an errata for an EOC they must ensure a corrected version of the EOC is placed on the website CMS also expects online formularies will reflect the most recently approved formulary file Plan sponsors must provide certain current contract year information on a website for members and prospective enrollees Renewing plan sponsors are also required to provide website content beginning October 1 for the next contract year Plan sponsors must maintain current contract year content on their website until at least December 31 In addition documents and information plates to beac TOMPO content must a Sear T a current contract a paai pa ie current phe wine ae salteapent alan y n CMS napay users will be able to quickly identify whi
15. creating a six 6 year compensation cycle However if an enrollee moves to a plan of a different plan type the agent or broker may receive an initial compensation and the six 6 year cycle starts over again Once the compensation cycle expires it does not restart until the beneficiary enrolls into another plan Plan sponsors may continue to pay agents or brokers renewal compensation beyond the six 6 year cycle at the plan s discretion as described in 120 5 4 The monthly MARx agent broker compensation report that is generated when an enrollment occurs will provide plan sponsors with the information necessary to determine whether they should make an initial or renewal payment 120 5 4 Specific Guidance for Developing and Implementing Compensation Strategy Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2274 a 423 2274 a Following is specific guidance for plan sponsors as they develop or modify their agent broker compensation strategy CMS defines year as a plan year meaning January through December 31 For example if a beneficiary turns 65 in and enrolls in a plan in September then the initial year for that beneficiary ends on December 31 of that year even though the beneficiary has only been in the plan for four 4 months In January of the next year the plan would begin paying renewal payments to the agent that assisted this beneficiary When a beneficiary enrolls after Januar
16. e Post stands and free standing inserts newspapers magazines e Event signage e Internet advertising e Pharmacists promotional buttons e Window stickers e Counter tents e Direct mail items such as postcards self mailers home delivery coupons and reply cards as long as they do not include enrollment forms Alternate Formats Alternate formats are used to convey information to beneficiaries with disabilities e g Braille large print and audio Assisting in Enrollment Assisting in enrollment consists of assisting a potential enrollee with the completion of an application and or objectively discussing characteristics of different plans to assist a potential enrollee with appraising the relative merits of all available individual plans based solely on the potential enrollee s needs As used in these Medicare Marketing Guidelines the phrase assisting in enrollment does not apply to assistance being provided by an individual or entity receiving direct or indirect compensation from the company with which the beneficiary is considering enrolling Banner and Banner Like Advertisements Banner advertisements are typically used in television ads and flash information quickly across a screen with the sole purpose of enticing a prospective enrollee to contact the plan sponsor to enroll or for more information A banner like advertisement is usually in some media other than television for example outdoor advertising
17. 2262 423 2264 If a plan sponsor submits an outreach proposal that CMS has already approved and that does not contain substantive changes then the CMS Regional Account Manager in conjunction with the appropriate CMS State Representatives will only review the targeted membership information audience number and outreach dates the contract s between the plan sponsor and its outreach subcontractor s the updates to benefit levels and income and resource criteria and the attestation CMS will respond to the plan sponsor within the ten 10 day time frame CMS has established for reviewing standardized marketing materials CMS Regional Office will file the outreach proposal for future reference CMS recognizes that the plan sponsor will have to make simple periodic changes to its outreach programs in order to update minimum income levels As stated previously CMS does not consider these updates to be substantive changes in that they do not prompt a full review of an outreach proposal However the plan sponsor is still responsible for submitting such changes to the appropriate lead CMS Regional Office for marketing reviews to ensure accuracy of such changes If the plan sponsor wishes to make substantive changes to the outreach process it must submit those changes to the appropriate CMS Regional Office Account Manager for review according to the review process above 70 11 PFFS Plan Provider Education and Outreach Programs Rev 93 Issu
18. 40 1 Marketing Material Identification Number Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 422 2264 423 2264 Plan sponsors are required to place a unique marketing material identification number on all marketing materials including standardized OMB forms This information will allow CMS to track the plan sponsor s marketing material within the marketplace and address beneficiary inquiries and or complaints should they arise This number is also used to identify and track materials in HPMS CMS requires a specific format for this identifier to allow immediate recognition of the document and or advertisement as a Medicare marketing material Except as noted below the material ID must be entered into HPMS in the same manner that it appears on the marketing material The material ID is made up of three parts The first part of the material identification number is the plan sponsors contract number H for MA or section 1876 cost plans R for regional PPO plans RPPOs or S for PDPs or Multi Contract Entity MCE identifier Y followed by an underscore The second part of the identifier is any series of alpha numeric characters chosen at the discretion of the plan sponsor The third part includes either the term CMS Approved or the term File amp Use as appropriate with a placeholder for the date 1 e two digits each for month and day followed by a four digit year For e
19. Additional details on what is required for an acceptable attestation can be found at 45 CFR 164 508 170 4 Sending Non plan and Non health Information Once Prior Authorization is Received Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Non plan and non health related content cannot be provided to members until after prior authorization is received Once the authorization is received e Non health related content cannot be included with plan related materials This includes mailings and websites as well as outbound telephone calls related to current plan information Note that if the plan sponsor uses a website to provide non health related content the link from the plan s Medicare product website must inform the beneficiary that he or she is leaving the Medicare product website and going to the non Medicare product website as specified in 100 1 e Health related content can be included with plan related materials e As with all other materials that plans send to Medicare beneficiaries plan sponsors are responsible for ensuring that any non plan related content provided as a result of beneficiary authorization is accurate and not confusing or misleading and does not inappropriately imply Medicare s approval or suggest that the content includes official information from the Medicare program In addition these materials should include the disclaimer Medicare has neither reviewed nor endorses this inf
20. Appeals Call Center Requirements 80 1 3 Required Scripts for Inbound Informational Calls 80 1 4 Requirements for Inbound Informational Scripts 80 1 5 Prohibited Activities For Inbound Informational Scripts 80 1 6 Requirements for Enrollment Scripts Calls 80 1 7 Prohibited Activities for Enrollments Scripts Calls 80 1 8 Requirements for Telephone Sales Scripts Inbound or Outbound 80 1 9 Requirements for All Other Inbound Outbound Scripts 90 Guidance on the Marketing Review Process 90 1 Plan Sponsor Responsibilities 90 2 Material Submission Process 90 2 1 Ad Hoc Enrollee Communications Submission 90 3 Material Disposition Definitions 90 3 1 Approved Disposition 90 3 2 Disapproved Disposition 90 3 3 Deemed Disposition 90 3 4 Withdrawn Disposition 90 4 Resubmitting Previously Disapproved Pieces 90 5 Time Frames for Marketing Review 90 5 1 45 Day Standard Review Period 90 5 2 10 Day Model Review Period 90 6 File amp Use Program Overview 90 6 1 Materials Qualified for the File amp Use Submission 90 6 2 Materials Not Qualified for File amp Use Submission 90 6 3 Restriction on the Manual Review of File amp Use Eligible Materials 90 6 4 Loss of File amp Use Certification Privileges 90 7 Additional Guidance for CMS Provided Language Materials 90 7 1 Standardized Language 90 7 2 Required Use of Standardized Model Materials 90 7 3 Model Materials 90 8 Template Materials 90 8 1 Standard
21. CMS does not review third party marketing materials developed by a third party entity which is not affiliated nor contracted with the plan sponsor Plan sponsors choosing to provide marketing materials and or services created by non benefit service providing third party entities must ensure that the following disclaimer is prominently displayed at the bottom center of the first page of the material or in the case of a website on each page and is of a similar font size and style as the message Medicare has neither reviewed nor endorsed this information In addition any marketing materials providing information on a subset of plan options and or services offered by a non benefit service providing third party entity must prominently display the following disclaimer on all materials The disclaimer must also be included on each webpage that lists compares or names available plans in the service area This is not a complete listing of plans available in your service area For a complete listing please contact 1 800 MEDICARE or consult www medicare gov TTY users should call 1 877 486 2048 24 hours a day 7 days a week or consult www medicare gov This disclaimer must be prominently displayed on each material or in the case of websites on each webpage that lists compares or names available plans Plan sponsors are responsible for ensuring that non benefit service providing third party entities comply with all MMG requirements p
22. II of the SB The side by side comparisons are eligible for a ten 10 day marketing review if no other non global changes are made to the standardized SB Section 1876 cost plans must use the standardized SB if they intend to have a plan appear in the Medicare Options Compare and should refer to the SB for 1876 cost plans in Appendix 1 Instructions for use of SB template are provided in 90 9 60 2 Part D ID Card Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 423 120 c All plan sponsors that offer Part D plans must provide a member identification card to a beneficiary no later than ten 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the first month of enrollment whichever occurs first Plans should refer to the notification on the TRR that contains the earliest notification to identify the start of the ten 10 calendar day timeframe The member identification card must comply with the most recent version of the National Council for Prescription Drug Program s NCPDP s Pharmacy and or Combination ID Card standard This standard is based on the American National Standards Institute ANSI INCITS 284 1997 standard titled Identification Card Health Care Identification Cards MA PD and section 1876 cost plans offering a Part D optional supplemental benefit may merge their medical and Part D ID cards by adding elements that would identify t
23. Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 a ii 423 2262 a ii 422 2266 423 2266 If CMS does not approve or disapprove marketing materials within the specified review time frame the following will apply e Materials subject to a forty five 45 day review period will be given the status of Deemed Approved on the forty sixth 46 day e Materials subject to a ten 10 day review period will be given a status of Deemed Approved on the eleventh 11 day e Plan sponsors that do not have a final contract will receive a conditional deemed approval After the contract is awarded the materials disposition will be changed to Deemed Approved and can then be used The status of Deemed Approval means that a plan sponsor may use the material Plan sponsors should include Deemed MMDDYYYY and follow the marketing material identification system described in 40 1 90 3 4 Withdrawn Disposition Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 A plan sponsor can choose to withdraw a marketing submission prior to CMS acting upon that marketing submission e g prior to beginning its review However plan sponsors cannot withdraw the marketing piece from HPMS therefore they should submit a written request to their CMS Regional Office Account Manager or Marketing Reviewer stating the reason s for the withdrawal CMS is not able to initiate withdraw
24. Medigap policy 70 6 Outbound Enrollment and Verification Calls to New all Enrollees Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2272 b 423 2272 b All plan sponsors are required to conduct outbound enrollment and verification OEV calls for enrollments effectuated by agents and brokers including both independent and employed agents and brokers to ensure individuals requesting enrollment understand the plan rules It is important for the plan sponsor s sales staff to obtain from the applicant the best phone number to be used for verification and to provide a description of the enrollment verification process to the applicant during the application process OEV calls must be made to the applicant after the sale has occurred they cannot be made at the point of sale The plan sponsor must ensure that the verification calls are not conducted by sales agents and that sales agents are not physically present with the applicant at the time of the verification call Plan sponsors may not use automated calling technologies to effectuate these outbound calls our expectation is that calls may be interactive The plan sponsor must conduct these calls for all enrollment requests generated by agents and brokers including both independent and employed agents and brokers Excluded from this requirement are enrollments into employer or union sponsored plans enrollments into PACE plans enrollments submitted
25. RFB HMO POS Plan Name HMO POS RFB Local PPO Plan Name PPO RFB PSO Plan Name PSO CCRC Plan Name HMO POS CCRC SNP Plan Name HMO POS SNP 50 Marketing Material Types and Applicable Disclaimers Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 In general CMS groups marketing materials into two distinct categories advertising and explanatory marketing materials Unless noted otherwise the following disclaimers must be present on all advertising and explanatory materials as directed Please note that if the document is a model document and the CMS model does not include the disclaimer the disclaimers are not required until the model is updated If plan sponsors choose to include the disclaimers provided in this guidance on model documents this is considered a model without modification and therefore can be submitted for a ten 10 day review If plan sponsors submit a model document and modify and or revise the disclaimers provided in this guidance the material should be submitted for a forty five 45 day review Documents that are standardized e g the SB should not include the following disclaimers unless they are already present on the standardized document For all materials disclaimers must be prominently displayed on the material and must be of the similar font size and style refer to 40 2 and 40 3 for more information In addition to the guidance provided in this sect
26. Requirements for Inbound Informational Scripts Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 423 2262 423 2264 Inbound informational scripts must be submitted for review and approval as an entire script talking points or bullet points If scripts are submitted as talking or bullet points the material must clearly differentiate acceptable language and practices from prohibited language and practices Inbound information scripts must e Include the purpose of the script in the heading e g advertising benefit information post enrollment information or situational responses e Include the applicable Federal contracting statement Plan sponsors must ensure that the language does not imply that they are endorsed by Medicare or are answering on behalf of Medicare Include all required language contained in the Medicare Marketing Guidelines that is appropriate to the purpose of the script e g all relevant disclaimers outlined in 50 Include a privacy statement clarifying that the beneficiary is not required fo provide any health related information to the plan representative unless it will be used to determine enrollment eligibility Use verbal responses to questions that follow the same guidelines required for similar printed materials in the same situation Provide TTY numbers in conjunction with all other phone numbers Clearly request the caller s consent when
27. Templates 90 8 2 Static Templates 90 9 Submission for Summary of Benefits Submitted as a Template Prior to Bid Approval 90 10 Submission of All Templates 90 11 Submission of Non English Alternate Formats Materials 90 12 Acceptable Formats 90 13 Submissions Outside of HPMS 90 14 Requirements for Joint Enterprise for PDPs and Regional Preferred Provider Organizations RPPOs 90 15 Multi Contract Entities MCEs 90 16 Review of Materials in the Marketplace 90 17 File amp Use Retrospective Monitoring Reviews 90 17 1 Template Materials Quality Review and Reporting of Errors 90 18 Specific Guidance on the Submission of Websites for Review 90 19 Service Area Low Income Subsidy Materials Functionality SA LIS Special Guidance on Multiple Submissions of Materials 90 20 Specific Guidance on the Submission of General Advertising Materials 90 21 Materials Not Subject To Review 90 22 Submission of Multi Plan Materials 100 Special Guidance on Plan Sponsor Websites 100 1 Plan Sponsor Website Requirements 100 2 Required Website Content 100 2 1 Pharmacy Access Information 100 2 2 Provider Access information 100 2 3 Specific Guidance Regarding Grievance Coverage Determination including Exceptions and Appeals Website Requirements 100 2 4 Low Income Subsidy LIS Website Premium Summary Table for People Receiving Extra Help 100 3 Prohibited Links 100 4 Required Disclaimers on Websites 100 5 Enrollment
28. about Original Medicare MA plans MA PD plans or PDPs in an unbiased way that does not steer or attempt to steer that enrollee toward a specific plan or limited number of plans Educational Event An event designed to inform Medicare beneficiaries about Medicare Advantage Prescription Drug or other Medicare programs that does not steer or attempt to steer potential enrollees toward a specific plan or limited number of plans Educational events may be hosted by the plan sponsor or an outside entity and are held in a public venue Educational events may not include any Sales activities such as the distribution of marketing materials or the distribution or collection of plan applications The intent of this guidance is not to preclude plans from educating beneficiaries about their products rather it is to ensure that events that are advertised as educational comply with CMS requirements More specifically plans may provide education at a sales or marketing event but may not market or sell at an educational event Explanatory Marketing Materials Explanatory marketing materials are a subset of marketing materials primarily intended to explain the benefits operational procedures cost sharing and or other features of a plan sponsor to current members or to those considering enrollment Explanatory marketing materials are further subdivided into enrollment materials pre enrollment marketing materials and post enrollment marketing
29. administrative requirements 1 CMS has received a signed certification form from the plan sponsor s CEO CFO or designee 2 materials submitted qualify for the File amp Use Certification process 3 a completed transmittal form is attached to the materials unless they are electronically submitted through HPMS and 4 all materials include the plan sponsor s contract number e g HHHHH RHE SiH or MCE identifier of Y as a prefix to the marketing materials identification number 90 7 Additional Guidance for CMS Provided Language Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 The following sections address CMS requirements when CMS issues documents and or language to be used as instructed 90 7 1 Standardized Language Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 c 423 2262 c Standardized language refers to language developed by CMS or other Federal agencies e g Office of Management and Budget OMB approved forms which is mandatory for use by plan sponsors and cannot be modified in a substantive or material way Impermissible modifications generally include altering the content format or language in any way or altering the format in a way that is not consistent with the form or manual instructions For OMB approved forms submitted as File amp Use refer to 90 6 1 90 7 2 Required Use of Standardized Model Mat
30. advocating follow up calls Use of phrases such as would you like or may we are acceptable Phrases such as we will are not acceptable refer to 70 4 regarding unsolicited contact for more information If applicable any references to a VAIS benefit must use the appropriate disclaimer located in 110 Always close by offering to send follow up materials published information for inbound informational calls Directing callers to the website is optional Include a greeting that can be delivered by either a CSR or Interactive Voice Response IVR e Clearly state the plan name the name of the programs being represented and a brief description of the plan e g an MA PD plan MA plan section 1876 cost plan or PDP If voice prompts are used for this purpose all choices and access directions must be clearly stated Options should include a re play option and an opt out to a CSR option In addition an after hours voice mail prompt may be provided e Provide options to access general information enrollment information or customer service These options can be provided by either a CSR or an IVR These options must be made available immediately after the plan name announcement Under no circumstances can callers be connected directly to an enrollment specialist e Repeat the option that is selected by the caller e g Thank you for selecting general information or I can help you with general information
31. also establish direct contracts with providers In this case the plan sponsor establishes provider contracts not to meet Medicare access requirements but rather to ensure enrollees that they will have access to providers who will agree to accept the PFFS plan Plan sponsors should focus on increasing outreach to providers and educating them about how PFFS plans work To encourage provider participation plan sponsors must ensure that providers have reasonable access to their terms and conditions of payment and that those providers are being paid correctly and timely At a minimum plans should prominently display their terms and conditions on their website CMS will be closely monitoring beneficiary and provider complaints and other marketplace based information to determine whether compliance and or enforcement actions are warranted CMS may require that PFFS plan sponsors with documented provider access problems provide CMS data about their provider education and outreach efforts 70 11 1 PFFS Plan Staff Requirement for Assisting Providers Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 114 PFFS plan sponsors are required to have staff available to assist providers with questions concerning plan payment and payment accuracy CMS encourages PFFS plan sponsors to better educate their provider relations staff on the rules of their terms and conditions of payment so that they can provide reliable information to providers a
32. and implemented in a way that the integrity of the training and testing is maintained In doing so they must have a process for handling instances in which agents do not pass the test on the first try Plan sponsors should document that each agent broker has been trained and passed the test at the appropriate level and must have the ability to provide this information to CMS upon request 120 4 Agent Broker Use of Marketing Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 Plan sponsors are responsible for all marketing materials used by their subcontractors to market their plan s All marketing materials used by plan sponsors or their subcontractors must be submitted by the plan sponsor that contracts with CMS e g the MAO or PDP sponsor offering the plan being marketed or in the case of a marketing material used by multiple plan sponsors by one plan sponsor on behalf of all affected plan sponsors to CMS for review and approval prior to use Marketing materials cannot be submitted directly by a third party to CMS Jt is the responsibility of plan sponsors to ensure that all applicable materials created by a third party meet the requirements outlined in the MMG Agents and brokers are permitted to create and distribute materials Materials that mention Medicare or plan specific benefits must be submitted to CMS for review and approval or File amp Use if applicable via the plan
33. associated links to members for their information For more information about MSA plans visit e www medicare gov Publications Pubs pdf 11206 pdf to view the booklet Your Guide to Medicare Medical Savings Account Plans Tax publications are available on the IRS website at http www irs gov or from 1 800 TAX FORM 1 800 829 3676 150 Use Of Medicare Mark For Part D Plans Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Section 1140 of the Social Security Act All MA PD plans PDPs section 1876 cost that provide Part D benefits will sign a licensing agreement to use the official Medicare Mark via the HPMS contracting module All applicant and renewing Part D sponsors will sign the Medicare Mark licensing agreements via the HPMS electronic signature process The license agreement is effective for a single contract year and Part D sponsors must renew annually to continue using the Medicare Mark logo 150 1 Authorized Users for Medicare Mark Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Section 1140 of the Social Security Act All MA PD plans and PDPs are authorized to use the Medicare Prescription Drug Benefit Program Mark only after receiving written communication from CMS This communication will include a licensing agreement which must be signed by the organization s CEO CFO in order to use the Medicare Prescription Drug Benefit Program Mark prior to exec
34. between use of plan and non plan providers 50 1 16 Additional Guidance Applicable to All PFFS Plan Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 In addition to the applicable requirements and disclaimers noted in 50 the following guidance is applicable to PFFS plans The following PFFS disclaimer must be prominently displayed within all enrollment explanatory materials including but not limited to websites and materials used at sales presentations by agents brokers employed and contracted e For non network PFFS plans A Medicare Advantage Private Fee for Service plan works differently than a Medicare supplement plan Your provider is not required to agree to accept the plan s terms and conditions of payment and thus may choose not to treat you with the exception of emergencies If your provider does not agree to accept our terms and conditions of payment they may choose not to provide health care services to you except in emergencies If this happens you will need to find another provider that will accept our terms and conditions of payment Providers can find the plan s terms and conditions of payment on our website at insert link to PFFS terms and conditions of payment e For full and partial network PFFS plans A Medicare Advantage Private Fee for Service plan works differently than a Medicare supplement plan We have network providers that is providers
35. can be adjusted by the user Therefore the twelve 12 point font requirement refers to how the plan sponsor codes the font for the web page not how it actually looks on the user s screen Plan sponsors are allowed to utilize social networking websites e g Facebook Twitter to promote their plan to Medicare beneficiaries However CMS intends to monitor the use of such social networking site for this purpose in order to ensure that plan sponsors do not mislead Medicare beneficiaries If warranted we will issue additional guidance limiting as appropriate plan sponsors use of social networking websites to market their Medicare products Plan sponsors must submit advertisements that will be utilized for Facebook or Twitter for review and approval Any marketing materials that a plan sponsor places on its website must be in a minimum twelve 12 point Times New Roman equivalent font CMS acknowledges that the plan sponsors do not have control over the actual screen size shown on individuals computer screens that can be adjusted by the user Therefore the twelve 12 point font requirement refers to how the plan sponsor codes the font for the web page not how it actually looks on the user s screen 100 2 Required Website Content Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 422 111 g 2 423 2264 423 128 b 7 and 423 2264 a The following information must be accessible via a link
36. claim forms or paperwork plan sponsors may indicate that their plan involves relatively little paperwork such as e Virtually no paperwork e Hardly any paperwork Given the nature of the Part C and D program it would be misleading to suggest that there are no forms or paperwork involved Plan sponsors cannot say e No paperwork e Noclaims or paperwork no complicated paperwork e Noclaim forms 40 7 Logos Tag Lines Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 0 423 2268 0 The guidelines regarding the use of unsubstantiated statements that apply to advertising materials do not apply to logos tag lines Plan sponsors may use unsubstantiated statements in their logos and in their product tag lines e g Your health is our major concern Quality care is our pledge to you XYZ plan means quality care This latitude is allowed only in logo product tag line language Such unsubstantiated claims cannot be used in general advertising text regardless of the communication media employed to distribute the message Notwithstanding the ability to use unsubstantiated statements as indicated above the use of superlatives is not permitted in logos product tag lines e g XYZ plan means the first in quality care or XYZ Plus means the best in managed care 40 8 Identification of All Plans in Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 4
37. e Each individual item must be worth 15 or less based on the retail value of the item The following additional rules must be followed when providing gifts of a nominal value whether pre or post enrollment e Ifanominal gift provided is one large gift that is enjoyed by all in attendance for example a concert or a magician the total retail cost must be 15 or less when it is divided by the estimated attendance For planning purposes anticipated attendance may be used but must be based on venue size response rate or advertisement circulation e Cash gifts are prohibited even if their worth is less than 15 Cash gifts include charitable contributions made on behalf of potential enrollees and those gift certificates and gift cards that can be readily converted to cash regardless of dollar amount NOTE Plan sponsors should refer to the Office of Inspector General s website regarding advisory opinions on gift cards at http www oig hhs gov fraud advisoryopinions asp The dollar amount associated with the definition will be periodically reassessed by CMS A plan sponsor may offer a prize of over 15 to the general public for example a 1 000 sweepstakes as long as the prize is offered to the general public and not just to Medicare beneficiaries is not routinely or frequently awarded and is awarded without regard to whether the individual enrolls in a plan 70 2 1 Exclusion of Meals as a Nominal Gift Rev 96 Issued 5 1
38. e Formally present benefit information to the audience via a scripted talk electronic slides handouts etc e Provide a scope of appointment form for a subsequent meeting if a beneficiary requests a one on one meeting then the beneficiary must fill out a scope of appointment e Provide educational content to the audience or passersby e Provide a nominal gift to attendees with no obligation Note that the value of any give away including entertainment must be consistent with CMS definition of nominal gift e Contribute cash towards prize money to a foundation or another entity if the event is jointly sponsored The plan cannot claim to be the sole donor of the prize and it must be clear that the prize is attached to the event and not the individual organization NOTE Plan sponsors that distribute enrollment applications during a sales event must provide the information in 30 11 required materials in the enrollment kit At marketing sales events plan sponsors must Announce all products plan types that will be covered during the presentation at the beginning of that presentation e g HMO PFFS MSA etc Submit all sales scripts and presentations for approval to CMS prior to their use during the marketing sales event see 80 for additional information Clearly read or state the following disclaimer during PFFS presentations events For non network PFFS plans A Medicare Advantage Private Fee for Service plan work
39. ensuring that any marketing materials developed on behalf of the plan or by third party or delegated entities adhere to CMS record retention requirements Any records that should be retained as a result of direction from the Department of Justice should be kept by plan sponsors and their affiliates 30 2 Limitations on Distribution of Marketing Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 a 423 2262 a 422 2260 423 2260 A plan sponsor is prohibited from advertising outside of its defined service area unless such advertising is unavoidable For situations in which this cannot be avoided e g advertising in print or broadcast media with a national audience or with an audience that includes some individuals outside of the service area such as a Metro Statistical Area that covers two regions plan sponsors are required to clearly disclose their service area NOTE Dual Eligible DE SNPs are responsible for making sure that the service area in which they market is consistent with the service area included in applicable State contracts 30 3 Co branding Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 CMS permits plan sponsors to enter into co branding arrangements as provided in this section The following guidelines should be followed in the case of a co branding arrangement e To ensure that CMS is made aware of any
40. following in the same general location same hotel for example e A plan sponsor conducts events where beneficiaries can get educational materials a blood pressure check and enroll in the plan e An agent goes into a senior housing complex or senior citizen center to talk about Original Medicare and or Medigap policies but then discusses an MA plan or PDP e An agent attends a community sponsored health fair and hands out plan specific benefits information including premium and or copayment amounts or the agent hands out only educational materials but gives a brief presentation that mentions plan specific premiums and or copayment amounts e A SHIP hosts an event that is not advertised to beneficiaries as educational A plan sponsor may be invited to discuss plan specific benefits e A plan sponsor participates in a health fair or health promotion event and distributes plan specific materials including enrollment applications 70 8 Marketing Sales Events Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Marketing sales events are events designed to steer or attempt to steer potential enrollees toward a plan or limited set of plans At marketing sales events plan representatives may discuss plan specific information like premium cost sharing or benefits and or distribute or collect applications All one on one appointments with Medicare beneficiaries are considered b
41. for drugs depending on their tier should include a column indicating the drug s tier placement and the corresponding tier label description e g Generic or Preferred Brand from the approved PBP Part D plans may also choose to include a column providing the co payment or co insurance amount for each tier Utilization Management UM Part D plans must indicate any applicable UM tools e g prior authorization step therapy and quantity limit restrictions for the drug A description of the indicator used to describe the UM tools must be provided somewhere within the document e g in footnotes For example a Part D plan may choose to designate a prior authorization on a drug by placing an asterisk next to the name of the drug e Because many beneficiaries may only know the name of their prescription and not its therapeutic class the abridged formulary must also include an index listing drugs in alphabetical order that directs the reader to the page containing complete information for that drug e g name tier placement and utilization management strategy e Plan sponsors must explain any symbols or abbreviations used to indicate utilization management restrictions drugs that are available via mail order excluded drugs free first fill drugs limited access drugs drugs covered in the coverage gap and drugs covered under the medical benefit for home infusion drugs only 60 5 2 Comprehensive Formulary Rev 93 Issued 06 0
42. g MA PD plan or PDP previously discussed or indicated in the reply card e Return beneficiary phone calls or messages as these are not unsolicited e Contact their members via an automated telephone notification to inform them about general information such as the AEP dates availability of flu shots upcoming plan changes and other important information Plan sponsors may not accept an MA plan or PDP appointment that resulted from an unsolicited contact with a beneficiary including if the call started based on a non MA or non PDP product We reiterate that any agent broker representing a Medicare health plan is subject to the CMS marketing requirements at any point in which a discussion with a beneficiary turns to Medicare health plans even if during the sale of an unrelated product such as long term care insurance See scope of appointment guidance in 70 9 1 Finally for those outbound calls refer to 70 4 70 6 and 80 that are allowable under these Medicare Marketing Guidelines plan sponsors must comply to the extent applicable with the following e Federal Trade Commission s Requirements for Sellers and Telemarketers e Federal Communications Commission rules and applicable State law e National Do Not Call Registry e Honor Do not call again requests and e Abide by Federal and State calling hours All outbound scripts utilized by the plan sponsor or its contractors must be submitted for review and approval prio
43. interfere with the legibility of the document NOTE Since Sections I and II of the SB will not be generated from the PBP in twelve 12 o0 point font the MA organization should change the font to ensure that the font size is twelve 12 point Colors and shading techniques are permitted but must not direct a beneficiary to or away from particular benefit item and must not interfere with the legibility of the document The SB may be printed in either portrait or landscape page format Plan sponsors offering more than one plan may describe several plans in the same document by displaying the benefits for different plans in separate columns within the benefit comparison matrix e g MA vs MA PD Section II Plan sponsors must only include similar plan types when describing several plans i e HMO to HMO but not HMO to PFFS or HMO to PPO However since the PBP will only print Sections I and II of the SB report for one plan the plan sponsor will have to create a side by side comparison matrix for two or more plans by manually combining the information into a chart format Plan sponsor using this format must include the following statement in Section I Where is lt the plan name gt available There is more than one plan listed in this Summary of Benefits If you are enrolled in one plan and wish to switch to another plan you may do so only during certain times of the year Please call Customer Service for more infor
44. item Note that CMS sets the maximum not the minimum for nominal gifts Please refer to 70 2 for the definition of a pre enrollment promotional gift which differs slightly from that of a post enrollment reward Outdoor Advertising ODA Marketing material intended to capture the attention of an audience passing the outdoor display e g billboards signs attached to transportation vehicles and to influence them to request more detailed information on the product being advertised Part C Program A term used to describe the program encompassed by all plan sponsors offering MA or MA PD coverage Part D Program A term used to describe the program encompassed by all plan sponsors offering Part D prescription drug coverage Part D Sponsor or Part D Plan Sponsor A Part D sponsor is an MAO that offers an MA PD plan a PDP sponsor offering a PDP or a section 1876 cost plan offering qualified prescription drug coverage Plan Benefit Package PBP The package of benefits to be offered in a specific geographic area by a sponsor under an MA plan MA PD plan PDP section 1876 cost plan or employer group waiver plan filed annually with CMS for approval NOTE For purposes of this guidance the term plan will be utilized to describe all plan types unless otherwise noted Plan Sponsor The term plan sponsor is utilized in these Medicare Marketing Guidelines to refer to the entity that has a contract with the Federal Govern
45. months the beneficiary is enrolled in the plan when a beneficiary disenrolls within the first three months under the following circumstances e The beneficiary qualifies for one of the following special election periods SEP e Disenrollment from Part D due to Other creditable coverage or Institutionalization Under the following exceptional circumstances Gains drops employer union sponsored coverage Because of a CMS sanction against the plan Because of plan terminations Because of a non renewing section 1876 cost plan During the Medigap trial period In order to coordinate with Part D enrollment periods or Jn order to coordinate with an SPAP Due to following changes in status Becoming dually eligible for both Medicare and Medicaid Qualifying for another plan based on special needs Becoming LIS eligible Qualifying for another plan based on a chronic condition or Moves into or out of institution Due to an auto or facilitated enrollment e The beneficiary is involuntarily disenrolled for one of the following reasons Death Moves out of the service area Non payment of premium Loss of entitlement Retroactive notice of Medicare entitlement Contract violation or Plan non renewal or termination 120 5 7 Adjustments to Compensation Schedules Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 423 2274 For 2010 and s
46. non claim specific notification information e The activities of a plan sponsor s employees independent agents or brokers subcontracted 7MOs or other similar type organizations that are contributing to the steering of a potential enrollee toward a specific plan or limited number of plans and may receive compensation directly or indirectly from a plan sponsor for marketing activities Marketing Materials The definition of marketing materials as used in CMS regulations and these Medicare Marketing Guidelines extends beyond the public s general concept of advertising materials Marketing materials include any informational materials targeted to Medicare beneficiaries which e Promote the plan sponsor or any MA plan MA PD plan section 1876 cost plan or PDP offered by the plan sponsor e Inform Medicare beneficiaries that they may enroll or remain enrolled in an MA plan MA PD plan section 1876 cost plan or PDP offered by the plan sponsor e Explain the benefits of enrollment in an MA plan MA PD plan section 1876 cost plan or PDP or rules that apply to enrollees e Explain how Medicare services are covered under an MA plan MA PD plan section 1876 cost plan or PDP plan including conditions that apply to such coverage Marketing Sales Event Marketing sales events are events designed to steer or attempt to steer potential enrollees toward a plan or a limited set of plans At marketing sales events the plan sponsor may pr
47. of applications by unlicensed agents and brokers to the authority in the State where the application was submitted Additionally plan sponsors must notify any beneficiaries that were enrolled in their plans by unqualified agents and advise those beneficiaries of the agents and brokers status Beneficiaries may request to make a plan change including a special election period Agents acting as customer service representatives are not required to hold a license and cannot engage in marketing activities 120 3 Agent Broker Training and Testing Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2274 b c 423 2274 b c Plan sponsors must ensure annually that all brokers and agents including those employed by MA and Part D plans selling Medicare products are trained and tested annually on Medicare rules and regulations and on details specific to the plan products that they sell To the extent that CMS provides training and testing for agents and brokers CMS certification will not confer any special advantage to the agents and brokers who participate Agent and broker use of this certification as a marketing tool is prohibited In order to sell Medicare products a broker or agent must receive a passing score of at least eighty five 85 percent on the test of Medicare rules and regulations Tests may be written or computerized Plan sponsors must ensure that their training and testing programs are designed
48. of the English language version on materials produced entirely in Spanish The two 2 color version is preferred but the grayscale black and negative versions may be used Medicare Cobertura Para Recetas M dicas 150 6 4 Mark Guidelines on Size Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act To maintain clear legibility of the Program Mark never reproduce it at a size less than one 1 inch wide The entire mark must be legible 3 ae 2 Q Medicare 150 6 5 Mark Guidelines on Clear Space Allocation Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act The clear space around the Medicare Prescription Drug Benefit Program Mark prevents any nearby text image or illustration from interfering with the legibility and impact of the mark The measurement x can be defined as the height of the letter x in Rx in the Program Mark Any type or graphic elements must be at least x distance from the mark as shown by the illustration MedicareR os ge x Prescription Drug Coverage a lt 150 6 6 Mark Guidelines on Bleed Edge Indicator Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act The Program Mark may not bleed off any edge of the item The mark should sit at least one eighth 1 8 inch inside any edges of the item
49. office This assistance can be in the member s home only if the member requests such a visit e Use the Authorization to Represent form limited to the specific purposes of completing and submitting paperwork on behalf of the member discussing the member s case with case workers and gathering information from and on behalf of the plan sponsor s member The Authorization to Represent form must specify that the authorization is limited to securing benefits under the Medicare Savings Program or the Medicaid Program and cannot extend to other programs unless agreed upon and noted by the member Authorization to Represent shall not give the outreach specialist the authority to sign any documents on behalf of the member make any enrollment decisions for the member or file a grievance or request an initial decision coverage determination or appeal on a member s behalf e Follow up with members who do not respond to the initial member letter This follow up may be in the form of a second and or third letter or telephone calls If the member does not respond to the third effort the plan sponsor must refrain from contacting the member for at least six months following the last outreach attempt e Provide assistance to members reapplying for financial benefits if and when required to do so by the Medicaid State agency e Subcontract all outreach efforts to another entity or entities In such cases while the plan sp
50. rates how well plan sponsors perform in different categories for example detecting and preventing illness ratings from patients patient safety and customer service and other measures Plan sponsors must provide information about their plan or plans ratings information to current and prospective enrollees by referring them to http www medicare gov by including it in their enrollment kits making it available on websites and upon request Information from http www medicare gov and the HPMS generated plan ratings document described below may not be altered in any way except as noted below Plan sponsors must download their plan performance rating information generated from the HPMS Part D Performance Metrics Module using the following navigation path HPMS Homepage gt Quality and Performance gt Part D Performance Metrics and Reports gt Plan Ratings Template Plan sponsors will select their contract number from the list and click on the Create PDF link to generate their customized contract specific template in PDF format which may not be altered Plan performance summary ratings for each upcoming contract year will be available in the fall of each year Once the plan rating information is downloaded plan sponsors must add the relevant ratings year to the top of the document and may also add the plan logo The plan rating information should be submitted as File amp Use under category code 9004 The material ID must be included on the fr
51. review and approval of the beneficiary communications to current members ad hoc enrollee communications as defined in 20 will not be considered marketing materials However CMS has the authority to review ad hoc enrollee communications and upon review to determine that these communications may no longer be used CMS has created an HPMS code 7013 for submission of ad hoc enrollee communications These materials will be submitted File amp Use CMS reserves the right to retrospectively review such materials to ensure that the information being conveyed to enrollees is accurate and not misleading Plan sponsors with concerns about whether a material fits the very narrow definition of an ad hoc enrollee communication should contact their Regional Office Account Managers or Marketing Reviewer NOTE Ad Hoc enrollee communications must include the following disclaimer to ensure beneficiaries have access to translator services If you need help understanding the information in this letter please contact customer service at 1 800 XXX XXXX for free language translator services 90 3 Material Disposition Definitions Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 For all marketing materials submitted for review by CMS one of the following dispositions will be rendered approved disapproved or deemed 90 3 1 Approved Disposition Rev 93 Issued 06 04 10 Effective Implementation
52. specifically to fill gaps in Original Medicare coverage A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare covered services and sometimes covers items and services that are not covered by Medicare such as care outside of the country Model Document For certain beneficiary informational documents CMS has provided model language which when used without modification except within bracketed areas entitles the plan sponsor to receive a shorter review period or to submit under File amp Use as outlined in 90 6 1 The use of CMS model documents is optional unless otherwise directed by CMS or if the material falls into the category of standardized model materials refer to 90 7 2 Plan sponsors that choose to create their own language must be sure to include all information that is in the model document Multi Contract Entities MCE A designation available for plan sponsors that have multiple MA PDP contracts with CMS Being designated as an MCE allows plans to submit template materials to CMS that are representative of all or a selection of the plan sponsors contracts The plan sponsors Account Manager has the ability to approve requests for MCE designation once a plan sponsor requests the designation Please note that in most instances MCE has replaced the designation of Multi Regional Teams MRTs Multi Contract Groups MCGs and if a plan has already attained an MRT
53. sponsor Section 1876 cost plan A plan operated by a Health Maintenance Organization HMO or Competitive Medical Plan CMP in accordance with a cost reimbursement contract under Section 1876 of the Social Security Act Standardized Language Language developed by CMS or other Federal agencies which is mandatory for use by the plan sponsor and cannot be modified except as noted within the relevant document e g ANOC EOC SB Plan Ratings State Pharmaceutical Assistance Program SPAP An SPAP is a State program which provides financial assistance for supplemental prescription drug coverage for Part D eligible individuals Template Materials A template material is any marketing material that includes placeholders for variable data to be populated at a later time Third Party Marketing Organization TMO An entity such as a Field Marketing Organization FMO General Agent GA or similar type of organization that has been retained to sell or promote a plan sponsor s Medicare products on the plan sponsor s behalf either directly or through sales agents or a combination of both Value Added Items and Services VAIS VAIS are non benefit items and services provided to a plan sponsor s enrollees An item or service is classified as a VAIS if the cost if any incurred to the plan sponsor in providing the item or service is solely administrative A cost is not automatically classified as administrative simply because it is e
54. sponsors must document outbound enrollment verification activities We expect that both the script and the enrollment verification letter will inform beneficiaries that they must notify the plan sponsor of their intent to cancel the processing of their enrollment within seven 7 calendar days from the date of the letter or call or the last day of the month in which the enrollment request was received whichever is later For AEP enrollment requests the script and the enrollment verification letter will inform beneficiaries that they must notify the plan sponsor of their intent to cancel the processing of their enrollment within seven 7 calendar days from the date of the letter or call or by December 7 whichever is later The outbound verification requirements apply to sales agents and other plan representatives only when they are acting in the role of sales agents and as such are steering beneficiaries to one or a subset of all available plans In other words if a licensed agent is acting strictly as a customer service representative that is carrying out customer service duties such as providing factual information or taking demographic information in order to complete an enrollment request at the initiative of an enrollee who has already decided to enroll in a plan the outbound enrollment verification requirements do not apply However if there is steering and or marketing by the CSR agent and an enrollment request results such an enrollm
55. sponsors that consolidate plans from one contract year to the next may Associate with the consolidated plan all or a subset of the prior year s schedules associated with the set of plans being consolidated These schedules must be adjusted relative to the previous year s schedules according to the rate adjustment guidelines Only adjust all or a subset of the existing compensation schedules associated with plans for which compensation schedules were created the previous year they may not create any new compensation schedules for the consolidating plans Plan sponsors that are undergoing service area expansions reductions e Cannot create new compensation schedules or use in the reduced service area schedules associated with the geographic areas that are no longer part of their new service area e May create new compensation schedules only in the portion of the expanded service area that cross State boundaries when they are expanding an existing service area and it crosses State boundaries 120 5 8 Third Party Marketing Entities Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2274 a 423 2274 a If the plan sponsor contracts with a third party entity such as a TMO or a similar type of entity to sell its insurance products or perform services for example training customer service or agent recruitment the amount paid to the third party for the enrollment must be consistent with the compen
56. that appointment to take place immediately following the sales presentation provided the beneficiary has completed the scope of appointment form Marketing sales events as described in 70 8 do not require documentation of beneficiary agreement because the scope of products that will be discussed should be indicated on all event advertising materials CMS has developed a model scope of appointment form which is posted at http www cms hhs gov ManagedCareMarketing 09_MarketngModelsStandardDocumentsandE ducationalMaterial asp TopOfPage Written scope of appointment forms must be submitted in HPMS under Category 4000 Code 4011 We encourage plan sponsors to use our model scope of appointment form Use of the model without modification may be submitted under File amp Use A modified form must be submitted for forty five 45 day review If the scope of appointment is gathered via a recorded phone call the plan sponsor must ensure that any associated scripts for such calls must be submitted to and approved by CMS prior to their use 70 9 2 Beneficiary Walk ins to a Plan or Agent Broker Office or Similar Beneficiary Initiated Face to Face Sales Event Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 g and h 423 2268 g and h In instances where a beneficiary visits a plan or an agent broker office on his her own accord the plan sponsor or agent broker should complete a scope of appointment form and secur
57. the SB header on each page or on each section of the SB PDPs will not need to print the auto generated headings which include the S number PBP number and segment numbers 13 If an organization chooses to submit an SB for CMS review without Section II and no hard copy changes it will be treated as a model without modification and will be reviewed within the ten 10 day time frame Additional General Instructions for MA MA PD Plans Only Applies to MA PD only and MA only 1 If an MA organization wants to include mandatory supplemental benefits beyond those benefits found in the benefit comparison matrix the MA organization must place the information in Section III of the SB The MA organization must include a brief description of the benefits and any co pay requirements 2 If the MA organization includes additional information about covered benefits in Section II the MA organization may include a page reference to this information in the appropriate box in the benefit comparison matrix using the following sentence See page lt gt for information about lt benefit category gt Please enter the benefit category exactly as it appears in the left column Instructions for Section I Beneficiary Information Applies to MA PD PDP and MA only This section which applies to all plan sponsors must be incorporated into the SB exactly as it is written within the standardized document unless otherwise noted NOTE The last senten
58. the need to use a State licensed marketing representative All required CMS enrollment procedures and guidance apply Plan sponsors are reminded that they may not require potential enrollees to interact with a licensed agent in order to obtain plan material or to enroll in a plan if the potential enrollee is not asking for advice or counseling Further agents cannot act as a customer service representative and agent simultaneously There are occurrences when a plan sponsor TMOs or other third party may employ individuals with the intent to act as both an agent and a customer service representative In these instances there should be a clear distinction within the organization as to the type of representative that will be answering calls their precise roles and level of knowledge and training The level of knowledge training and licensure dictates a representative s appropriate responsibilities For example a licensed agent has a higher level of training and may perform the duties within the scope of a customer service representative as described above However an unlicensed call center representative is not qualified to perform duties beyond their degree of knowledge training and licensure When an unlicensed customer service representative encounters questions from a beneficiary that are beyond the scope of their abilities they must advise the caller to call a specified number and speak to a licensed agent for further guidance regarding plan ch
59. their ratios into compliance with this provision Upon receiving two of these advisements within a given contract year CMS will require that all materials submitted by the plan that qualify as File amp Use be submitted as such until the number of materials submitted meets the ninety ten 90 10 threshold If an organization fails to comply after CMS has taken aforementioned steps additional compliance actions may be taken All materials must include a marketing material identification number as outlined in 40 1 90 6 4 Loss of File amp Use Certification Privileges Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 b 423 2262 b A plan sponsor may lose File amp Use Certification status if it e Uses materials that do not meet the requirements of this chapter e Fails to file two or more materials at least five 5 calendar days prior to distribution or publication or e Is found after a targeted review by CMS to consistently submit a large number of File amp Use materials through a forty five 45 day review process or to consistently submit through the File amp Use process materials that do not meet the requirements of these Medicare Marketing Guidelines If CMS revokes a plan sponsor s File amp Use Certification privileges the plan sponsor may be reinstated under File amp Use Certification after at least six months have passed since its privileges were taken away If a plan sp
60. they offer with the exception of employer based plans refer to 130 This website page must include the name of the plan sponsor and clearly indicate that it is a Medicare contractor See 50 regarding marketing material types and applicable disclaimers All marketing materials that include a web address for the sponsor s website should link directly to the organization s Medicare specific pages CMS expects that plans will design their Medicare related website s with beneficiaries as the primary audience A plan sponsor may provide access to its organization s other lines of business on its Medicare based website However to avoid beneficiary confusion any links provided by the plan sponsor to health related or non health related products services must be clearly labeled as such to allow the beneficiary to make an informed decision and understand that by clicking on those links he she will be leaving the Medicare specific web pages Plan sponsors should reference 170 to ensure compliance regarding the use of beneficiary information requirements In addition any formulary information placed on websites must comply with 60 5 4 in addition to 100 of the guidance Any marketing materials that a plan sponsor places on a website must be in a minimum twelve 12 point Times New Roman equivalent font CMS acknowledges that the plan sponsors do not have control over the actual screen size shown on individuals computer screens that
61. to display the names and or logos of non provider entities not having substantially similar names and or logos of a network provider or providers on all marketing materials including the member identification card Co branding information added to previously approved template materials is not subject to re review as long as the changes are limited to populating existing variable fields e g organization name logos or contact information 30 3 1 Co branding with Network Providers Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 In addition to the above requirements plan sponsors are prohibited from displaying the names and or logos of co branded network providers on the plan sponsor s member identification card unless the provider names and or logos are related to a member s selection of a specific provider provider organization for example physicians and hospitals Plan sponsors that choose to co brand with network providers must include on marketing materials other than ID cards the following language Other lt Pharmacies Physicians Providers gt are Available in Our Network All co branding names and or logos of providers and or pharmacies should be on all other marketing materials Neither the plan sponsor nor its co branding partners whether through marketing materials or other communications may imply that the co branding partner is endorsed by CMS or that i
62. to the agent for January through April because Plan A was responsible for those payments Additionally Plan B is responsible for recovering any payments covering October through December Finally Plan Z is responsible for paying the agent from October through December Plan Z should not have paid anything to the agent for January through September If the member changes plans in January of the following year Plan Z cannot chargeback for October through December because this is not a rapid disenrollment Example Table 4 Disenrollm 2na Disenrollm 3 Enrollmen Following t Effective ent Enrollment ent Enrollment Contaci Effective Effective Effective Effective Date Year Date Date Date Date Beneficiary January 1 May 1 May 1 October 1 October 1 January 1 Recovers payments Pays agent from the the agent agent for Plan A AA the yearly the months amount of May through December P Aye abenus Recovers monthly nothing amount for datai each month YP ee for actual Plan B months the beneficiary is n beneficiary a member of the plan S eee member of beginning as with May Peace Pays agent Does not quarterly recover Plan Z amount any covering payment the months s from of October previous November year and December Makes payment Plan T s for the new year Plans should not recover funds but should pay only for the actual
63. whether they would like to receive a specific material or group of materials using a different medium The plan sponsor must specify to the member the materials in question If the plan sponsor does not receive a response from the member then the plan sponsor must assume that the member wants to receive the information in hard copy CMS may review plan electronic communication and portable media policies procedures systems and documentation during monitoring and compliance visits In addition plans electing to provide any materials using different media types must e Provide hard copies of all member materials available to members upon request Note that requests for hard copies of plan web pages are excluded from this requirement e Ensure that the process is completely voluntary Members must be informed of the option and be given the choice to opt in If a member no longer wishes to receive plan communications through electronic or portable media they must be able to opt out upon request e Document each member s choice of media type an election opt in to receive plan communications using that type e Have safeguards in place to ensure that member contact information is current communication materials are delivered and received timely and appropriately and important materials are identified in a way that members understand their importance e Have a process for automatic mailing of hard copies when electronic versions or choice
64. with respect to changes in providers or pharmacies addresses and phone numbers Plan sponsors are also required to provide information about contracted providers and pharmacies upon request e The first time a plan sponsor sends change pages a cover letter should be included to explain that the plan sponsor will now be sending change pages to members as opposed to a complete directory When sending out change pages the plan sponsor must include a cover letter that explains that the member can receive a complete directory upon request In addition the plan sponsor should include information on how to obtain provider pharmacy network information on the Internet and or by telephone In instances where significant changes to the provider pharmacy network occur the organization must send a special mailing of change pages immediately The requirement to send a special mailing for significant changes is in addition to all the other mailing timeframes In general the plan sponsor can define significant changes when determining whether a special mailing is necessary However CMS may also determine if a mailing is needed and may direct the plan sponsor to conduct such a mailing 60 4 1 Pharmacy Directories Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 423 128 b 5 423 128 c 1 E All Part D plans must include information regarding all contracted network pharmacies in their marketing materials provided at the
65. 1 Scope of Appointment Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 422 2268 g and h 423 2268 g and h In conducting marketing activities an MA or Part D plan sponsor may not market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary and documented by the plan prior to the appointment Distinct lines of plan business include MA and PDP products The scope of appointment must be agreed to by the Medicare beneficiary prior to any personal individual marketing appointment Agents and brokers can document the scope of appointment in writing via a scope of appointment form If the scope of appointment is being documented by recording a phone call in advance of the appointment the call should be placed by the plan sponsor and not the agent broker The sales person is bound to only discuss during that appointment those products that have been agreed upon by the beneficiary during that appointment If other products need to be discussed at the request of the beneficiary a second scope of appointment form must be completed for the new product type and then the marketing appointment may be continued Upon CMS request the plan sponsor must be able to produce documentation To further clarify the requirements around documentation e Plan sponsors must secure scope of appointment documentation prior to the appointment A beneficiary cannot agree to the s
66. 22 112 a 7 amp ii 423 128 d A plan sponsor must list the hours of operation for its customer service call center in all places where a customer service number is provided for current and prospective enrollees to call ID cards are excluded from this requirement Refer to 80 1 for additional guidance The number must be a toll free number Plan sponsors must also list the hours of operation for 1 800 MEDICARE any time the 1 800 MEDICARE number or Medicare TTY is listed e g 24 hours a day 7 days a week 40 11 1 Agent Broker Phone Number Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 112 a 7 G amp ii 423 128 d Materials that include an agent broker s phone number should clearly indicate that calling the agent broker number will direct an individual to a licensed insurance agent broker If an agent broker phone number is listed then the plan sponsor s customer service phone and the TTY number must also be included and all requirements regarding the customer service number in these Marketing Guidelines must be met e g hours of operation etc NOTE Business cards that include the agent broker s phone number are not required to indicate on the card that calling the number will direct the individual to a licensed insurance agent broker 40 12 Use of TTY Numbers Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Section 501 and Section 504 of
67. 23 2264 When plan sponsors submit multiple separate and distinct bids and PBPs to cover the same region service area there is no requirement that all Medicare plans offered by the plan sponsor be identified in all marketing materials At their discretion plan sponsors may identify or mention more than one plan in a single marketing piece so long as there is a distinction made between plan type and benefits offered if benefits are mentioned in the piece 40 9 Marketing to Beneficiaries of Non Renewing Medicare Plans Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Beneficiaries of non renewing Medicare plans that have chosen not to renew their contracts send the non renewal letters to beneficiaries no later than October 2 If October 2 falls on a non mail date then plan sponsors must ensure that the non renewal letter is sent in advance to ensure that beneficiaries receive the non renewal letter by the receipt date of October 2 CMS allows plan sponsors to market on October 1 if they choose to do so however plan sponsors may not accept enrollment requests from beneficiaries of non renewing Medicare plans without a valid election period in effect Further information on appropriate election periods can be found in Section 30 of both Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Medicare Prescription Drug Benefit Manual 40 10 Product Endorsements Testimonials Re
68. 27 TTY users should call 1 877 486 2048 24 hours a day 7 days a week e The Social Security Office at 1 800 772 1213 between 7 a m and 7 p m Monday through Friday TTY users should call 1 800 325 0778 or e Your State Medicaid Office In addition CMS encourages plans to insert the following on all enrollment materials that include Part D benefit and premium information People with limited incomes may qualify for Extra Help to pay for their prescription drug costs If you qualify Medicare could pay for up to seventy five 75 percent or more of your drug costs including monthly prescription drug premiums annual deductibles and co insurance Additionally those who qualify will not be subject to the coverage gap or a late enrollment penalty Many people are eligible for these savings and don t even know it For more information about this Extra Help contact your local Social Security office or call 1 800 MEDICARE 1 800 633 4227 24 hours per day 7 days per week TTY users should call 1 877 486 2048 50 1 5 Information on Enrollment Limitations Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Plans must indicate on all enrollment explanatory materials that members may enroll in a plan only during specific times of the year Plans may either describe all enrollment periods in detail or refer individuals to the customer service department for more information For
69. 4 10 Effective Implementation 06 04 10 42 CFR 423 4 423 128 c 1 v As provided in 42 CFR 423 128 c 1 v a Part D plan upon the request of a Part D eligible individual must provide the Part D plan s formulary 42 CFR 423 4 defines formulary as the entire list of Part D drugs covered by a Part D plan These provisions together require a Part D plan sponsor to provide a comprehensive written formulary to any potential or current enrollee upon his or her request NOTE If an individual contacts the Part D plan to request a comprehensive formulary the Part D plan may offer to provide the individual with coverage information for specific drugs That is a customer service representative may offer to look up the individual s prescription s in order to provide information about coverage tier placement and utilization management procedures for his or her drugs Customer service representatives also may inform individuals that current and comprehensive formulary information is available on the Part D plan s website Nevertheless the Part D plan still must provide the requested comprehensive written formulary unless the individual indicates otherwise The comprehensive formulary must include the same information provided within the abridged formulary document except that the comprehensive formulary must include the entire list of drugs covered by the Part D plan and excludes the disclaimer informing beneficiaries that the
70. 422 60 c 423 32 b Plan sponsors may accept enrollment requests via an incoming inbound telephone call to a plan sponsor s representative or agent note that the guidance regarding inappropriate transfer of calls as noted in 80 1 5 still applies Telephone enrollment scripts and processes must follow the guidance provided in 40 1 3 of Chapter 2 of the Medicare Managed Care Manual and 40 1 3 of Chapter 3 of the Medicare Prescription Drug Benefit Manual Telephone enrollment scripts must be submitted in their entirety for review and approval The telephone enrollment scripts must clearly differentiate acceptable language and practices from prohibited language and practices In developing and submitting scripts for enrollment via inbound calls plan sponsors must e Clearly state the individual is requesting enrollment into plan name and the plan type e Comply with at a minimum all applicable requirements described in the CMS Eligibility and Enrollment Guidance in 40 1 3 of Chapter 2 of the Medicare Managed Care Manual and 40 1 3 of the Medicare Prescription Drug Benefit Manual e Provide confirmation of having accepted the telephone enrollment request such as a confirmation tracking number or other tracking mechanism e Although not part of the telephone enrollment request plan sponsor may close the call with e A summary of the plan into which the individual has requested enrollment e A statement that the in
71. 6 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 f and 423 2268 f Hold time messages recorded information played to a caller while waiting on hold that discuss health education features and other general information e g hours of operation flu shot reminders are allowed Hold time messages that include information regarding disease management programs or health education or other generic statements such as Thank you for holding will not require CMS review and approval However other health related features on hold time messages should be submitted for a forty five 45 day review Plan sponsors may not include information on non health related services e g financial service information on hold time messages Refer to 80 1 4 for additional information on scripts 30 15 Use of the Medicare Name Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Section 1140 of the Social Security Act Under Section 1140 of the Social Security Act 42 U S C 1320b 10 it is forbidden for any person to use words or symbols including Medicare Centers for Medicare and Medicaid Services Department of Health and Human Services or Health and Human Services in a manner that would convey the false impression that the business or product mentioned 1s approved endorsed or authorized by Medicare or any other government agency This rule extends to downstream contractor
72. 64 423 2264 All advertising and explanatory materials must include the statement that the plan sponsor contracts with the Federal government Exceptions include e Banner and banner like ads e Outdoor advertising and e Television and Internet banner ads At least one of the following statements must be used by MA MA PD or Cost plans as the contracting statement The statements should not be modified and may be either in the text of the piece or at the end bottom of the piece e A An insert plan type HMO plan PPO plan PFFS plan POS plan PSO plan with a Medicare contract e A Medicare Advantage organization with a Medicare contract e A Health plan with a Medicare contract e A Federally Qualified HMO with a Medicare contract e A Federally Qualified Medicare contracting HMO e Medicare approved insert plan type HMO plan PPO plan PFFS plan POS plan PSO plan Cost plan MSA plan or e A Coordinated Care plan with a Medicare Advantage contract e A Coordinated Care plan with a Medicare Advantage contract and a contract with the state Medicaid program This disclaimer would be applied to all D SNP marketing materials that have a contract with the state Medicaid program e A Coordinated Care plan with a Medicare Advantage contract but without a contract with the state Medicaid program This disclaimer would be applied to all D SNP marketing materials that do not have a c
73. 7 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 p 423 2268 p Plan sponsors may not provide meals or have meals subsidized to prospective enrollees at sales marketing events any event or meeting at which plan benefits are being discussed and or plan materials are being distributed Refer to 70 7 for guidance regarding education events Plan sponsors are however allowed to provide refreshments and light snacks to prospective enrollees Plan sponsors must use their best judgment on the appropriateness of food products provided and must ensure that items provided could not be reasonably considered a meal and or that multiple items are not being bundled and provided as if a meal Meals may be provided at educational events provided the event meets CMS strict definition of an educational event and complies with the nominal gift requirement in 70 2 Meals are not allowed at sales marketing events Refer to 70 7 for guidance regarding educational events While CMS does not intend to define the term meal or create a comprehensive list of food products that qualify as light snacks items similar to the following could generally be considered acceptable Fruit Raw vegetables Pastries Cookies or other small bite size dessert items Crackers Muffins Cheese Chips Yogurt Nuts It is the responsibility of plan sponsors to monitor the activities of all agents selling their plan s and ensure
74. BP or will be covered by original Medicare for the remainder of the contract year Additionally if the newly covered service is covered outside the contract the enrollee must be told that he or she could receive this service from any Medicare provider including out of network Medicare providers The plan sponsor may use a variety of mechanisms to inform enrollees of the change in coverage At a minimum the MAO must provide notice on the plan website within 30 days with subsequent publication in the next plan newsletter or other mass mailing not specifically dedicated to the NCD notification Alternatively MAOs may choose to provide this information to enrollees in a targeted way such as via email or one time mailings specific to this issue In the case of a non NCD related change to plan rules during a contract year note that these rule changes must be positive for enrollees relative to the rules articulated in the plan sponsor s post enrollment material the plan sponsor must notify CMS and obtain its approval and must also notify enrollees at least thirty 30 days before the effective date of the change The plan sponsor may use a variety of mechanisms to inform enrollees of the mid year change including one time mailings newsletters and other vehicles For more information on application of Medicare coverage policies to Medicare Advantage see Chapter 4 section 80 National and local coverage determinations of this manual at h
75. CFR 422 2264 423 2264 With a few exceptions outlined below all plan sponsors must accept enrollment in a plan through the Online Enrollment Center OEC The OEC is accessible through http www medicare gov Plans accepting enrollment requests through the OEC must state the following disclaimer on their websites Medicare beneficiaries may enroll in lt plan name gt through the CMS Medicare Online Enrollment Center located at http www medicare gov NOTE There are few exceptions for certain plan types that are not required to or cannot accept enrollment through the OEC These plan types include section1876 cost plans Medicare Savings Account MSA plans and 800 series employer group waiver plans SNPs and Religious Fraternal Benefit plans may but are not required to accept enrollment through the OEC 50 1 22 Enrollment and Marketing Materials after Non Renewal or Service Area Reduction SAR Notice to CMS Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 506 Enrollment and marketing materials must prominently announce to prospective enrollees the decision to non renew or reduce the service area For efficient operation of the program plan sponsors that are non renewing or reducing their service area should cease marketing of the non renewed reduced plan s after August 31st The following is model language that may be used as an attachment or addendum or in a script for customer servi
76. CFR 422 503 423 2260 Plan sponsors that choose to allow online enrollment via their website should refer to 30 77 and ensure that all applicable materials are posted in such a manner as to allow beneficiaries the ability to read them prior to accessing an enrollment form An exception to this is alternate formats refer to 90 11 for further details Apart from compliance with section 508 of the Rehabilitation Act refer to 30 0 plan sponsors need only to indicate at the beginning of the online enrollment mechanism that alternate format materials are available by contacting the plan directly Note that the plan sponsor cannot make the Medicare beneficiary read or sign off on these documents as a condition of enrollment rather they must only make them available 110 Guidance about Value Added Items and Services Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Chapter 4 of the Medicare Managed Care Manual 90 110 1 Definition of Value Added Items and Services VAIS Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Chapter 4 of the Medicare Managed Care Manual 90 The definition examples and policy requirements of VAIS are provided in Chapter 4 of the Medicare Managed Care Manual Plan sponsors should refer to 170 regarding use of beneficiary information for the provision of information about health related VAIS VAIS may be offered by MA plans PDPs EGWPs and section 1876 cos
77. Chapter 3 Medicare Marketing Guidelines For Medicare Advantage Plans Medicare Advantage Prescription Drug Plans Prescription Drug Plans and Section 1876 Cost Plans Rev 96 Issued 5 17 11 Table of Contents 10 Introduction 20 Definitions 30 Plan Sponsor Responsibilities 30 1 Record Retention Requirements 30 2 Limitations on Distribution of Marketing Materials 30 3 Co branding Requirements 30 3 1 Co branding with Network Providers 30 3 2 Co Branding with State Pharmaceutical Assistance Programs SPAP 30 4 Provider Name in Plan s Name or Downstream Entity s Name 30 5 Use of Data from Medigap Issuers 30 6 Plan Sponsor Responsibility for Subcontractor Activities and Submission of Materials for CMS Review 30 7 Anti Discrimination 30 8 Requirements for Plans with Non English Speaking Populations 30 9 Requirements for Plans with Special Needs Populations 30 10 Compliance with Section 508 of the Rehabilitation Act 30 1 Required Materials in Enrollment Kit 30 12 Required Materials for New and Renewing Members at Time of Enrollment and Annually Thereafter 30 13 Required Ongoing Materials for New and Renewing Members 30 14 Hold Time Messages 30 15 Use of the Medicare Name 30 16 Referral Programs 30 17 Privacy and Confidentiality 30 18 Plan Ratings Information from www medicare gov 30 19 Extended Marketing Period for Plans With Five Star Ratings 40 General Marketing Requirements 40 1 M
78. D plan sponsor should notify the plan sponsor s Account Manager in advance of the co branding arrangement and must agree to adhere to all applicable Medicare Marketing Guidelines States have also asked whether it would be discriminatory if the SPAP during its education and outreach campaign informs the beneficiary which plan sponsors have agreed to co brand We do not believe that this would discriminate against other plan sponsors as long as all plan sponsors have been offered the option to co brand with the State and the standards for co branding offered by the State do not vary materially from one plan to another In other words as long as the SPAP gives all Part D plan sponsors equal opportunity to co brand with them and is providing the same benefits for all beneficiaries regardless of the co branded plan sponsors the SPAP is not discriminating Entities with a co branded relationship that involves remuneration between parties in a position to influence the referral of Medicare payable business should carefully scrutinize the relationship for compliance with the fraud and abuse laws including the Federal anti kickback statute 30 4 Provider Name in Plan s Name or Downstream Entity s Name Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Plan sponsors whose legal or marketing names include the logos and or names of network providers or whose downstream entities legal or marketin
79. For section 1876 cost plans For section 1876 cost plans that are closed to new enrollment the pre enrollment language in Section I will not apply to existing members Therefore these section 1876 cost plans should include the following disclaimer in their ANOC Existing Cost Plan members should disregard the Introduction of Section I of the Summary of Benefits SB NOTE Any additional information regarding the contractor s closed status should also be included in the cover letter Instructions for Section II Benefit Comparison Matrix For section 1876 cost plans Section 1876 cost plans may include the following footnote on each page of the benefit comparison matrix The text of the footnote should appear at the bottom of every page Tf you go to a provider outside of lt insert name of plan gt s network who accepts Medicare patients you re covered under Original Medicare You would pay the Part A and Part B deductibles and coinsurance Appendix 2 Plan Sponsor Website Chart Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 The following chart applies only to URL guidelines and plan sponsors website content requirements Please refer to the applicable sections for specific marketing requirements pertaining to other marketing materials Subiect MustUse MustNotUse Reason All plan sponsors must maintain a Web page or if they choose a website dedicated to the Medicar
80. Formal e Educational For example Informal store kiosk Changes to marketing sales events e g cancellations changes of room and other updates and edits should be updated in HPMS as soon as possible but must be updated in HPMS at least forty eight 48 hours prior to the scheduled event Cancellations Notification of cancelled sales events should be made whenever possible more than forty eight 48 hours prior to the originally scheduled date and time of the event CMS has established the following requirements on how all plan sponsors should notify beneficiaries when advertised scheduled sales events have been cancelled The method used to notify beneficiaries of the cancellation may vary depending on the individual plan s circumstances 1 If a sales event is cancelled Jess than forty eight 48 hours before its originally scheduled date and time the plan sponsor must e Notify its Regional Office Account Manager of the cancellation and cancel the event in HPMS e Ensure a representative of the plan sponsor is present at the site of the cancelled sales event at the time that the event was scheduled to occur to inform attendees of the cancellation and distribute information about the plan sponsor The representative should remain on site at least 15 minutes after the scheduled start of the event If the event was cancelled due to inclement weather a representative is not required to be present at the site 2 If a sales ev
81. II will be identical to the SB report in HPMS Any deviation from this language outside of an approved hard copy change or global hard copy change will result in CMS disapproval of the material Deviations include things like the insertion of footnotes plan specific clarifications or format alterations except as indicated in the SB instructions Plans should be generating their SB via the path in HPMS General requirements and guidance for SB are provided below 1 Nn Plan sponsors must adhere to the language and format of the standardized SB and are permitted to make changes only if approved by CMS Changes in the language and format of the SB template will result in the disapproval of the SB The title Summary of Benefits and the organization s CMS contract number must appear on the cover page of the document The entire SB must be provided together as one document e g all three sections OR sections one and two if section three is not being utilized The entire SB must be submitted for review as one document If plans opt to utilize the premium table and or Section II and or Section IV it will result in a forty five 45 day review Front and back cover pages are acceptable Font size of twelve 12 point or larger must be used for the SB Plan sponsors may use bold or capitalized text to aid in readability provided that these changes do not steer beneficiaries to or away from particular benefit items or
82. If an IVR is used opt out options must be noted immediately after this announcement e g Tf this is not the information you want press or say 1 to return to the main menu Or if you would like to speak to a customer service representative press or say 4 NOTE Plan sponsors are not required to collect a beneficiary s medication and pharmacy information to calculate an estimated total annual cost for various plans during a customer service call 80 1 5 Prohibited Activities For Inbound Informational Scripts Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 422 2264 423 2262 423 2264 Plan sponsors are not permitted to e Include information about other lines of business as part of the inbound script however scripts can ask if the caller would like to receive information about other lines of business offered by the plan sponsor e Transfer the caller to the enrollment area e Request prospective beneficiary identification numbers e g Social Security number bank account numbers credit card number HICN as part of pre enrollment inbound informational scripts except information regarding the required special needs status when determining the appropriateness of enrollment in a SNP or member specific scripts requesting a beneficiary s member ID number 80 1 6 Requirements for Enrollment Scripts Calls Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR
83. MCG status no action is needed to convert it to MCE status National Plans e National PDPs The term national plan means a PDP sponsor that at a minimum offers plans in each of the 34 PDP regions that include the 50 States and the District of Columbia PDP sponsors that offer plans in more than the minimum 34 PDP regions e g those that include the 50 States the District of Columbia and one or more territories are also considered national plans PDPs sponsored by a joint enterprise can also use the term national if the joint enterprise offers plans at a minimum in all 34 PDP regions that include the 50 States and the District of Columbia Refer to Federal Register Vol 70 FR 13398 e National Medicare Advantage and Medicare Advantage Prescription Drug MAs MA PDs Plans The term national plan means a Medicare Advantage Organization MAO that offers MA MA PD plans in each of the 50 States and the District of Columbia An MA or MA PD is considered to be a national plan regardless of whether or not the MAO offers a plan in one or more of the territories Nominal Value Any promotional activities or items offered by plan sponsors including those that will be used to encourage retention of members must be of nominal value Nominal value is currently defined as either an individual item worth 15 or less or aggregate items throughout the year worth 50 or less where prices are based on the retail purchase price of the
84. NOTE Since 2010 HPMS has automatically appended all plan names with the standardized plan type label described below Starting in 2011 the standardized plan type label will also distinguish which plans are Special Needs Plans SNPs Please Note Employer Group Waiver Plans i e 800 series plans will be appended with the standardized plan type labels below There is no further distinction between 800 series plans and individual market plans The following table outlines the standardized plan type terminology to be generated for each active HPMS plan type Table 40 16 1 Standardized Plan Type Terminology Standardized Plan Type Terminology Plan Type Plan Name with Standardized Plan Type Label HMO Plan Name HMO HMO SNP Plan Name HMO SNP PPO Plan Name PPO PPO SNP Plan Name PPO SNP HMO POS Plan Name HMO POS HMO POS SNP Plan Name HMO POS SNP ESRD II SNP Plan Name HMO POS SNP PSO Plan Name PSO PSO SNP Plan Name PSO SNP MSA Plan Name MSA MSA Demo Plan Name MSA RFB PFFS Plan Name PFFS PFFS Plan Name PFFS ESRD I Plan Name PFFS 1876 Cost Plan Name Cost 1833 Cost Plan Name Cost PDP Plan Name PDP Regional PPO Plan Name Regional PPO Regional PPO SNP Plan Name Regional PPO SNP Employer PDP Plan Name Employer PDP Employer PFFS Plan Name Employer PFFS RFB HMO Plan Name HMO
85. R 160 Use of Federal Funds Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Division F Title V 503 b Departments of Labor HHS and Education Appropriations Act 2009 as enacted by 5 Omnibus Appropriations Act 2009 Pub L 111 8 123 Stat 524 802 March 11 2009 CMS prohibits the use of Federal funds for non plan related activities that are designed to influence State or Federal legislation or appropriations by MAOs Part D sponsors section 1876 cost plans PACE plans and MA demonstration plans Specifically the Department of Health and Human Services Annual Appropriations Acts very specifically states that no appropriated funds may be used to pay the salary or expenses of any grant or contract recipient or agent acting for such recipient related to any activity designed to influence legislation or appropriations pending before the Congress or any State legislature 170 Allowable Use of Medicare Beneficiary Information Obtained from CMS Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 All MA Part D PACE and section 1876 cost plans sign a data use attestation under which they agree that they will restrict the use of Medicare data to those purposes directly related to the administration of the Medicare managed care and or outpatient prescription drug benefits for which they have contracted with CMS to administer Plan sponsors also agree not to use that inform
86. S Section 1140 of the Social Security Act 42 U S C 1320b 10 prohibits the use of the Department s name and logo the agency s name and marks and the word Medicare or Medicaid in a manner which would convey the false impression that such item is approved endorsed or authorized by CMS or DHHS or that such person has some connection with or authorization from CMS or DHHS Use absolute superlatives 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 Compare their organization plan s to another organization plan s by name unless they have written concurrence from all plan sponsors being compared for example studies or statistical data as described in 40 4 This documentation must be included when the material is submitted for review Plan sponsors may State that the plan sponsor is approved for participation in Medicare programs and or that it is contracted to administer Medicare benefits Use the term Medicare approved to describe their benefits and services within their marketing materials 99 66 Use qualified superlatives e g one of the best among the highest rank 40 6 Statements Related to Claim Forms and Paperwork Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 If a piece of material addresses the issue of
87. a service area when the comparison is done by an objective third party e g SHIPs State agency or independent research organizations that conduct studies For more information on non benefit service providing third party providers refer to 40 14 6 70 12 7 Providers Provider Group Websites Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Provider websites may provide links to plan enrollment applications and or provide downloadable enrollment applications The site must provide the links downloadable formats to enrollment applications for all plan sponsors with which the provider participates As an alternative providers may include a link to the CMS Online Enrollment Center NOTE The preceding requirement is not applicable to certain plan types such as section 1876 cost plans Medicare MSAs 800 series employer group waiver plans and Religious Fraternal Benefit plans SNPs may use the links and the SNP should rotify e provider that they may use the OEC link if they choose to but that it is not 80 Special Guidance on Telephonic Activities and Scripts Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 80 1 Customer Service Call Center Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 g 1 423 128 d 1 From October 15 to February 14 all plan sponsors are required to operate a toll fr
88. a that includes aggregate marketplace information on several other plans it will not be required to submit data on all plan sponsors included in the study However the study details such as the number of plans included must be disclosed e Plan sponsors referencing a CMS study should include reference information publication date page number in the HPMS Marketing Material Transmittal comments field For non CMS sponsored studies plan sponsors are to submit the sample and number of plans surveyed in the HPMS marketing material transmittal comments Plan sponsors are prohibited from using CMS Medicare or the Department of Health amp Human Services DHHS logos even when referencing a CMS study e Additional information may be requested by the Account Manager or CMS marketing reviewer to help in facilitate the review of submitted materials 40 5 Prohibited Terminology Statements Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 To ensure accurate and fair marketing by all plan sponsors CMS prohibits the distribution of marketing materials that are materially inaccurate misleading or otherwise make material misrepresentations Plan sponsors may not Misrepresent themselves their plans or the benefits and services covered by their plans Claim within their marketing materials that they are recommended or endorsed by CMS Medicare or the Department of Health amp Human Services DHH
89. actions of agents brokers selling their products and plans agents brokers should be wary of any company selling beneficiary contacts that claims to be permissible under our guidance Plan sponsors should also note that Medicare Marketing Guidelines and regulations apply to Medicare age ins as well as existing beneficiaries In addition permission given by a beneficiary to be called or otherwise contacted is to be considered short term event specific and may not be treated as open ended permission for future contacts All business reply cards BRC used for documenting beneficiary agreement for a contact must be submitted to CMS for review approval Additionally plan sponsors that develop a BRC should include a statement on the BRC that by replying to this card a sales person may call you 70 5 Specific Guidance on Telephonic Contact Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 d 423 2268 d Because telephonic contact with Medicare beneficiaries is performed for a variety of reasons the following guidance has been developed to further clarify the scope of the restriction on unsolicited contact CMS makes a distinction between contact with beneficiaries to establish a new relationship with a plan sponsor or independent sales agent and contact that is with a plan member or a beneficiary where a business relationship already exists e g the agent has sold the beneficiary non Medicare products i
90. acy does not have a central number for enrollees to call then plans must list each plan s chain pharmacy and phone number in the directory If the chain pharmacy does not have a TTY number plan sponsors are instructed to list the TRS Relay number 711 Plan sponsors should not list their own customer service number as a pharmacy phone number or TTY number e Part D sponsors may indicate which of their network pharmacies support e prescribing in their pharmacy directories e Part D sponsors must indicate which of their retail pharmacies provides an extended day supply of medications If a plan sponsor chooses to use the CMS model pharmacy directory and the disclaimers are not contained within the model inserting the disclaimers will still make the material eligible for a ten 10 day review If Part D sponsors use a search engine on their websites in lieu of posting the pharmacy directory the search engine must include all of the information listed above 60 4 2 Provider Directories Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 b 3 Q 422 111 e MA MA PD and section 1876 cost plans provider directories must contain all information within the CMS model provider directory Note that for DE SNPs the Medicaid indicator in the provider directory is a required element for those plans that have a contract with the State Medicaid Agency A provider directory that includes the Medicaid indic
91. agents If a contracted agent represents a single plan sponsor and is paid a fixed amount of money that does not vary based on enrollment that agent may be considered employed for purposes of applying CMS agent broker compensation requirements While CMS does not dictate how plans should pay compensation e g monthly quarterly annually CMS prohibits plans from paying compensation in advance e g paying five 5 years residuals up front Referral fees are equivalent to finder s fees and governed by CMS regulations This means that referral fees must be included in compensation schedules and fall within CMS compensation rules While referral fees are part of total compensation they are a one time fee and not subject to the six 6 year compensation cycle e Bonuses announced or unannounced prior to payment must be included in compensation schedules and fall within CMS rules A bonus does not fall outside CMS rules because it was not announced to agents or brokers in advance e Compensation for dual enrollments should be paid independently e g when a beneficiary enrolls in both a section 1876 cost plan and a standalone PDP compensation should be paid for both enrollments e When a beneficiary enrolls in an MA PD plan compensation should be paid using the MA compensation amount Plan sponsors should not pay both the MA and PDP compensation amounts e For Medicare beneficiaries enrolling in a plan mid year and having no pr
92. aimer on marketing and enrollment materials that refer to its star ratings Plan performance summary star ratings are assessed each year and may change from one year to the next NOTE Plan sponsors are responsible for translating plan ratings information as specified in 30 8 Translation of plan ratings information will not be considered an alteration of the document Additionally EGWPs are excluded from this requirement 30 19 Extended Marketing Period for Plans With Five Star Ratings Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 a 4 423 2264 a 3 As noted above plan performance summary star ratings apply to plan sponsors for the plan contract year January December Plans with a five star summary rating may market to and enroll beneficiaries throughout the year with enrollment under the Five Star Special Enrollment Period SEP taking effect on the first day of the subsequent month during the period for which the plan has the five star rating January 1 December 1 If a plan sponsor with a summary rating of five stars during the current year is assessed a summary rating of less than five stars for the upcoming year the plan sponsor must discontinue marketing for the purposes of accepting enrollments under the Five Star SEP by November 30 of the current year 40 General Marketing Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11
93. al Nutrition Therapy Smoking Cessation HIV screening for high risk groups To qualify for a reward the target item must be offered in whole as defined above for example a plan may not reward current enrollees just for annual blood pressure readings vs the entire annual wellness visit The reward items given to plan enrollees for doing any of the above target activities are subject to the following requirements e Fach reward item must have a retail value monetary cap not to exceed 5 per item additionally the aggregate retail value of all reward items offered annually may not exceed 50 in the aggregate on an annual basis per member per year e Must be offered to all current eligible members without discrimination e Must not be offered in the form of cash or other monetary rebates e May not be items that are considered a health benefit e g a free checkup e May not consist of lowering or waiving co pays e May not be used in pre enrollment advertising marketing or promotion of the plan e May not be structured to steer enrollees to particular providers practitioners or suppliers e May be discussed in direct mailings to enrollees as long as there is no violation of the HIPAA Privacy laws e Must be tracked and documented during the contract year e Are subject to grievances by the enrollee consequently the plan must explicitly advise enrollees of the right to grieve and the process for filing a grievance
94. al interest oft e providera or oui k or their eee or agents While conducting a health screening providers may not distribute plan information to patient CMS is concerned with provider activities for the following reasons e Providers may not be fully aware of all plan benefits and costs and e Providers may confuse the beneficiary if the provider is perceived as acting as an agent of the plan versus acting as the beneficiary s provider Providers may face conflicting incentives when acting as a plan sponsor representative For example some providers may gain financially from a beneficiary s selection of one plan over another plan Additionally providers generally know their patients health status The potential for financial gain by the provider influencing a beneficiary s selection of a plan could result in recommendations that do not address all of the concerns or needs of a potential plan enrollee Beneficiaries often look to health care professionals to provide them with complete information regarding their health care choices e g providing objective information regarding specific plans such as covered benefits cost sharing drugs on formularies utilization management tools and eligibility requirements for SNPs To the extent that a provider can assist a beneficiary in an objective assessment of the beneficiary s needs and potential plan sponsor options that may meet those needs providers are encouraged to do so To this
95. al of a marketing submission and is acting on behalf of the plan sponsor as specified in its written request 90 4 Resubmitting Previously Disapproved Pieces Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 To expedite the review of previously disapproved pieces plan sponsors should clearly indicate all changes updates made to a material when it is resubmitted Plan sponsors may meet this requirement by highlighting any text changes and or inserting notes to altered areas on the material Plan sponsors may develop an alternative process for identifying changes e g bulleting all changes made within the comments section of HPMS when submitting the material provided they discuss alternatives with and receive approval from the Account Manager Through this process CMS expects that all areas changed from the first submission can be easily identified in the review process and reviewers can confidently complete reviews knowing plans have not altered the material in other ways To that end CMS recommends that when resubmitting a material plan sponsors insert language in the comments section of HPMS attesting no other areas have been altered outside of the identified changes 90 5 Time Frames for Marketing Review Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 a 423 2262 a With the exception of those materials that qualify for File amp Use as outlined in
96. al should be the date the English version is eligible for use in the market place generally five 5 days after the piece is filed in HPMS 4 The submitted Alternate Formats material will receive a Material Status of Alternate Formats Materials submitted as an alternate format material may be used immediately The designation of Alternate Formats will inform the Regional Office reviewer that there are non English versions submitted If the plan sponsor decides to submit additional Alternate Formats materials with its attestations at a later date it may use the same process described above for each new material as needed Please note that any changes or revisions that are made to the English version should be accurately reflected in non English materials and re uploaded as required Plan sponsors use of alternative formats materials will be subject to verification monitoring review and associated penalties for violation of CMS policy as discussed in 30 8 If materials are found to be inaccurate or do not convey the same information as the English version plan sponsors may not continue to distribute materials until revised materials have been approved Plan sponsors will be allowed to submit Alternate Format materials once the original English version of the material submission is complete Users will be allowed to upload multiple alternate format files for contracts and for plan benefit packages If a
97. all current Medigap enrollees not just a subset Additionally the Medigap issuer plan sponsor must adhere to all HIPAA Privacy Rules and other applicable Federal or State privacy laws If during the course of an outbound call regarding Medigap products the beneficiary initiates interest inan MA MA PD cost plan or PDP product offered by the Medigap issuer then that MA MA PD cost plan or PDP product may be discussed as long as the call is recorded Refer to 70 4 on unsolicited contact 30 6 Plan Sponsor Responsibility for Subcontractor Activities and Submission of Materials for CMS Review Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 422 504 h 1 422 504 h 2 i 423 505 h 1 423 505 h 2 4 422 2262 423 2262 Plan sponsors that contract with CMS are responsible for all activities undertaken by their subcontractors on their behalf including but not limited to all materials used that meet CMS definition of a marketing material all sales activities and any and all scripts used to facilitate a sale CMS must review all applicable marketing materials prepared by a plan sponsor s sub contractor s excluding marketing materials for employer union enrollees Marketing materials may not be submitted directly by the third party to CMS rather materials must be submitted directly by the plan sponsor that contracts with CMS e g the MAO or PDP sponsor offering the plan being marketed It is t
98. all scripts that do not fall into the categories previously addressed inbound informational calls enrollment scripts or inbound outbound telephone sales calls e Scripts must include a privacy statement clarifying that the beneficiary is not required to provide any health related information to the plan representative unless it will be used to determine enrollment eligibility e Outbound auto dialings that are informational in nature will not be required to include this disclaimer in their scripts e Plan sponsors are prohibited from requesting beneficiary identification numbers e g Social Security Numbers bank account numbers credit card numbers HICNs This policy does not extend to calls to existing members to conduct normal business related to enrollment in the plan e g CTM complaint resolution Note that in limited circumstances plans may inquire about an individual s special needs status to determine the appropriateness of enrollment in a SNP e Plan sponsors must say they are contracted with Medicare to provide prescription drug benefits or that they are a Medicare approved MA PD plan MA only plan section 1876 cost plan with or without Part D benefits or PDP e Plan sponsors cannot use language in scripts that imply they are endorsed by Medicare calling on behalf of Medicare or that Medicare asked them to call the member Plan sponsors must incorporate in their scripts all applicable disclaimers as noted in 50
99. als Ad hoc enrollee communications materials are informational materials that are targeted to current enrollees are customized or limited to a subset of enrollees or apply to a specific situation and which do not include information about the plan s benefit structure but apply to specific situations or cover member specific claims processing or other operational issues These materials are not considered marketing materials Examples of these materials include the following e Letters about a shortage of formulary drugs due to a manufacturer recall letter e Letters to communicate that a beneficiary is receiving a refund or is being billed for underpayments e Letters describing member specific claims processing issues and e Customer service correspondence pertaining to unique questions or issues that affect an individual or small subset of the plan s enrollment Advertising Advertising materials are primarily intended to attract or appeal to a potential plan sponsor enrollee Advertising materials contain less detail than other marketing materials and may provide benefit information at a level to entice a potential enrollee to request additional information Examples of advertising materials include e Television ads e Radio ads e Outdoor advertising ODA such as billboards or signs attached to transportation vehicles e Banner and banner like ads e Print ads newspaper magazine flyers brochures posters church bulletins
100. als available in any language that is the primary language of more than five percent of a plan s PBP service area In addition enrollee information as identified in 30 9 must be made available to the visually impaired upon request Alternate Formats materials must be based on previously approved English versions of the same material NOTE Non English marketing materials submitted by plan sponsors must attest to the completeness and accuracy of the material through an electronic attestation in HPMS CMS expects that when plan sponsors complete the electronic attestation in HPMS they are attesting that any translated or alternate format versions are identical in content to the English material Plan sponsors that submit Non English Alternate Formats materials must designate the material as Alternate Formats in HPMS using the following process during data entry 1 The material must be given a unique Material ID 2 The user must select YES in the Alternate Formats field 3 Upon selecting YES in the Alternate Formats field the user will be required to enter the Material ID of the original English version in the Alternate Formats Original Material ID field NOTE This field will only display if the Alternate Formats field has YES selected NOTE The approval date for non English materials should be the date that appears on the English version The File amp Use date for non English materi
101. als found to be non model yet uploaded by the plans sponsors for model review will be disapproved Repeated submission of non model materials as models or submission of models inappropriately coded as used without modification will be viewed as a compliance issue To facilitate reviews plan sponsors should indicate the model exhibit title and applicable CMS chapter manual or HPMS memorandum date in the comments section of HPMS whenever a model document is submitted If the document is an attachment to a CMS issued memorandum the plan sponsor should indicate the subject and the date CMS issued the HPMS memorandum CMS expects that the final versions of a model document will be submitted Any models submitted with brackets and variable fields should be submitted via the template process see 90 8 and 90 10 for additional information 90 8 Template Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 A template material is any marketing material that includes placeholders for variable data to be populated at a later time by the plan sponsor CMS classifies template materials as either standard templates or static templates Plan sponsors must submit the final populated version of standard templates in HPMS Static templates include placeholders that are exempt from being submitted once populated Utilizing template materials allows a plan sponsor to submit one master do
102. also added the following website field in HPMS for PFFS plans PFFS Terms and Conditions of Payment website Note that this field should be populated with the web address for where the MAO maintains its PFFS plan terms and conditions of payment Use the following navigation path in HPMS to enter the appropriate information for this new web address HPMS Homepage gt Contract Management gt Basic Contract Management gt Select a Contract Number gt Org Marketing Data 70 12 Marketing Guidance for the Provider Setting Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 j and k 423 2268 j and k As used in specific guidance about provider activities the term provider refers to all providers contracted with the plan and its sub contractors including but not limited to pharmacists pharmacies physicians hospitals and long term care facilities These Medicare Marketing Guidelines are designed to guide plan sponsors and providers in assisting beneficiaries with plan selection while at the same time striking a balance to ensure that provider assistance results in plan selection that is always in the best interest of the beneficiary Providers that have entered into co branding relationships with plan sponsors must also follow these guidelines 70 12 1 Plan Activities and Materials in the Health Care Setting Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11
103. an and less than signs e g lt 10 00 Copay 15 00 Copay gt Template materials will have only one marketing identification number regardless of the number and combination of variable elements If a material meets all requirements for static templates as outlined in 90 8 2 plan sponsors should not indicate the material is a template when uploading the material in HPMS Static templates may be submitted in this manner given that CMS does not require populated versions of static templates be uploaded at a later date Conversely if a material meets requirements for standard templates as outlined in 90 8 1 plan sponsors must indicate the material is a template when uploading the material in HPMS Standard templates require that plan sponsors submit the final template material that has been populated in the placeholders with plan specific information When submitting a material with variable placeholders in the HPMS plan sponsors should indicate that the material is a standard template when initially submitting the piece by checking the Template Material field and entering a Template Material ID as required Plan sponsors should submit standard templates using current material codes and categories that define a piece Templates must be populated within 30 days of the approved date thirty 30 days of the File amp Use distribution date or thirty 30 days of the approved bid for materials filed prior to bid approval Plan sp
104. and internet banner ads and is intended to be very brief and to entice someone to call the plan sponsor or to alert someone that information is forthcoming Co Branding Co branding is defined as a relationship between two or more separate legal entities one of which is an organization that sponsors a Medicare plan The plan sponsor displays the name s or brand s of the co branding entity or entities on its marketing materials to signify a business arrangement Co branding arrangements allow a plan sponsor and its co branding partner s to promote enrollment in the plan Co branding relationships are entered into independent of the contract that the plan sponsor has with CMS Corporate Website An organization s web page may include information on the organization s mission history contact information products and services NOTE All plans are required to have a website with the web address provided in the HPMS contract management module A web address is an address that is typed into the web browser also known as a URL Universal Resource Locator A web link is a shortcut within a website or web page that connects the user to another location on the Internet A web page is a single element of a website usually an HTML based document Direct mail Is information sent to a beneficiary to attract attention or interest to a potential enrollee and allow him her to request additional information Education Informing a beneficiary
105. are partial network PFFS plans should indicate the category or categories of services for which network providers are available These providers have already agreed to see members of our plan If your provider is not one of our network providers then the provider is not required to agree to accept the plan s terms and conditions and thus may choose not to treat you with the exception of emergencies If your provider does not agree to accept our payment terms and conditions they may choose not to provide health care services to you except in emergencies If this happens you will need to find another provider that will accept our payment terms and conditions Providers can find the plan s terms and conditions on our website at insert link to PFFS terms and conditions If the material is part of an enrollment kit it must also contain a leaflet for provider education on plan rules and information 50 1 16 e DE SNPs must also insert a statement that premiums co pays co insurance and deductibles may vary based on the level of help received 50 1 17 e SNPs must also insert eligibility requirements for SNP enrollment e g This plan is available to anyone who meets the Skilled Nursing Facility SNF level of care and resides in a nursing home on enrollment explanatory materials 50 1 18 50 1 2 Federal Contracting Statement Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 22
106. are Advantage MA Medicare Prescription Drug Plan PDP rules and 1876 cost contracts Chapter 42 of the Code of Federal Regulations Parts 422 423 and 417 These Medicare Marketing Guidelines are for use by Medicare Advantage organizations offering MA plans and MA prescription drug MA PD plans section 1876 cost contracts and Prescription Drug plan PDP sponsors These Medicare Marketing Guidelines are not applicable to Program of All Inclusive Care for the Elderly PACE plans since PACE plans are governed by separate guidance which is not discussed in this document or to section 1833 cost plans The scope of the term marketing as used in the Medicare statute at Section 1851 h and 1860D 12 b 3 D 12 of the Act and CMS regulations extends beyond the public s general concept of advertising materials Pursuant to 42 CFR 422 2260 and 423 2260 marketing materials include any informational materials targeted to Medicare beneficiaries In addition CMS definition of marketing extends beyond materials to include activities conducted by the plan sponsor or an individual or organization on behalf of the plan sponsor that steer or attempt to steer a potential enrollee toward a plan or limited number of plans for which the individual or entity performing marketing activities expects compensation directly or indirectly for such marketing activities As such CMS authority for marketing oversight encompasses various materials and activi
107. are available for use by the plan sponsor The use of CMS model documents is optional unless otherwise directed by CMS or if the material falls into the category of standardized model materials refer to 90 7 2 Plan sponsors that choose to modify the model language other than populating variable fields must ensure that all elements provided in the model are included in the non model document Generally model documents used without modification will result in a ten 10 day marketing review period or may be submitted via File amp Use as specified in 90 6 1 Model documents modified by the plan sponsor will result in a forty five 45 day review period The following modifications to CMS model materials will still render the material allowable for use under the ten 10 day review period populating variable fields correcting grammatical errors changing the font adding the plan name logo and adding the CMS marketing material identification number Unless otherwise required plans may choose to retain the title of the model document or modify the title to make it more beneficiary friendly Note that any reference to the words exhibit model or appendix contained within the title of the model document must be removed Any other modifications made to the document will make the material subject to the standard forty five 45 day review process and or ineligible for File amp Use submission It is important to note that materi
108. arketing Material Identification Number 40 1 1 Marketing Material Identification Number for Non English or Alternate Format Materials 40 2 Font Size Rule 40 3 Footnote Placement 40 4 Reference to Studies or Statistical Data 40 5 Prohibited Terminology Statements 40 6 Statements Related to Claim Forms and Paperwork 40 7 Logos Tag Lines 40 8 Identification of All Plans in Materials 40 9 Marketing to Beneficiaries of Non Renewing Medicare Plans 40 10 Product Endorsements Testimonials 40 11 Customer Service Call Center Hours of Operation 40 11 1 Agent Broker Phone Number 40 12 Use of TTY Numbers 40 13 Additional Materials Enclosed with Required Post Enrollment Materials 40 14 Marketing of Multiple Lines of Business 40 14 1 Multiple Lines of Business General Information 40 14 2 Multiple Lines of Business Exceptions 40 14 3 Multiple Lines of Business Television 40 14 4 Multiple Lines of Business Internet 40 14 5 Multiple Lines of Business HIPAA Privacy Rule 40 14 6 Non Benefit Service Providing Third Party Marketing Materials 40 15 Providing Materials in Different Media Types 40 16 Standardization of Plan Name Type 50 Marketing Material Types and Applicable Disclaimers 50 1 Guidance and Disclaimers Applicable to Advertising Materials 50 1 1 Guidance and Disclaimers Applicable to Explanatory Materials 50 1 2 Federal Contracting Statement 50 1 3 Disclaimers When Benefits Are Mention
109. as well as all other relevant requirements outlined in these Medicare Marketing Guidelines e g hours of operation TTY number etc 90 Guidance on the Marketing Review Process Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 422 2262 423 2262 Except where otherwise noted all marketing materials must be reviewed prior to their use by the plan sponsor or any downstream organization that performs marketing activities on behalf of the plan sponsor CMS marketing review process is detailed in this section 90 1 Plan Sponsor Responsibilities Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 423 2262 423 2264 CMS reviews marketing materials to ensure that they are consistent with this chapter and are not materially inaccurate or misleading or otherwise make material misrepresentations of the plan sponsor or the products they offer Generally CMS does not review marketing materials for typographical or grammatical errors unless such errors render the marketing materials inaccurate or misleading Plan sponsors are responsible for conducting a quality check prior to submitting all materials for review to CMS Generally MA MA PD and section 1876 cost plan sponsors should not submit current contract year marketing materials for CMS review and approval after June 30 of that contract year Note that this date does not apply to File amp Use materials Prio
110. at do not qualify for File amp Use are those that pose greater risk to a Medicare beneficiary if they are inaccurate in any way These documents include but are not limited to e SB e Member Handbook e Member ID card e Enrollment forms e Disenrollment forms e Errata sheets In addition explanatory marketing materials as defined in 50 1 4 unless expressly identified by CMS as qualified for the File amp Use processes must be submitted for either a forty five 45 or ten 10 day review process as provided in HPMS 90 6 3 Restriction on the Manual Review of File amp Use Eligible Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 b 423 2262 b Plan sponsors that choose to utilize File amp Use must submit at least ninety 90 percent of marketing materials that qualify for File amp Use under this process More specifically plan sponsors choosing to utilize File amp Use should request a manual review of no more than ten 10 percent of materials that qualify for File amp Use including but not limited to model materials that qualify for File amp Use submission If CMS determines that a sponsor falls below the ninety 90 percent threshold for a given month reports will be run by CMS at the end of each month reflecting the cumulative compliance for the contract year thus far the organization will be so advised by the Marketing Reviewer and or Account Manager and urged to bring
111. at the service area or segment level NOTE PDPs cannot offer a local plan Marketing Steering or attempting to steer a potential enrollee towards a plan or limited number of plans or promoting a plan or a number of plans Assisting in enrollment and education do not constitute marketing CMS authority for marketing oversight includes a range of different marketing materials and activities While not an exhaustive list the following would fall under CMS purview per the definition of marketing e General audience materials such as general circulation brochures direct mail newspapers magazines television radio billboards yellow pages or the Internet e Marketing representative materials such as scripts or outlines for telemarketing or other presentations e Presentation materials such as slides and charts e Promotional materials such as brochures or leaflets including materials for circulation by third parties for example physicians or other providers e Membership communications and communication materials including membership rules subscriber agreements member handbooks and wallet card instructions to enrollees e Communications to members about contractual changes and changes in providers premiums benefits plan procedures etc e Membership activities for example materials on plan policies procedures rules involving non payment of premiums confirmation of enrollment or disenrollment or
112. at will be printed for the plan sponsor s membership 100 2 3 Specific Guidance Regarding Grievance Coverage Determination including Exceptions and Appeals Website Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 b 8 423 128 b 7 Plan sponsors must include the following specific information on the organization s website e A summary of the plan sponsor s grievance coverage determination including exceptions and appeals processes e Instructions for requesting a coverage determination including an exception including The telephone number designated for receiving oral requests Plan sponsors must accept standard and expedited requests for benefits expedited and standard and may choose to accept oral requests for payment The mailing address and fax number designated for receiving written requests e Instructions for requesting a redetermination appeal including The telephone number designated for receiving oral requests plan sponsors must accept expedited requests verbally and may choose to accept standard requests verbally The mailing address and fax number designated for receiving written requests e A link to the plan sponsor s redetermination request form if the plan has developed one e Any form developed by the plan sponsor to be used by a physician or enrollee to satisfy a prior authorization or other utilization manageme
113. ation The electronic attestation does not have to be completed by the same person who signed the original contract Following are the certification procedures for MA MA PD and section 1876 Cost Plans e Each plan sponsor should submit the File amp Use Certification marketing materials to CMS at least five 5 calendar days prior to distribution and certify by the plan sponsor s CEO CFO or designee that the materials are in compliance with CMS requirements As each item of marketing material is submitted each plan sponsor is responsible for ensuring the accuracy and completeness of its marketing materials and adhering to CMS requirements All certification forms must be sent to CMS refer to Model File amp Use Certification form Appendix 3 The requirement for submission of a signed certification form is a one time only requirement and the signed certification is effective until further notice A completed and signed certification form must be received from the plan sponsor before it may submit File amp Use certification materials The plan sponsor should mail the signed certification to its appropriate CMS Regional Office The File amp Use certification form see Appendix 3 states that the plan sponsor agrees that all advertising materials and model documents that are used are accurate truthful and not misleading e CMS will verify that the marketing materials submitted under the File amp Use Certification process meet the following
114. ation to develop market or operate lines of business unrelated to their Medicare plan operations For purposes of these Data Use Attestations CMS provided data includes information provided by beneficiaries in the course of their enrollment in a Medicare plan as well as data obtained solely as a result of access to CMS systems granted to the contracting organization or sponsor because it is a Part C Part D PACE or section 1876 cost plan contractor Except in cases in which the enrollee gave information as part of a commercial relationship prior to enrollment in the Medicare plan the contracting organization or sponsor was only given the information on the application as a result of the contract with CMS While plan sponsors with a previous commercial relationship with Medicare beneficiaries and employers offering Medicare plans may have obtained their personal data through that relationship and therefore are not obligated to follow the guidelines set forth in the Data Use Agreement we encourage plan sponsors to follow these data use guidelines as a good business practice for protecting beneficiaries from potentially unwelcome marketing and other communications Examples of what is considered a previous commercial relationship include membership in such products as Long term care insurance Life insurance policies Non Medicare employer or retiree plans Medigap policies While it is important to protect Medicare beneficiaries from potential
115. ator will still qualify for a ten 10 day review Plan sponsors are required to disclose all of the plan sponsor s contracted providers to each enrollee in a clear accurate and standardized form prior to the effective date of enrollment or within ten 10 calendar days of receipt of the enrollment confirmation and at least annually thereafter the directory is provided to new members upon enrollment and current members on an annual basis unless the plan sponsor uses change pages as outlined in 60 4 MA MA PD and section 1876 cost plan sponsors that do not combine the model provider pharmacy directories must list all Part B and Part D eligible contracted pharmacies in the provider directory Plan sponsors may indicate which of their participating physicians or physician practices support e prescribing Model directories that include e prescribing information will still be considered a model document eligible for a ten 10 day review 60 4 3 Primary Care Provider PCP and Specialty Directories Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 422 111 b 3 422 111 e 423 128 b 5 423 128 c 1 E Plan sponsors may print a separate directory for each sub network and disseminate this information to members in that particular sub network This practice is permissible provided that the directory clearly states that the lists of providers for other networks is available and will be provided to members upon request Plan s
116. be referred to CMS s External Affairs Office at 7500 Security Blvd C1 16 03 Baltimore MD 21244 1850 or by telephone to 410 786 7214 150 5 Prohibition on Misuse of the Medicare Prescription Drug Benefit Program Mark Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act and 42 U S C 1320b 10 42 U S C 1320b 10 prohibits the misuse of the Medicare name and marks In general it authorizes the Inspector General of the Department of Health and Human Services DHHS to impose penalties on any person who misuses the term Medicare or other names associated with DHHS in a manner which the person knows or should know gives the false impression that it is approved endorsed or authorized by DHHS Offenders are subject to fines of up to 5 000 per violation or in the case of a broadcast or telecast violation 25 000 150 6 Mark Guidelines Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act The Medicare Prescription Drug Benefit Program Mark is a logotype comprised of the words Medicare Rx with the words Prescription Drug Coverage directly beneath Medicare macnn x lt ye g gt Presi ription Drug Coverage Always use reproducible art available electronically Do not attempt to recreate the Program Mark or combine it with other elements to make a new graphic Artwork will be supplied in EPS TIFF or JPG format after n
117. ccurately and quickly Plan sponsors must be committed to providing accurate information to providers that is also easily accessible For example providers should be able to obtain accurate information on member cost sharing amounts including applicable deductibles and plan payment rates when they call the plan PFFS plan sponsors should address in a timely manner any inadequate capacity of plan contacts such as excessive busy signals or excessive lack of timely response to voicemail messages 70 11 2 PFFS Plan Terms and Conditions of Payment Contact and Website Fields in HPMS Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 114 Fields are available in HPMS to allow MAOs offering PFFS plans to directly provide CMS with their plan terms and conditions of payment provider contact information All PFFS plan sponsors must complete the data entry for these fields in HPMS and update the information as needed CMS has added the following contact field in HPMS for PFFS plan sponsors PFFS Terms and Conditions of Payment Contact for Public website Note that this field should be populated with the contact that will facilitate provider access to the MAO s PFFS plan terms and conditions of payment Use the following navigation path in HPMS to enter the appropriate information for this new contact HPMS Homepage gt Contract Management gt Contract Management gt Select a Contract Number gt Contact Data CMS has
118. ce in Section I will automatically include the following This document may be made available in other formats such as Braille large print or other alternate formats Plan sponsors contracting with CMS are obligated to follow the regulatory requirements of the Americans with Disabilities Act and the Civil Rights Act of 1964 Compliance with these requirements satisfies the intent of the above referenced SB sentence No additional requirements are imposed by the above referenced SB sentence The following five paragraphs apply to MA and MA PD plans 1 Section I as generated by the PBP will include the applicable H number and plan number at the top of the document MA organizations must delete this information 2 The fourth paragraph How can I compare my options contains a sentence We also offer additional benefits which may change from year to year If this is not applicable to your plan you must remove this sentence 3 The second question and answer in Section I includes the plan s service area the PBP will generate a list of counties with an indicating those counties that are partial counties The MA organization may list the zip codes of these counties in this section or provide a cross reference in Section III and list the zip codes here 4 Refer to s 9 and 10 in the SB General Instruction section above for information on additional sentence requirements for Section I of the SB Instructions for Section II Benef
119. ce representatives lt Insert plan sponsor name gt will not be renewing its Medicare contract or will not be serving the following areas effective January 1 lt Upcoming Year gt or will not be offering individual beneficiary coverage You may choose to enroll in our plan but your coverage will automatically end on December 31 lt Current Year gt insert if appropriate lt areas plan sponsor will not be serving gt You are also entitled to enroll in a new MA PD plan section 1876 cost or PDP beginning October 1 lt current year gt through January 31 lt Upcoming Year gt However if you want your enrollment in the new plan to take effect on January 1 lt upcoming year gt the new plan must receive your application by December 31 You may also have the option of enrolling in a Medicare Cost Plan if one is offered in your area If you do not enroll in another MA PD plan Medicare Cost Plan or PDP plan by December 31 lt current year gt you will be disenrolled from our plan and enrolled in Original Medicare on this date You will receive additional information in the fall about your rights and additional options 50 2 Plan Sponsor Mailing Statements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2272 b 423 2272 b In order to ensure that beneficiaries can quickly and easily identify the contents of a plan sponsor s mailing all plan sponsors that mail information to prosp
120. ch year s information they are reviewing e g 2012 Summary of Benefits and 2011 Summary of Benefits The website content for the upcoming contracting year must be submitted to CMS as described in 90 18 and contains all information in Appendix 2 Plan sponsors must include a date stamp on each Web page to indicate when it was last updated Additionally each Web page should include the material ID at the bottom of the Web page When a website is first approved each Web page should contain the material id used in the initial website submission If a webpage is updated the material ID of that page should correspond with the unique material ID for the Web page submission as indicated in 90 18 When placing previously submitted materials on the website i e SB formulary provider directory the materials should retain their unique material ID Plan sponsors are required to include the approved material ID on their Medicare website For example e Pharmacy directory SXXXX_XX CMS Approved MMDDYYYY In addition to the information noted in 100 2 1 100 2 2 100 2 3 100 2 4 and Appendix 2 the following information must be included on all plan sponsor websites e Toll free customer service number TTY number physical or Post Office Box address and hours of operation e Plan Description for each product offered by the plan sponsor Service area s Benefits Applicable conditions and limitations Premiums Cost
121. cket to providers who contact the plan for information The contents of the provider education material packet could include the plan s terms and conditions of payment the beneficiary provider education leaflet and the CMS provider education letter Refer to the web link http www cms hhs gov PrivateFeeforServicePlans e Furnish a provider educational material packet to providers within the plan sponsor s service area who have not already received a packet upon receipt of the first claim e Develop a process to obtain current provider information from prospective and current enrollees and proactively contact and educate the enrollee s current providers These providers can be furnished with a provider educational material packet e Ensure the beneficiary provider education leaflet is widely available to enrollees so that they may in turn furnish it to their providers e Non network PFFS plan sponsors have the option of establishing direct contracts under which providers agree in advance to treat plan members and accept the plan s terms and conditions of payment PFFS plan sponsors that establish payment rates less than Original Medicare must have direct contracts with sufficient providers in order to meet Medicare access requirements under federal regulations at 42 CFR 422 114 a 2 i or a 2 11 However PFFS plan sponsors that have met Medicare access requirements by establishing payment rates at or above Original Medicare may
122. cope over the phone unless it is recorded and then sign the documentation form at the beginning of the sales appointment Any scope of appointment form must be completed by the beneficiary and returned prior to the appointment If it is not feasible for the scope of appointment form to be executed prior to the appointment an agent may have the beneficiary sign the form at the beginning of the marketing appointment However CMS expects plans to record and maintain documentation on why it was not feasible to obtain the scope of appointment prior to the appointment e The documentation must be in writing in the form of a signed agreement by the beneficiary or a recorded oral agreement A plan sponsor or agent cannot agree to the scope of appointment on behalf of the beneficiary but can confirm the appointment See 70 5 1 Specific Guidance on Third Party Telephonic Contact e Plan sponsors are allowed and encouraged to use a variety of technological means to fulfill the scope of appointment requirement including conference calls fax machines designated recording line pre paid envelopes and e mail etc e A beneficiary may sign a scope of appointment form at a marketing sales event for a future appointment In these instances the forty eight 48 hour waiting period does not apply For example if a beneficiary attends a marketing presentation and after the presentation requests an individual appointment the sales person can arrange for
123. cument Variable elements can be specific to one plan or can apply to multiple plans within the same plan sponsor that utilize the same base materials Examples of variable elements include date and location information for sales presentations benefits that may vary between plans cost sharing premium and plan sponsor names 90 8 1 Standard Templates Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 A standard template is a marketing material that includes placeholders for variable data to be populated and resubmitted in HPMS at a later time For standard templates plan sponsors must submit the final material that has been populated in the placeholders with plan specific information Plan sponsors are required to indicate the master document is a template when submitting the material in HPMS see 90 10 for additional information 90 8 2 Static Templates Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 A static template is a marketing material that includes placeholders for variable data that are excluded from being resubmitted in HPMS once populated To meet the criteria for a static template ALL variable data within the material must be exempt from being resubmitted in HPMS as noted below For static templates plan sponsors should not indicate the master document is a template when submitting the material in HPMS se
124. d In order to submit the new replacement or additional materials with this classification plans should use the SA LIS functionality in HPMS Plans should select the alternate format function in HPMS when submitting non English versions of materials with this classification 90 20 Specific Guidance on the Submission of General Advertising Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 Direct mail and advertising materials may be submitted as File amp Use provided the materials are not explanatory marketing materials that contain benefit and plan premium information as detailed in 50 1 4 Direct mail and general advertising materials that are explanatory marketing materials that contain benefit and plan premium information as described in 50 1 4 will not be eligible for File amp Use 90 21 Materials Not Subject To Review Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2260 422 2262 423 2260 423 2262 The following items are examples of materials that are not subject to review by CMS and hence should not be uploaded into HPMS While the materials listed below are not subject to CMS review plan sponsors are still responsible for ensuring that all materials intended for Medicare beneficiaries meet all the applicable requirements in these Medicare Marketing Guidelines In addition plan sponsors should have a means of tracking and maintainin
125. d with prior approval of CMS marketing materials may be submitted directly to CMS by mail express mail fax or some other method Please note that if materials are submitted to CMS outside of HPMS the review period begins when CMS receives materials 90 14 Requirements for Joint Enterprise for PDPs and Regional Preferred Provider Organizations RPPOs Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 422 2264 423 2262 423 2264 Joint enterprises are expected to e Market the plan under a single name throughout a region and e Provide uniform benefits formulary enrollee customer service grievance coverage determination and appeal rights throughout the region Marketing materials for the joint enterprise may only be distributed where one or more of the contracted plan sponsors creating the single entity is licensed by that State as a risk bearing entity or qualifies for a waiver under 42 CFR 423 410 or 42 CFR 422 372 All marketing materials must be submitted under the joint enterprise s contract number and must follow CMS requirements 90 15 Multi Contract Entities MCKEs Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 If a plan sponsor operates in the jurisdiction of more than one of the CMS Regions marketing materials should be submitted to the appropriate reviewer in the lead region e g the region where the plan sponsor s Account Ma
126. dividual will receive a notice acknowledging receipt of the enrollment e g acknowledging request for additional information or denial of enrollment e g not eligible e Contact information for questions including toll free telephone and TTY numbers NOTE Enrollment scripts may not be submitted as talking or bullet points 80 1 7 Prohibited Activities for Enrollments Scripts Calls Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 60 c 423 32 b Plan sponsors are not permitted to Conduct outbound telephone enrollment except as required to perform outbound education and verification calls refer to 70 6 Transfer outbound calls to inbound lines for telephone enrollment Market or enroll other lines of business as part of the telephone enrollment script and Request or collect credit card numbers or bank account information for any purpose during the telephone enrollment call 80 1 8 Requirements for Telephone Sales Scripts Inbound or Outbound Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 422 2268 423 2262 423 2264 423 2268 Any telephone sales scripts inbound or out bound must be submitted verbatim talking or bullet points are unacceptable however plans are asked encouraged to include commonly asked questions in talking points or bullet points to CMS for review Plan sponsors should incorporate all requ
127. dress where up to four members reside the following requirements apply e fa member at that address subsequently requests that the plan sponsor mail another copy of the directory the plan sponsor must mail him her a directory e When mailing a directory to one address the plan sponsor must include the names of all those enrollees at that mailing address or they may list one name and include all others on the cover letter accompanying the directory e Ifamember has previously elected to receive a provider directory electronically the plan sponsor may fulfill the requirement of mailing an annual directory through e mail Note that if the e mail sent to members contains a link to the plan sponsor s website as opposed to an attachment with the directory the e mail must clearly direct the member to the location of the directory on the plan sponsors website 60 4 6 Changes to Provider Network Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 111 e All MA and MA PD plan sponsors must make a good faith effort to provide written notice of termination of a contracted provider at least thirty 30 calendar days before the termination effective date to all members who are patients seen on a regular basis by the provider whose contract is terminating irrespective of whether the termination was for cause or without cause When a contract termination involves a primary care professional all members who are patients of t
128. e NOTE The approval date for non English materials should be the date that appears on the English version The File amp Use date for non English material should be the date the English version is eligible for use in the market place generally five 5 days after the piece is filed in HPMS 40 2 Font Size Rule Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 All text included on materials including footnotes and internal tracking numbers must be printed with a font size equivalent to or larger than Times New Roman twelve 12 point The equivalency standard applies to both the height and width of the font Exceptions e Ifaplan sponsor publishes a notice to close enrollment in the Public Notices section of a newspaper the plan sponsor need not use twelve 12 point font and can instead use the font normally used by the newspaper for its Public Notices section e Because neither CMS nor the plan sponsor has any control over the actual screen size shown on individuals computer screens that can be adjusted by the user for Internet marketing materials the twelve 12 point font requirement refers to how the plan sponsor codes the font for the Web page not how it actually appears on the user s screen e Television Ads 40 3 Footnote Placement Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 Plan sponsors should adopt a standard procedure for fo
129. e 90 10 for additional information The following variable placeholders are excluded from the population requirement Dates e Events e Addresses phone or fax numbers e Hours of operation e Organization or company names e Plan name e Logos e Agent A gency e Persons names and pronoun variations e URLs e Member specific variables i e case numbers drug specific references and coverage determination decisions and e Co branding information Materials with any other variable placeholders including those for plan specific benefits premium and cost sharing information must be submitted through the standard template process and finalized by uploading the Final Expedited Review Populated Template in HPMS 90 9 Submission for Summary of Benefits Submitted as a Template Prior to Bid Approval Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 To ensure plan sponsors are able to submit information efficiently and with minimal burden CMS allows plan sponsors to create and submit an SB prior to bid approval Should plan sponsors choose to exercise this option they may submit an SB with variable placeholders around plan benefits and cost sharing information These materials should be submitted as templates and populated after bid approval These populated materials will not need to be resubmitted to the appropriate CMS Regional Office reviewer for additio
130. e Advantage or Prescription Drug program Beneficiaries should be able to find a plan s program information with a minimum of difficulty URL Guidelines All marketing materials can include a Web address that connects to either a corporate website or to the plan s Web page All links on a plan s website must be clearly labeled with navigational icons that indicate the information iehouldibetieari contained in the link i j SOUC DEG Ear lO Website Links a to foreign beneficiary how to rug sales navigate the website Any links to health related or non health related products services must be clearly labeled as such All plan sponsors must include a Required date stamp on each Web page to Information inform the beneficiary that the information might not be current The website must contain the plan sponsors toll free customer service It is important to make Contact number TTY number and either a available to beneficiaries Information physical address or Post Office Box different methods to address Plans must also include contact the plan hours of operation Subiect MustUse MustNotUse Reason Service Area All plan sponsors must use a minimum 12 point Times New Roman or equivalent font for all Internet content For Part D Regions served by the plan sponsor must be listed If the Part D plan is a national plan then it must be identified as such For Part C The plan must list the s
131. e work performed and no more and no less than fifty 50 percent of the aggregate compensation amount paid for that beneficiary in the initial year of the six 6 year In addition all parties should ensure that their compensation arrangements including arrangements with 7MOs and other similar type entities comply with all fraud and abuse laws including the Federal anti kickback statute 120 5 6 Specific Guidance for Recovering Compensation Payments Charge backs Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 423 2274 Plans are required to recover compensation payments from agents under two circumstances 1 when a beneficiary disenrolls from a plan within the first three months of enrollment rapid disenrollment and 2 any other time a beneficiary is not enrolled in a plan Note When a member enrolls in a plan effective October 1 November 1 and December 1 and subsequently changes plans effective January 1 of the following year it is not considered a rapid disenrollment Therefore plans cannot charge back agent compensation payments If however a beneficiary enrolls in October and disenrolls in December then the plan should charge back because of a rapid disenrollment Example 1 A beneficiary enrolls in Plan D with an effective date of February 1 In April the beneficiary disenrolls Since the beneficiary rapidly disenrolled Plan D must recover all compensation paid for that enrollment
132. e in a raffle or drawing Plan sponsors should use other mechanisms e g raffle tickets random numbers for conducting the drawings e Use prohibited statements at marketing sales event as stated in these Medicare Marketing Guidelines e Solicit enrollment applications prior to the start of the AEP 70 8 1 Notifying CMS of Scheduled Marketing Events Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Plan sponsors must upload all formal and informal marketing sales events via HPMS prior to advertising the event or seven 7 calendar days prior to the event s scheduled date whichever is earlier For detailed instructions including the earliest upload date please refer to the Marketing Events section in the user guide of the HPMS Marketing module Note that EGHP events that are only for EGHP members should be excluded from entry in HPMS CMS recognizes that plan sponsors may have last minute events scheduled CMS will permit these events to be uploaded into HPMS However CMS expectations are that at least 90 of all formal and informal events will be uploaded at least seven 7 calendar days prior to the event s schedule date Failure to adhere to a 90 upload requirements may result in a compliance action In the Event Name field plan sponsors should begin each Event Name field entry with either one of the following followed by the actual event name e Informal e
133. e is defined as the average time spent on hold by a caller following an interactive voice response IVR or touch tone response system and before reaching a live person e Eighty 80 percent of incoming calls must be answered within thirty 30 seconds e Disconnect rate of all incoming calls must not exceed five 5 percent 80 1 1 Pharmacy Technical Help Call Center Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 423 128 d 1 Plan sponsors offering Part D coverage must operate a toll free pharmacy technical help call center or make available call support to respond to inquiries from pharmacies and providers regarding the beneficiary s Medicare prescription drug benefit This requirement can be accommodated through the use of on call staff pharmacists or by contracting with the organization s PBM during non business hours as long as the individual answering the call is able to address the call at that time Inquiries will concern such operational areas as claims processing benefit coverage claims submission and claims payment The call center must operate or be available during the entire period in which the plan sponsor s network pharmacies in its plans service areas are open Please note that plan sponsors whose pharmacy networks include twenty four 24 hour pharmacies must operate their pharmacy technical help call centers twenty four 24 hours a day as well The pharmacy tech
134. e that entities involved in the outreach will not share member information with anyone not involved in the outreach process Ensure that contracts with entities taking part in some aspect of outreach activities meet Medicare Advantage Administrative Contracting requirements listed in the Medicare Managed Care Manual Chapter 11 and 100 5 Work closely with CMS Regional Office staff during the outreach submission and review process so that CMS can work cooperatively with stakeholders e g SHIPs State Agency to ensure better education and preparation prior to the outreach process initiation Communicate directly with stakeholders e g SHIPs State Agency to ensure better education and preparation prior to the outreach initiation process The plan sponsor may e Conduct outreach for only a portion of its plan membership Selection of the focus population may be based upon demographic data and or may focus on a specific geographic area However the plan sponsor must provide outreach to all individuals within those pre identified population segments Additionally if the plan sponsor receives an inquiry from a plan member not previously identified in the targeted group it must provide assistance to that member as if he or she had been included in the initial group e Provide hands on assistance to the member in completing all necessary applications for financial assistance including submitting the paperwork to the appropriate State
135. e the beneficiary s signature prior to discussing MA PDP or cost plans Plan sponsors and agents brokers should note on the scope of appointment form that the beneficiary was a walk in In this instance the forty eight 48 hour waiting period does not apply 70 10 Specific Guidance on Outreach to Dual Eligible Members Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 a 4 423 2264 a 3 This section provides guidance to plan sponsors on dual eligible outreach program requirements and the process for submitting outreach program details and outreach materials e g letters call scripts to CMS for approval In addition this section also provides CMS staff with operating procedures for reviewing and approving the outreach programs A number of plan sponsors enrolled members are due to financial status eligible for State financial assistance through State Medicaid Programs This assistance provides them an array of financial savings ranging from partial payment of Medicare Part B premiums to full payment of Medicare premiums and other plan cost sharing Historically some of those eligible do not apply for these State savings programs because e The individuals equate Medicaid with welfare and associate a social stigma with the terms e They are not aware of the savings that are available e They do not understand the eligibility requirements or e They find the process sometimes complex and difficult t
136. e the website available for public use during the CMS review period however plan sponsors must include the disclaimer Pending CMS Approval on their website until CMS has granted final approval In this instance plans do not need to include a date for pending approval Use of the website while under CMS review applies only to the website text and not documents contained on the website for example a plan may not post an unapproved member handbook on the website Plan sponsors are reminded that websites are required to meet all CMS guidelines Section 508 of the Rehabilitation Act compliance requirements and any other guidance noted in 100 90 19 Service Area Low Income Subsidy Materials Functionality SA LIS Special Guidance on Multiple Submissions of Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 HPMS restricts multiple submissions of materials that have a Y in the plan designation column on the marketing look up code listing in HPMS refer to the marketing code look up in HPMS This requirement was implemented to ensure that CMS has the ability to capture the final plan version of materials in HPMS Therefore if a plan sponsor attempts to upload a material with this classification e g SB ANOC EOC when the same document type has been previously submitted for review under a specific contract number and plan ID the plan designation check boxes will be disable
137. ected version is placed on the website If there are any changes or corrections to materials for example the benefit or cost sharing information differs from that in the approved bid the plan sponsor will be required to correct those materials for prospective enrollees and send errata sheets addenda reprints to current members by a reasonable timeframe In cases where non compliance is discovered the plan sponsor may be subject to penalties including intermediate sanctions and civil money penalties 60 8 Mid Year Changes Requiring Enrollee Notification Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 d 3 Mid year benefit enhancements are no longer permitted However if a national coverage determination takes effect mid year and is covered under the contract or is covered on a fee for service basis outside the contract but the plan sponsor chooses to offer coverage to beneficiaries such services may be added mid year All National Coverage Determinations NCDs are effective on the date the decision memorandum is released the same as the date it is posted to the National Coverage Analysis page of the Medicare Coverage Center website at http www cms gov mcd index_list asp list_type nca The MAO is required to notify all enrollees of the new coverage or change in coverage of the item or service within 30 days of the release date of the NCD regardless of whether the NCD is covered under the P
138. ective or current Medicare beneficiaries should prominently display one of the following four statements on the front of the envelope or the mailing itself if no envelope is being sent Plan sponsors are permitted to meet this requirement through the use of ink stamps or stickers if necessary in lieu of pre printed statements Any delegated or sub contracted entities and downstream entities that conduct mailings on behalf of a plan sponsor must comply with this requirement Advertising pieces This is an advertisement Plan information Important plan information Health and wellness information Health or wellness or prevention information Non health or non plan information Non health or non plan related information Pe SS All mailings should include one of these four mailing statements If a mailing is not advertising or a health and wellness mailing but is related to an enrollee s plan plan sponsors should categorize it as a plan information mailing However if the mailing contains non health or non plan related information refer to 170 2 for examples a plan sponsor should use the non health or non plan related information mailing statement Plan sponsors may not modify these mailing statements and must use them verbatim Mailing statements should only be placed on the mailing when no envelope accompanies the mailer e g tri fold brochure or postcard Plan sponsors may place one of the f
139. ed 06 04 10 Effective Implementation 06 04 10 42 CFR 422 114 a 1 CMS strongly encourages all PFFS plan sponsors to develop and implement a provider education and outreach program to encourage a wide range of providers to accept PFFS enrollees PFFS plan sponsors must develop provider relation strategies a provider education process and educational materials that include establishing relationships with and educating providers in the PFFS plan s service area PFFS plan sponsors must conduct effective outreach to providers to help them understand how PFFS plans work and to overcome any resistance that may be particularly caused by concerns about the timeliness and accuracy of payments In order to address these issues PFFS plan sponsors must ensure that they clearly inform providers about how to obtain their terms and conditions of payment how to get payment or coverage questions quickly answered and how to appeal payment decisions Following are examples of practices that CMS encourages PFFS plan sponsors to incorporate in their provider education and outreach programs In addition there may be other approaches that PFFS plan sponsors may utilize in order to develop provider education and outreach programs e Use the appropriate staff e g provider relations specialists to educate providers in the plan s service area and State provider associations e g medical and hospital associations e Furnish a provider educational material pa
140. ed 50 1 4 Explanatory Materials that Mention Plan Benefit and Premium Information 50 1 5 Information on Enrollment Limitations 50 1 6 Availability of Non English Translations 50 1 7 Applicable Disclaimers for the Marketing of Educational Events 50 1 8 Disclaimer on Advertisements and Invitations to Sales Marketing Events 50 1 9 Disclaimers Applicable to Advertising that Promotes a Nominal Gift 50 1 10 Pharmacy Network Limitations 50 1 11 Required Access Information Disclaimers 50 1 12 Disclaimer for Materials that are Co branded with Providers 50 1 13 Disclaimer When Using Third Party Marketing Materials 50 1 14 Additional Guidance for Preferred Provider Organization PPO and Point of Service Plans POS 50 1 15 Additional Guidance for Section1876 Cost Plans 50 1 16 Additional Guidance Applicable to All PFFS Plan Materials 50 1 17 Additional Guidance for Dual Eligible SNP Materials 50 1 18 Additional Guidance for SNP Materials 50 1 19 Radio Advertisements 50 1 20 Television Advertisements 50 1 21 Online Enrollment Center Disclaimers for Websites 50 1 22 Enrollment and Marketing Materials after Non Renewal or Service Area Reduction SAR Notice to CMS 50 2 Plan Sponsor Mailing Statements 60 Specific Guidance on Required Documents 60 1 Summary of Benefits SB 60 2 Part D ID Card Requirements 60 3 ID Card Information for PPOs and PFFS Plans 60 4 Directories 60 4 1 Pharmacy Directories 60 4 2 Pro
141. ederal Contracting Statement 50 1 2 Disclaimers When Benefits Are Mentioned 50 1 3 Disclaimers on Materials that Mention Plan Benefit and Premium Information 50 1 4 Information on Enrollment Limitations 50 1 5 Availability of Non English Translations 50 1 6 The bullets below outline additional disclaimers based on specific materials or plan types They are included in this guidance as a reference tool for plans and reviewers but should not be considered an exhaustive list It is the responsibility of the plan sponsor to ensure all disclaimers and requirements throughout 50 are contained within the appropriate materials Part D sponsors materials mentioning Part D benefits must also indicate You may be able to get Extra Help to pay for your prescription drug premiums and costs To see if you qualify for Extra Help call 1 300 MEDICARE 1800 633 4227 TTY users should call 1 877 486 2048 24 hours a day 7 days a week the Social Security Office at 1 800 772 1213 between 7 a m and 7 p m Monday through Friday TTY users should call 1 800 325 0778 or Your Medicaid Office only required for pieces referencing Part D benefits or cost sharing 50 1 4 NOTE This language has been bracketed as optional language for those US territories in which the Extra Help Program does not apply MA and MA PD plans must also insert Individuals must have both Part A and Part B to enroll 50 1 5
142. ee call center for both current and prospective enrollees that operates seven 7 days a week at least from 8 00 A M to 8 00 P M according to the time zones for the regions in which they operate During this time period current and prospective enrollees must be able to speak with a live customer service representative From February 15 until the following annual enrollment period plan sponsors are still required to operate a toll free call center for both current and prospective enrollees that operates from 8 00 A M to 8 00 P M Monday through Friday During this time period on Saturdays Sundays and holidays plan sponsors are permitted to use alternative technologies to meet the customer service call center requirements For example a plan sponsor may use an interactive voice response system or similar technologies to provide the required information listed below and or allow a beneficiary to leave a message in a voice mail box A customer service representative must then return the call in a timely manner no more than one business day later Call centers must meet the following operating standards e Provide information in response to inquiries outlined in 80 1 3 e Follow an explicitly defined process for handling customer complaints e Provide interpreter service to all non English speaking limited English proficient LEP and hearing impaired beneficiaries e Average hold time must not exceed two 2 minutes The average hold tim
143. eficiaries before removing a Part D drug from the Part D plan s formulary adding prior authorization quantity limits step therapy or other restrictions on a drug or moving a drug to a higher cost sharing tier Part D plans can determine the most effective means by which to communicate formulary change information to these parties including electronic means Part D sponsors should refer to 30 3 4 of Chapter 6 of the Medicare Prescription Drug Benefit Manual regarding the notice requirements 60 5 7 Provision of Notice to Other Payers Regarding Formulary Changes Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 120 b 5 Prior to removing a covered Part D drug from its formulary or making any change in the preferred or tiered cost sharing status of a covered Part D drug a Part D sponsor must provide at least sixty 60 days notice to CMS State Pharmaceutical Assistance Programs entities providing other prescription drug coverage authorized prescribers network pharmacies and pharmacists prior to the date such change becomes effective Part D sponsors should refer to 30 3 4 2 of Chapter 6 of the Medicare Prescription Drug Benefit Manual for additional information on this notice requirement 60 6 Part D Explanation of Benefits Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 423 128 e Part D plan sponsors must send an Explanation of Benefits EOB to plan enrollees durin
144. ements for specific plan sponsors through general advertising e g radio television New affiliation announcements are those providers that have entered into a new contractual relationship with the plan sponsor Providers may make new affiliation announcements within the first 30 days of the new contract agreement An announcement to patients of a new affiliation which names only one plan sponsor may occur only once when such announcement is conveyed through direct mail e mail or phone Additional direct mail and or e mail communications from providers to their patients regarding affiliations must include all plans with which the provider contracts Any affiliation communication materials that describe plans in any way e g benefits formularies must be approved by CMS Multiple plan sponsors can either have one plan sponsor submit the material on behalf of all the other plan sponsors or have the piece submitted and approved by CMS for each plan sponsor mentioned prior to use Materials that indicate the provider has an affiliation with certain plan sponsors and that only list plan names and or contact information does not require CMS approval 70 12 4 SNP Provider Affiliation Information Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Providers may feature SNPs in a mailing announcing an ongoing affiliation This mailing may highlight the provider s affiliation or arrangement b
145. end providers may certainly engage in discussions with beneficiaries when patients seek information or advice from their provider regarding their Medicare options All payments that plans make to providers for services must be fair market value consistent for necessary services and otherwise comply with all relevant laws and regulations including the Federal and any State anti kickback statute For enrollment and disenrollment guidance related to beneficiaries residing in long term care facilities e g enrollment period for beneficiaries residing in long term care facilities and use of personal representatives in completing an enrollment application please refer to Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Medicare Prescription Drug Benefit Manual Providers should remain neutral parties in assisting plan sponsors with marketing to beneficiaries or assisting with enrollment decisions Providers not being fully aware of plan benefits and costs could result in beneficiaries not receiving information needed to make an informed decision about their health care options Therefore it would be inappropriate for providers to be involved in any of the following actions e Offering sales appointment forms e Accepting enrollment applications for MA MA PD plans or PDPs e Making phone calls or directing urging or attempting to persuade beneficiaries to enroll in a specific plan based on financial or any other interests of t
146. ent is cancelled more than forty eight 48 hours before the originally scheduled date and time the plan sponsor must cancel the event in HPMS must notify the Regional Office Account Manager and must notify beneficiaries of the cancellation by the same means the plan sponsor used to advertise the event Zf beneficiaries are notified of a cancellation more than forty eight 48 hours before the event then there is no expectation that a representative of the plan sponsor will be present at the site of the event Examples of reasonable notification are e If an announcement of the sales event was made in the newspaper then the cancellation of the event must also be announced through the same newspaper If the newspaper s production and or distribution schedule prohibits timely notification the plan sponsor must provide evidence to the respective Account Manager newspaper guidelines with submission timelines run dates etc e If beneficiaries were identified through personal calls then a representative of the plan sponsor must call the beneficiaries to inform them of the cancellation e If beneficiaries RSVP for the sales event then a representative of the plan sponsor must call the beneficiaries to inform them of the cancellation e If an announcement of the sales event was sent through a mass mailing then the plan sponsor should consult with the Regional Office Account Manager to decide upon the most reasonable way to notify beneficiar
147. ent request is subject to the OEV requirements A model outbound enrollment verification call script and letter is available at http www cms hhs gov ManagedCareMarketing 09_MarketngModelsStandardDocumentsand EducationalMaterial asp TopOfPage 70 7 Educational Events Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 1 423 2268 1 Educational events are events designed to inform Medicare beneficiaries about MA Prescription Drug or other Medicare programs but do not steer or attempt to steer potential enrollees toward a specific plan or limited number of plans Educational events may not include any sales activities such as the distribution of marketing materials or the distribution or collection of plan applications Educational events must be explicitly advertised as educational otherwise they will be considered by CMS as sales marketing events Educational events are held in public venues and do not extend to in home or one on one settings The intent of this guidance is not to preclude plan sponsors from educating beneficiaries about their products rather it is to ensure that events that are advertised as educational comply with CMS requirements More specifically plan sponsors may provide education at a sales or marketing event but may not market or sell at an educational event The following are examples of acceptable materials and activities by plan sponsors or t
148. er Benefits formulary pharmacy network premium and or co payments co insurance may change on January 1 lt XXXX gt Exception The benefit change disclaimer does not need to be included within the text of enrollment forms 50 1 4 Explanatory Materials that Mention Plan Benefit and Premium Information Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 a 2 422 2264 423 128 a 2 423 2264 Explanatory materials for all plan sponsors that mention benefit and plan premium information must e Include a disclaimer stating You must continue to pay your Medicare Part B premium This disclaimer is not required if the Part B premium is entirely paid by rebates under the plan This statement is required even if the plan premium is 0 Note that full benefit Dual Eligible SNPs for whose members the State pays the Part B premium should indicate that the Part B premium is covered for full dual members e Indicate that limitations copayments and restrictions may apply e Part D sponsors must include the following in all explanatory materials that reference Part D premiums or other costs for Part D Plans may include the following language in paragraph or bullet form if the plan sponsor is sending out an individual letter You may be able to get Extra Help to pay for your prescription drug premiums and costs To see if you qualify for extra help call e 1 800 MEDICARE 1 800 633 42
149. ered Part D drug is being Notice of ee Hea ce allah a changing its preferred or tiere Formulary cost sharing status Change The reason why the covered Part D drug is being removed from the formulary or changing its preferred or cost sharing status Alternative drugs in the same therapeutic category class or cost sharing tier and the expected cost sharing for those drugs and The means by which enrollees may obtain an updated coverage determination or an exception to a coverage determination Appendix 3 Model File amp Use Certification Form Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Applicable to MA MA PD MA only Section 1876 cost plans Pursuant to the contracts s between the Centers for Medicare amp Medicaid Services CMS and insert organization name hereafter referred to as the Medicare health plan governing the operations of the following health plan insert health plan name and Contract number the Medicare health plan hereby certifies that all qualified materials for the above listed health plan is accurate truthful and not misleading Organizations using File amp Use Certification agree to retract and revise any materials without cost to the government that are determined by CMS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines In addition organizations may be held accountable for any beneficiary financial loss as a result of mista
150. erials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 c 423 2262 c Standardized model materials are model documents that a plan must utilize without modification In instances where CMS provides a standardized model document plan sponsors must use the document without altering the text or its order Unless otherwise directed the only allowable alterations to standardized models include populating variable fields correcting grammatical errors adding the plan name logo and adding the CMS marketing material identification number Standardized models differ from non standardized model materials in that standardized models are mandatory for use by plan sponsors as written Conversely plan sponsors may or may not use non standardized model documents see 90 7 3 When utilizing a standard model material plan sponsors must remove any reference to the words exhibit model or appendix contained within the title of the model document note that the title of the standardized model should remain For CY2012 standardized model materials that are mandatory for use by plans include e Summary of Benefits e Annual Notice of Change Evidence of Coverage e Errata ANOC EOC e Plan Ratings 90 7 3 Model Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 c 423 2262 c For certain materials CMS has developed model documents that
151. erials to the plan sponsor who will ensure compliance with the MMG requirements and that the appropriate disclaimers are provided on the materials as provided in section 50 1 13 Plan sponsors utilizing third parties for telephone calls to plan enrollees must adhere to all guidance in 70 5 1 40 15 Providing Materials in Different Media Types Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 64 422 111 423 48 and 423 128 Social Security Act 1852 c 1 and 1860D 4 a 1 A The Social Security Act 1852 c 1 and 1860D 4 a 1 A and Medicare regulations describe how information must be provided to beneficiaries in a clear accurate and standardized form but do not limit the methods of transmittal As such a plan sponsor may elect to provide materials to members or prospective enrollees using a different medium other than traditional paper i e electronic or portable media like e mail CD DVD With respect to materials that CMS deems mandatory the SB ANOC EOC the provider pharmacy directory Part D Explanation of Benefits and the Model Part D Transition Letter plan sponsors have the option of contacting members to determine medium in which they would like to receive the materials Plan sponsors that choose this option must either contact members in writing e g by letter postcard newsletter article secure website or via a recorded telephone conversation to determine
152. ermitted to Provide objective information on plan sponsors specific plan formularies based on a particular patient s medications and health care needs Provide objective information regarding plan sponsors plans including information such as covered benefits cost sharing and utilization management tools Make available and or distribute PDP enrollment applications but not MA or MA PD enrollment applications for all plans with which the provider participates e Refer their patients to other sources of information such as SHIPs plan marketing representatives their State Medicaid Office local Social Security Office CMS website at http www medicare gov or 1 800 MEDICARE e Print out and share information with patients from CMS website The Medicare and You Handbook or Medicare Options Compare from http www medicare gov may be distributed by providers without additional approvals There may be other documents that provide comparative and descriptive material about plans of a broad nature that are e written by CMS or have been previous ie ilies by via a computer spiel ree access ae Has aoe Plan paler eset ee contracted providers of the provisions of these rules 70 12 3 Provider Affiliation Information Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Providers may announce new affiliations and repeat affiliation announc
153. eting Appointments 70 9 1 Scope of Appointment 70 9 2 Beneficiary Walk ins to a Plan or Agent Broker Office or Similar Beneficiary Initiated Face to Face Sales Event 70 10 Specific Guidance on Outreach to Dual Eligible Members 70 10 1 Guidance on Dual Eligibility 70 10 2 Guidance for Dual Eligible Outreach Program 70 10 3 Outreach Submission Requirements for Dual Eligibility 70 10 4 CMS Review Approval of Outreach Process for Dual Eligibility 70 10 5 Reviewing New Outreach Programs for Dual Eligibility 70 10 6 Reviewing Previously Approved Outreach Programs for Dual Eligibility 70 11 PFFS Plan Provider Education and Outreach Programs 70 11 1 PFFS Plan Staff Requirement for Assisting Providers 70 11 2 PFFS Plan Terms and Conditions of Payment Contact and Website Fields in HPMS 70 12 Marketing Guidance for the Provider Setting 70 12 1 Plan Activities and Materials in the Health Care Setting 70 12 2 Provider Based Activities 70 12 3 Provider Affiliation Information 70 12 4 SNP Provider Affiliation Information 70 12 5 Comparative and Descriptive Plan Information 70 12 6 Comparative and Descriptive Plan Information Provided by a Non Benefit Service Providing Third Party 70 12 7 Providers Provider Group Websites 80 Special Guidance on Telephonic Activities and Scripts 80 1 Customer Service Call Center Requirements 80 1 1 Pharmacy Technical Help Call Center Requirements 80 1 2 Coverage Determinations and
154. example Members may enroll in the plan only during specific times of the year Contact lt plan gt for more information Exception Section 1876 cost plans not offering Part D benefits DE SNPs and Institutional SNPs I SNPs should indicate that eligible beneficiaries can enroll at any time Section 1876 cost plans should indicate that eligible beneficiaries can enroll at any time but may elect the Part D optional supplemental benefit if offered only during specific times of the year Additionally MA and MA PD plans must also include a statement on explanatory materials that individuals must have Part A and Part B to enroll in the plan 50 1 6 Availability of Non English Translations Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Plan sponsors that meet the five 5 percent threshold for language translation Refer to Section 30 8 must place the following alternate language disclaimer on all materials as noted in 30 11 30 12 30 13 and the Part D Transition Letter This information is available for free in other languages Please contact our customer service number at 1 800 XXX XXXX for additional information The Alternate Language disclaimer should be placed in both English and all non English languages that meet the five 5 percent threshold for the PBPs the document relates to The non English disclaimer should be placed below the English version and in t
155. f Chapter 2 of the Medicare Managed Care Manual an individual is generally not eligible to elect an MA plan if he she has been medically determined to have ESRD Plan sponsors may not engage in discriminatory practices such as targeting marketing to beneficiaries from higher income areas Additionally plan sponsors may not state or otherwise imply that plans are available only to seniors rather than to all Medicare beneficiaries Only SNP sponsors may limit enrollment to dual eligibles institutionalized individuals or individuals with severe or disabling chronic conditions and or may target items and services to corresponding categories of beneficiaries 30 8 Requirements for Plans with Non English Speaking Populations Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 e 423 2264 e All plan sponsors call centers must have interpreter services available to call center personnel to answer questions from non English speaking beneficiaries Call centers are those centers that receive calls from current and prospective enrollees This requirement is in place regardless of the percentage of non English speaking beneficiaries in a service area Beginning with marketing materials for the 2012 AEP plan sponsors must make the marketing materials noted in 30 30 12 30 13 and the Part D Transition Letter available in any language that is the primary language of more than five 5 percent of a plan sponso
156. f a plan s solicitation for referrals 30 17 Privacy and Confidentiality Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 118 422 752 a 4 423 136 423 752 a 4 Plan sponsors and providers are responsible for following all Federal and State laws regarding confidentiality and disclosure of patient information to plan sponsors for marketing purposes This obligation includes compliance with the provisions of the HIPAA Privacy Rule and its specific rules regarding uses and disclosures of beneficiary information In addition plan sponsors are subject to sanction for engaging in any practice that may reasonably be expected to have the effect of denying or discouraging enrollment of individuals whose medical condition or history indicates a need for substantial future medical services e g health screening or cherry picking HIPAA and privacy documents e g a HIPAA privacy document for a beneficiary s signature in a provider s office are not considered marketing documents and therefore do not need to be submitted in HPMS Refer to 90 21 regarding materials not subject to review Additional information on the HIPAA Privacy Rule and its disclosure requirements can be found at http www hhs gov ocr privacy 30 18 Plan Ratings Information from www medicare gov Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 a 4 423 2264 a 3 The Medicare program
157. f the plan sponsor s PBP and Premium Table for PDPs PDPs with identical benefits offered in different regions may insert a table indicating the premium in each region This section is standardized language that should not be modified except as indicated in the SB instructions e Section III An optional free form text area which is limited to six pages This section can be used by plans to further describe special features of the program e Section IV DE SNPs must provide each prospective enrollee prior to enrollment with a comprehensive written statement that describes e The benefits that the individual is entitled to under Title XIX Medicaid e The cost sharing protections that the individual is entitled to under Title XIX Medicaid e A description of the benefits and cost sharing protections that are covered under the DE SNP for dual eligible individuals Plans sponsors are required to include the SB in their enrollment kits and must make the SB available upon request Therefore plan sponsors must create and submit an SB for CMS approval DE SNPs must include the SB in their enrollment kit to fulfill the comprehensive written statement of benefit requirement Because the SB is a standardized document CMS expects that the language for sections I and II will be identical to the SB report in HPMS Any deviation from this language outside of an approved hard copy change or global hard copy change will result in CMS disap
158. g months in which enrollees utilize their prescription drug benefits Part D sponsors must ensure that enrollees who utilize their prescription drug benefits in a given month receive their EOB by the end of the month following the month in which they utilized their prescription drug benefits The EOB must include the following information e The drugs for which payment was made and the total amount of payment for those drugs including true out of pocket TrOOP eligible amounts e A notice of the enrollee s right to request an itemized statement The EOB should contain sufficient information necessary for the beneficiary to understand their prescription drug coverage and benefits However to the extent a beneficiary requests additional items not already addressed in the EOB a plan must provide this information e A notice of the enrollee s appeal and grievance rights including the exceptions process e Include the cumulative year to date total amounts of benefits total drug spend provided relative to The deductible if applicable The initial coverage limit for the current year if applicable The annual out of pocket threshold e This cumulative total must include adjustments made as a result of retroactive adjustments for example those based on information received from other plans reversed claims and supplemental payer adjustments e The cumulative year to date total of TrOOP costs This cumulative total
159. g names include the logos and or names of network providers are required to include the following disclaimer language on all of their marketing materials Plan sponsors must prominently display the disclaimer at the bottom of the first page of the material in similar font and style as the message Other lt Pharmacies Physicians Providers gt are Available in Our Network The plan sponsor its downstream entities and its network providers whether through marketing materials or other communications may not imply that the network provider is endorsed by CMS or that their products or services are Medicare approved Additionally plan sponsors must include a statement that states Other plans may be available in the service area 30 5 Use of Data from Medigap Issuers Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 If a Medigap issuer chooses to sponsor an MA plan MA PD plan section 1876 cost plan or PDP it is permitted to use its current Medigap plan enrollment information to market the MA MA PD cost or Part D plan to those enrollees to the extent permitted by the HIPAA Privacy Rule and other applicable Federal or State privacy laws However in doing so the Medigap issuer plan sponsor may not conduct outbound calls to market its MA MA PD cost or Part D plans The Medigap issuer plan sponsor may conduct other marketing activities related to its MA MA PD cost or PDP plans to
160. g such materials so as to have them available upon request by CMS e Privacy notices privacy notices however are subject to enforcement by the Office for Civil Rights e Press releases that do not include any plan specific information e g information about benefits premiums co pays deductible benefits how to enroll networks e Certain member newsletters newsletters are not subject to review as marketing materials unless sections are used to enroll disenroll and communicate with members on product specific information e g benefits or coverage membership operational policies rules and or procedures e Blank letterhead fax coversheet that do not include promotional language e General health promotion materials that do not include any specific plan related information e g health education and disease management materials In general health promotion materials should meet CMS definition of educational e Non Medicare beneficiary specific materials that do not involve an explanation or discussion of Part D MA or section 1876 cost plans e g notice of check return for insufficient funds letter stating Medicare ID number provided was incorrect billing statements invoices sales and premium payment coupon book e Sales representative recruitment and training documents e Medication Therapy Management MTM program material that address issues that are unique to individual members e Materials used in the ed
161. hapter 12 of the Prescription Drug Benefit Manual Section 1876 cost plans offering Part D benefits must send the combined standardized ANOC EOC to their enrollees by September 30th of each year Section 1876 cost plans that do not offer Part D benefits must send the combined ANOC EOC by December 1 of each year To ensure that plan sponsors are mailing their ANOC EOC timely plan sponsors must indicate the actual mail date in HPMS within three 3 days of mailing Plan sponsors that mail in waves should enter the actual date of the last wave For instructions on meeting this requirement refer to the update material section of the Marketing Module User Guides in HPMS Plan sponsors must use the standardized ANOC EOC errata model to correct any errors Plan sponsors are expected to submit the errata model for review via HPMS Although the ANOC EOC errata model is standardized it is not eligible for File amp Use submission The ANOC EOC errata document must be submitted under code 1030 and is subject to a ten 10 day prospective review Plan sponsors that elect to revise correct and resend updated corrected ANOC EOC to beneficiaries rather than simply sending enrollees the errata model document must attach the standardized errata model document to the front of the corrected ANOC EOC CMS expects that current versions of ANOC EOC will be available on the website If a plan issues an errata for an ANOC EOC they must ensure the most up to date corr
162. haring protections under the SNP as compared to protections under the relevant State Medicaid plan The written statement should be provided in the form of a SB that includes Section IV DE SNPs may not impose cost sharing requirements on specified dual eligible individuals that would exceed the amounts permitted under the State Medicaid plan if the individual were not enrolled in the DE SNP This requirement will assist a prospective dual eligible enrollee in determining if he she will receive any value from enrolling in the DE SNP that is not already available under the State Medicaid program Marketing materials that discuss or mention DE SNP information must also include a statement in explanatory materials that premiums co pays co insurance and deductibles may vary based on the level of Extra Help that beneficiaries may receive and that the beneficiary should contact the plan for further details 50 1 18 Additional Guidance for SNP Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2 422 4 a 1 iv 422 111 b 2 iii 422 2264 423 2264 Plan sponsors must include the eligibility requirements for SNP enrollment on enrollment explanatory materials Some examples are e This plan is available to anyone who meets the Skilled Nursing Facility SNF level of care and resides in a nursing home e This plan is available to all people with Medicare who have been diagnosed with HIV AIDS
163. hat all outreach materials meet all applicable Medicare Advantage Marketing Guidelines requirements that apply to materials outside the dual eligible outreach category as described throughout this guidance e Provide outreach to all levels of dual eligibles including those levels that do not provide plan sponsors with additional capitation amounts from CMS All outreach materials and telephone scripts must include eligibility information that includes the QI 1 level as described at http www cms hhs gov DualEligible e Clarify in outreach materials that the member may voluntarily offer information including financial information but that the member is not obligated to provide this information However information regarding Medicaid status is needed to confirm eligibility fora DE SNP e Clarify in outreach materials and discussions with members that the member s failure to provide information will in no way adversely affect the beneficiary s membership in his or her health plan but that Medicaid status will be needed to confirm eligibility fora DE SNP Clarify in outreach materials to include member letters that the Medicare Savings Programs are part of either the State Medicaid program or State medical assistance programs State in materials and discussions with members that the plan sponsor will not share the information with any other entity not directly associated with determining eligibility or under contract to partic
164. hat primary care professional must be notified 60 5 Formulary and Formulary Change Notice Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 423 120 b 5 423 128 a e Part D sponsors must provide a list of drugs known as a formulary to enrollees at the time of enrollment and at least annually thereafter Because CMS regulations do not specify whether this list should be an abridged or comprehensive list of covered drugs and given concerns that a comprehensive formulary would be costly for plan sponsors to print and distribute and confusing for enrollees to use CMS allows plan sponsors to provide an abridged version of their formulary See 60 5 1 Part D sponsors are responsible for ensuring that their marketed formularies both those in print and those available on their websites are consistent with their HPMS approved formulary file e Each covered drug must display at the correct cost sharing tier and with the approved utilization management edits i e prior authorization step therapy or quantity limits e The formulary drug category and class must also be consistent e The applicable HPMS approved formulary file submission ID number and version number must be included The HPMS approved formulary file submission ID number is the HPMS formulary submission ID number of the approved formulary that is being marketed In the event that a discrepancy is identified the plan sponso
165. hat were submitted under File amp Use to ensure compliance by those plans that utilize this feature Failing to abide by the File amp Use Certification requirements may result in corrective action against the plan sponsor to protect the interest of Medicare enrollees Plan sponsors submitting marketing materials under the File amp Use Certification process through HPMS will be reminded of their responsibility to adhere to CMS requirements and to submit an electronic attestation at the time a material is submitted 90 17 1 Template Materials Quality Review and Reporting of Errors Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 422 2264 423 2262 423 2264 CMS may also conduct retrospective reviews quality checks or audits of populated templates CMS also expects that plan sponsors will perform quality reviews and testing as necessary to ensure that the means of populating and distributing templates with information from the approved bid is accurate When errors are discovered a plan sponsor must report them to its Account Manager In addition plan sponsors may be required to remedy the error by providing beneficiaries with updated information via errata sheets or addenda Note that any materials such as errata sheet or addenda must be reviewed and approved by CMS prior to their use 90 18 Specific Guidance on the Submission of Websites for Review Rev 96 Issued 5 17 11 Effective 5 17 11 Implemen
166. he provider e Mailing marketing materials on behalf of plan sponsors e Offering anything of value to induce plan enrollees to select them as their provider e Offering inducements to persuade beneficiaries to enroll in a particular plan or organization e Health screening is a prohibited marketing activity e Accepting compensation directly or indirectly from the plan for beneficiary enrollment activities e Distribute materials applications within an exam room setting Providers contracted with plan sponsors and their contractors are permitted to do the following e Provide the names of plan sponsors with which they contract and or participate See 70 12 3 for additional information on affiliation e Provide information and assistance in applying for the LIS e Make available and or distribute plan marketing materials including provider affiliation materials for a subset of contracted plans only as long as providers offer the option of making available and or distributing marketing materials from all plans with which they participate CMS does not expect providers to proactively contact all participating plans to solicit the distribution of their marketing materials rather if a provider agrees to make available and or distribute plan marketing materials for some of its contracted plans it should do so knowing it must accept future requests from other plan sponsors with which it participates To that end providers are p
167. he Part D benefit or create a separate ID card for the Part D benefit Either card must comply with the specifications outlined in the most recent version of the NCPDP Pharmacy and or Combination ID Card Implementation Guide In addition to the NCPDP Pharmacy and or Combination ID Card standard requirements the front of the Part D ID Card must include the Medicare Prescription Drug Benefit Program Mark Refer to 150 for more information Plan sponsors must ensure that the identification number on the ID card is not the SSN or Healthcare Insurance Claim Number HICN of the enrolled member Plans must include the CMS contract number and PBP number on the member ID card ID cards may be printed using a font size equivalent to the NCPDP standard ID cards are not required to include e The marketing material identification number e Hours of operation e Disclaimers noted in 50 Refer to 30 3 regarding co branding requirements related to ID cards 60 3 ID Card Information for PPOs and PFFS Plans Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 CMS recommends that all Medicare health plan sponsors especially PPOs and PFFS plan sponsors include the phrase Medicare limiting charges apply on Member ID cards However use of this phrase is optional CMS believes that use of this phrase on a card that most non contracting providers will see is a reliable method of informing pr
168. he responsibility of the plan sponsor to ensure that all applicable materials created by a third party meet the requirements as outlined in these Medicare Marketing Guidelines To that end it is the responsibility of the plan sponsor to have a system in place to account for and control the materials that are being utilized by all third party contractors Employer group health plans should refer to 130 of this chapter 20 3 of Chapter 9 of the Medicare Managed Care Manual and 20 3 of Chapter 12 of the Prescription Drug Benefit Manual for more guidance 30 7 Anti Discrimination Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 110 422 2268 c 423 2268 c Plan sponsors may not discriminate based on race ethnicity national origin religion gender age mental or physical disability health status claims experience medical history genetic information evidence of insurability or geographic location within the service area All items and services of a plan sponsor are available to all eligible beneficiaries in the service area with the following exceptions e Certain products and services may be made available to enrollees with certain diagnoses e g medication therapy management program for individuals with chronic illnesses or medically necessary coverage provisions e Enrollment in the low income subsidy LIS as there may be additional eligibility standards NOTE As provided in 20 2 o
169. he same font size as the English version Plans must also include a phone number the beneficiary can call for the information in other language NOTE ID cards are excluded from this requirement 50 1 7 Applicable Disclaimers for the Marketing of Educational Events Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 CMS requires use of the following disclaimer on all announcements advertising and explanatory when an educational event is organized sponsored or promoted by a plan sponsor This event is only for educational purposes and no plan specific benefits or details will be shared This disclaimer is not required when a plan sponsor is invited to be a participant in an educational event sponsored organized or promoted by an entity other than the plan sponsor 50 1 8 Disclaimer on Advertisements and Invitations to Sales Marketing Events Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 Advertisements and invitations to Sales Marketing events in any form of media that are used to invite beneficiaries to attend a group session with the possibility of enrolling those individuals must include the following two statements on advertising and explanatory materials e A sales person will be present with information and applications e For accommodation of persons with special needs at sales meetings call lt insert phone and TTY number gt
170. heir representatives at an educational event e Any materials designed to inform potential enrollees about MA or other Medicare programs but do not steer or attempt to steer potential enrollees toward a plan or a limited number of plans Specifically any material distributed or made available to beneficiaries at an educational event must be free of plan specific information this includes plan specific premiums co payments or contact information and any bias toward one plan type over another e A banner with the plan name and or logo displayed See 40 7 and 50 for disclaimer guidance e Promotional items including those with plan name logo and toll free customer service number and or website Promotional items must be free of benefit information and consistent with CMS definition of nominal gift e A business card if the beneficiary requests information on how to contact the plan or agent for additional information as long as the business card is free of plan marketing or benefit information e Meals may be provided as described in 70 2 1 e Plan sponsors may participate in educational health fairs and health promotional events as either a sole sponsor or co sponsor of an event hosted by multiple organizations as long as the event does not include a sales presentation and is billed as educational NOTE Plan sponsors that intend to market at these events should not refer to the event as educational and must comply with
171. hin ie ii ienn care facility ey in i Be psi Giannena all olan cece relationships Long term care facility staff are permitted to provide residents that meet the I SNP criteria a an E brochure for each I SNP with which the facility contracts The brochure ion criteria and the benefits of being enrolled in an I SNP The ices may deve a people card or telephone number for the resi to agree to a meeting or request additional information ont or responsible party to call 70 12 2 Provider Based Activities Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 j 423 2268 j CMS holds plan sponsors responsible for any comparative descriptive material developed and distributed on their behalf by their contracting providers The plan sponsor must ensure that any providers contracted and its subcontractors including downstream providers or agents with the plan sponsor comply with the requirements outlined in this chapter The plan sponsor must ensure that any providers contracted including subcontractors or agents with the plan sponsor to perform functions on their behalf related to the administration of ihe pian ros i seine al activities relatea to prap in enrollment and education agree itii e plan sponsor through its contract In addition the pli saan ad eile a including providers or agents are prohibited Jom ragja or Pe to steer an hapa pe labial a imal conn ore on the nanci
172. ibility Rev 96 Issued 5 17 11 Effective 5 19 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 The CMS review process for new outreach proposals differs from the review process for previously approved outreach proposals The processes for both submissions are detailed in 70 10 5 70 10 5 Reviewing New Outreach Programs for Dual Eligibility Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 422 2268 423 2262 423 2264 423 2268 The plan sponsor is responsible for submitting the outreach proposal to CMS and working with CMS through the review and approval process even if a subcontractor developed the proposal CMS will hold the plan sponsor fully responsible for all the provisions of the outreach program and for assuring the members of their rights and protections outlined in the MA program regulations Because CMS considers outreach materials to be a form of marketing CMS will review outreach proposals according to current time frames for reviewing marketing material CMS will conduct its initial review and provide comments to the plan sponsor within forty five 45 days of receipt of a new not previously approved proposal At this time the plan sponsor should not submit this material through HPMS but as a separate filing outside the normal marketing material submission process Plan sponsors must submit one complete copy paper and electronic of the material
173. ication and the plan sponsor has submitted a File amp Use certification to CMS e Provider directory including combined provider directory and pharmacy directory e Standardized combined ANOC EOC e Pharmacy directories e Abridged and comprehensive formularies e Certain CMS enrollment disenrollment letters and e Certain claims grievance organization coverage determinations including exceptions and appeals model letters e OMB approved forms File amp Use submissions for direct mail and general advertising materials may be allowed provided the materials are not explanatory marketing materials that mention benefit and plan premium information as stated in 50 1 4 Materials that are not eligible for File amp Use submission are direct mail and general advertising materials that are explanatory marketing materials that mention benefit and plan premium information as described in 50 1 4 The HPMS Marketing Module identifies those materials that qualify for File amp Use under the material code look up functionality NOTE If a plan sponsor s does not have File amp Use certification they are considered ineligible to submit documents as File amp Use In this instance any such submissions would be subject to compliance actions 90 6 2 Materials Not Qualified for File amp Use Submission Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 b 423 2262 b Materials th
174. id plan members to talk about its Medicare products However plan sponsors may not conduct unsolicited calls to their Medigap enrollees regarding their MA Part D or section 1876 cost plan products e Contact members to promote other plan types i e plans may contact their PDP members to promote their MAPD offerings and discuss plan benefits e Contact their members to discuss educational events e Contact their members to conduct normal business related to enrollment in the plan including calls to members who have been involuntarily disenrolled to resolve eligibility issues e Call former members after the disenrollment effective date to conduct disenrollment surveys for quality improvement purposes Disenrollment surveys may be done by phone or sent by mail but neither calls nor mailings may include sales or marketing information e Under limited circumstances and subject to advance approval from the appropriate CMS Regional Office call LIS eligible members that a plan is prospectively losing due to reassignment to encourage them to remain enrolled in their current plan e Call beneficiaries who have expressly given permission for a plan or sales agent to contact them for example by filling out a BRC or asking a customer service representative CSR to have an agent contact them This permission applies only to the entity from which the beneficiary requested contact for the duration of that transaction for the scope of product e
175. ies about the event cancellation 70 9 Personal Individual Marketing Appointments Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Personal individual marketing appointments typically take place in the Medicare beneficiary s home however these appointments can also take place in other venues such as a library or coffee shop Appointments must follow the scope of appointment guidance See 70 9 1 At these appointments the plan sponsor s representative may e Distribute plan materials CMS encourages plan sponsors to provide the enrollment kit at one on one appointments e nform beneficiaries on how to get plan information e g mail website customer service e Discuss various plan options e Provide educational content e Distribute or collect enrollment forms The plan sponsor s representative may not do the following e Discuss plan options that were NOT agreed to by the Medicare beneficiary see scope of appointment information in 70 9 1 e Market non health care related products such as annuities life insurance or VAIS e Ask a beneficiary for referrals e Solicit accept an enrollment request application for a January 1 effective date prior to the start of the Annual Enrollment Period AEP unless the beneficiary is entitled to a Special Election Period SEP or is within their initial coverage election period initial enrollment period 70 9
176. ies to all organizations plan types CMS will allow an organization to make changes to hard copy SBs on a very limited basis All Plan sponsors must obtain hard copy change request approval prior to submitting their SBs to CMS for review NOTE Hard copy change requests related to the description of benefits should not be submitted until CMS has approved all bids Plans may submit administrative hard copy requests e g changes to local phone or website location prior to the bid approval Hard copy changes are only permitted to correct inaccurate or misleading information or errors generated from the PBP SB software CMS will not allow changes in wording based on individual preferences The fact that a hard copy change request was approved in a prior year is no guarantee that it will be approved in a subsequent year Any approved hard copy changes will not result in changes to the Medicare Options Compare or to the Plan Benefit Package PBP Plans should validate the data entered in the PBP as well as reference the SB crosswalk to ensure the correct sentences are generated for the specific benefit being described Hard copy changes will not be considered once the PBP is closed for corrections How to Request a Change Applies to MA MA PD and PDP Hard copy change requests must be submitted via the SB hard copy change module in HPMS When requesting a hard copy change plan sponsors should provide The contract number and PBP
177. ievance organization determination and appeals processes and the procedures members must follow to file a grievance or to request an organization determination or appeal Subiect MustUse MustNotUse Reason All plans must include a description of their quality assurance policies Quality and procedures including Assurance medication therapy management Policies and and drug and or utilization Procedures management quality assurance activities and programs provided by Part C plans All plans must include a notice of Potential for possible contract termination or Contract reduction in service area and the Termination effect these actions may have on its members All plans must provide access to the following links Summary of Benefits Enrollment Instructions and These materials are Forms required for beneficiaries to be able to make an informed choice and to enroll in a particular program Required Links Evidence of Coverage LIS Premium Summary Chart Privacy Notice Plan Transition Process Information related to plan s exception and appeals process Section of CMS website regarding Best Available Evidence For all Part D plans and PDPs must provide notice on their website regarding removal or change in the preferred or tiered cost sharing status of a Part D drug The notice must contain the following The name of the affected covered Part D drug Information on whether the If applicable cov
178. iew and or print The formulary should include the tier level and tier label description as well as the quantity limit amount and quantity limit days supply Unlike for the printed abridged and comprehensive formularies it is not acceptable to merely indicate that UM applies to a drug for the downloadable formulary documents The UM documents must include all prior authorization and step therapy criteria applied to each formulary drug While Part D sponsors may make minor modifications on plan websites with regard to the HPMS prior authorization and step therapy criteria to address issues such as abbreviations and or grammatical truncation Part D sponsors will be expected to display all of the information contained within the HPMS files For drugs with a Part B versus D administrative prior authorization requirement the following statement must be included This drug may be covered under Medicare Part B or D depending upon the circumstances Information may need to be submitted describing the use and setting of the drug to make the determination The information in the comprehensive formulary and UM documents must Be available at the start of each new contract year enrollment period Be updated at least once per month and must be accessible by a drug name search Include the date when the formulary and utilization management documents were last updated to include Updated MM YYYY or No changes made since MM YYYY Be posted as PDF f
179. iles that allow for printing content copying for accessibility page extraction and document assembly In addition to the PDFs Part D plans may also post the comprehensive formulary in other downloadable formats CMS suggests that Part D plan sponsors also provide a search tool that allows individuals to search for their specific prescription drug The search tool may not be used as a substitute for the downloadable comprehensive formulary prior authorization and step therapy criteria documents PDFs However if a search tool is made available it must be available for all formulary drugs In addition CMS also expects the search tool to include the following elements Definition of formulary Part D plan sponsors may either include this information or provide a link to this information in an introductory screen An explanation of how to use the search tool The following statement lt Part D Plan Name gt covers both brand name drugs and generic drugs Generic drugs have the same active ingredient formula as a brand name drug Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration FDA to be as safe and effective as brand name drugs A statement that the formulary may change during the year Search results that indicate whether a drug is covered its tier placement including the tier number and tier label description and any applicable utilization management requirements If quant
180. individuals including non members who ask to opt out of receiving future marketing communications are not sent such communications For marketing multiple lines of business plan sponsors must comply with the HIPAA rules outlined in 40 14 5 and 170 regarding use of beneficiary information Plan sponsors that advertise multiple lines of business within the same marketing document must keep the organization s lines of business clearly and understandably distinct from the other products Plan sponsors must make this distinction by utilizing different formatting styles that delineate the two products For example the document might highlight the name of the MA or PDP product in bold and underlined font and then include a paragraph to describe the product in regular font next go on to highlight the name of a non MA PDP product in bold and underlined font and then include a paragraph describing the non plan product in regular font Also if a plan sponsor advertises non Medicare products with plan material it must pro rate any costs so that costs of marketing non Medicare materials are not included as plan related costs in the plan sponsor s bid to CMS 40 14 2 Multiple Lines of Business Exceptions Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 423 2268 Plan sponsors must ensure that all marketing activities conform to the guidance provided in this document with regard to marketing thr
181. information only CMS will review plan sponsors web pages to ensure that plans are maintaining the separation between Part C Cost and Part D product lines and information on other lines of business 40 14 5 Multiple Lines of Business HIPAA Privacy Rule Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 45 CFR 160 Generally plan sponsors are not required to obtain authorization from enrollees to use or disclose an enrollee s protected health information with regard to providing communication about replacements of or enhancements to the plan sponsor s benefits or the plan sponsor s health related value added products and services These categories are exceptions to the definition of marketing in the HIPAA Privacy Rule In complying with these exceptions plan sponsors may use and disclose protected health information to make communications to enrollees about other lines of business provided by the covered entity However plan sponsors must obtain authorization from an enrollee prior to using or disclosing the enrollee s protected health information for any marketing that does not fall within the exceptions to the definition of marketing under the HIPAA Privacy Rule For example enrollee authorization is needed if the product is a pass through of a discount available to the public at large such as an accident only policy a life insurance policy or an item or service that is not health related 40 14 6 Non Benefit Ser
182. information that it may cost more to get care from out of network providers except in an emergency or urgent care situation 50 1 14 Section 1876 cost plans must insert information on premium and cost sharing for services received through the plan and optional supplemental benefit packages 50 1 15 Non network PFFS plans must also insert A Medicare Advantage Private Fee for Service plan works differently than a Medicare supplement plan Your provider is not required to agree to accept the plan s terms and conditions and thus may choose not to treat you with the exception of emergencies If your provider does not agree to accept our payment terms and conditions of payment they may choose not to provide health care services to you except in emergencies If this happens you will need to find another provider that will accept our payment terms and conditions Providers can find the plan s terms and conditions on our website at insert link to PFFS terms and conditions If the material is part of an enrollment kit it must also contain a leaflet for provider education on plan rules and information 50 1 16 Full and partial network PFFS plans must also insert A Medicare Advantage Private Fee for Service plan works differently than a Medicare supplement plan We have network providers that is providers who have signed contracts with our plan for full network PFFS plan insert all services covered under Original Medic
183. ion materials must also comply with the other requirements and responsibilities provided in these Medicare Marketing Guidelines 50 1 Guidance and Disclaimers Applicable to Advertising Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Advertising materials generally contain less detail than explanatory marketing materials Advertising materials may provide basic benefit information to entice a potential enrollee to request information As a general rule materials that contain basic benefit information are considered advertising Although not an exhaustive listing some examples of advertising materials include Banner and banner like ads see exception as provided in 50 1 2 Direct mail Counter tents Event signage Internet advertising see exception as provided in 50 1 2 Outdoor advertising see exception as provided in 50 1 2 Pharmacists promotional buttons Post stands Print ads Radio ads Television ads and see exception as provided in 50 1 2 Window stickers The following disclaimers are applicable to advertising materials It is the responsibility of the plan sponsor to ensure it meets all requirements contained within the referenced sections as well as any additional disclaimer requirements throughout 50 related to specific materials or plan types e g SNP PFFS invitations to events Federal Contracting Statement 50 1 2
184. ion Drug Benefit Program Mark 150 4 Restrictions on Use of Medicare Prescription Drug Benefit Program Mark 150 5 Prohibition on Misuse of the Medicare Prescription Drug Benefit Program Mark 150 6 Mark Guidelines 150 6 1 Mark Guidelines Negative Program Mark 150 6 2 Mark Guidelines Approved Colors 150 6 3 Mark Guidelines on Languages 150 6 4 Mark Guidelines on Size 150 6 5 Mark Guidelines on Clear Space Allocation 150 6 6 Mark Guidelines on Bleed Edge Indicator 150 6 7 Mark Guidelines on Incorrect Use 150 7 Part D Standard Pharmacy ID Card Design 160 Use of Federal Funds 170 Allowable Use of Medicare Beneficiary Information Obtained from CMS 170 1 When Prior Authorization From the Beneficiary Is Not Required to Use Beneficiary Information Obtained from CMS 170 2 When Prior Authorization From the Beneficiary Is Required to Use Beneficiary Information Obtained from CMS 170 3 Obtaining Prior Authorization 170 4 Sending Non plan and Non health Information Once Prior Authorization is Received Appendices Appendix Summary of Benefits Appendix 2 Plan Sponsor Website Chart Appendix 3 Model File amp Use Certification Form 10 Introduction Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 These Medicare Marketing Guidelines MMG reflect the Centers for Medicare amp Medicaid Services CMS current interpretation of the marketing requirements and related provisions of the Medic
185. ions may begin using the mark on marketing materials including the Part D membership ID card that are required to be submitted to CMS for review Organization requests to distribute other items materials that are not included in this chapter bearing the Medicare Prescription Drug Benefit Program Mark must be submitted to CMS at least thirty 30 days prior to the anticipated date of distribution Requests should be sent to CMS External Affairs Office Visual amp Multimedia Communications Group at 7500 Security Blvd Baltimore MD 21244 1850 Mail Stop C1 16 03 Once a request has been approved the following will apply 1 approval will be effective for a period not to exceed one year or at the time of termination from the Part D program and 2 approval will be granted only for those items for which use of the mark was requested in the request letter and for which written approval was granted 150 4 Restrictions on Use of Medicare Prescription Drug Benefit Program Mark Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act Unless otherwise approved all unauthorized individuals organizations and or commercial firms may not distribute materials bearing the Medicare Prescription Drug Benefit Program Mark Unauthorized use of the Medicare Prescription Drug Benefit Program Mark should be reported immediately so that appropriate legal action can be taken Reports of unauthorized use should
186. ior plan history as indicated on the compensation report plan sponsors may pay the full year initial compensation amount e A plan sponsor will have the opportunity prior to each contract year to determine that it will no longer use independent agents and brokers When a plan sponsor and or a contracted independent agent or broker elect to terminate their contract any remaining cycle years of existing business will be governed by the terms of that contract 120 5 4 1 Additional Marketing Fees Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 a 423 2274 a A plan sponsor may not charge a beneficiary or allow its marketing representatives to charge a beneficiary a marketing fee outside of the approved premium for the purpose of compensating a marketing representative All costs associated with the marketing of a plan are the responsibility of the plan sponsor An enrollee cannot be held responsible for the cost of marketing beyond the base premium Any such costs are considered part of the plan sponsor s administrative costs and must be included in the plan sponsor s bid submission 120 5 5 Compensation Calculation Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2274 a 423 2274 a The aggregate compensation amount paid for selling or servicing an enrollee during each of the five individual renewal years of a six 6 year cycle must be fair market value FMV for th
187. ipate in the outreach process Clarify in outreach materials that the plan sponsor is only providing an initial eligibility screening and that only the appropriate State Agency can make a final eligibility determination Provide guidance to a member on how to proceed with the application process even if the plan sponsor s screening process indicates that the member is probably not eligible for assistance under any of the dual eligibility programs Provide adequate training to staff conducting the outreach If the plan sponsor subcontracts this effort to another entity it must ensure that the subcontractor s staff is adequately trained to provide outreach Include alternate sources of information in outreach materials member letters and or brochures that contain outreach information telephone numbers must also include the telephone number for beneficiaries to call the SHIP and the appropriate State Agency Outreach materials may also include the telephone number for the 1 800 MEDICARE 1 800 633 4227 and the T7Y number for Medicare 1 800 486 2048 Include privacy guidelines in outreach materials telephone scripts and internal processes and or contracts with entities performing outreach for the plan sponsor Contractual privacy guidelines must clearly state that all financial information collected from members of the plan sponsor will not be used for any other purpose by the entity collecting the data Privacy guidelines must also stat
188. ired disclaimers as provided in 50 as well as all other relevant requirements as outlined in these Medicare Marketing Guidelines For outbound scripts plan sponsors must pay close attention to the guidance on marketing through unsolicited contacts in 70 4 and 70 5 on specific telephone contact This guidance extends to all downstream contractors Inbound calls made directly to a sales department or sales agent must clearly inform the beneficiary if when the nature of the call moves from a sales presentation to telephonic enrollment This must be done with the full and active concurrence of the Medicare beneficiary ideally with a yes no question When conducting outbound sales calls e Scripts must include a privacy statement clarifying that the beneficiary is not required to provide any health related information to the plan representative unless it will be used to determine enrollment eligibility e Plan sponsors are prohibited from requesting beneficiary identification numbers e g Social Security Numbers bank account numbers credit card numbers HICNs but in limited circumstances may inquire about an individual s special needs status to determine the appropriateness of enrollment in a SNP 80 1 9 Requirements for All Other Inbound Outbound Scripts Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 422 2268 423 2262 423 2264 423 2268 The following guidance applies to
189. is account to pay for your health care costs but only Medicare covered expenses count toward your deductible The amount deposited is usually less than your deductible amount so you generally will have to pay out of pocket before your coverage begins e Display MSA or Medical Savings Account in all headers of all marketing displays e Include the member s obligation to continue to pay Medicare Part B premiums as well as the fact that there are no plan premiums e Not imply that an MSA plan functions as a supplement to Medicare e Not use the term network to describe a list of contracted preferred providers if available e Include the following statement Medicare MSA Plans don t cover prescription drugs If you join a Medicare MSA Plan you can also join a Medicare Prescription Drug Plan to get drug coverage NOTE MSAs cannot offer Part D but enrollees can enroll in a separate PDP plan MSAs should reference all of the MA and PDP plan sponsors offerings and not just the MSA plan so the beneficiary knows that he she can choose any PDP and is not restricted to the MSA plan sponsor s own PDP offering 42 CFR 422 4 c 2 e Provide specific information to beneficiaries related to all aspects of the MSA plan s cost sharing especially what is and is not counted towards the deductible and how the MSA accounts are invested the nature of the risk associated with the accounts and the record of
190. it comparison matrix using the following sentence See page lt gt for additional information about Enter benefit category exactly as it appears in the left column All information included in Section III must be verified with the information entered into the PBP report in HPMS Section IV of Template for DE Special Needs Plans Effective 2010 and beyond a comprehensive written statement is a MIPPA requirement for all DE SNPs The purpose of this requirement is to help prospective enrollees to determine whether they can receive any value from enrolling in a SNP This requirement applies to all DE SNPs regardless of whether they have a contract with the state Comprehensive written statement must cover benefits and cost sharing information under SNP and State Medicaid plan A template with the required format is available in HPMS under the bid submission module In order for plans to describe their benefits the Section IV SB template can be downloaded using the following navigation path Plan Bids gt Bid Submission gt CY XXXX gt Documentation gt SB Template for DE SNPS Adding only Section IV to the SB will trigger a 45 day review process If a plan does not have a Section III the Medicaid language does not have to be labeled as Section IV but it must be distinct from Sections I II of the SB Plans should not substitute SB Section II with Section IV In addition the format for Section IV is standardized and should be not altered in an
191. it Comparison Matrix The SB benefit comparison matrix will be generated by the PBP in chart format with the required language Therefore the information included in the PBP must first be correct in order for the SB comparison matrix to be correct The order and content of information presented in the benefit comparison matrix must be the same as the information presented in the PBP with the exception of the permitted and or necessary changes discussed below Instructions for Section III Plan Specific Features Section III is used by plan sponsors to describe special features of a program or to provide additional information about benefits described within Sections I and II Section II is optional and is not standardized with regard to format or content It may contain text graphics pictures maps This section is limited to a maximum of six pages of text and graphics The page limit is defined as six single sided pages or three double sided pages However there is one exception to this limit Plan sponsors translating the SB to another language may add pages as necessary to ensure the translation conveys the same information as the English language version Plan sponsors may provide additional information in Section III about covered benefits described within the benefit comparison matrix If the organization chooses to further describe its covered benefits in Section III it may reference the information in the relevant section of the benef
192. it pays instead of Medicare and the beneficiary pays any applicable cost share or co pay Model language is provided to incorporate into sales presentations describing the special aspects of PFFS plans which differ from supplements and other MA plans refer to http www cms hbhs gov PrivateFeeforServicePlans PFFS plans should refer to the above web link for additional information on the inclusion of balance billing notification in the EOC Additionally enrollment kits for PFFS plans must provide enrollees with a complete description of plan rules detailing information on a provider s choice whether to accept the plan s terms and conditions of payment CMS has developed a model document that beneficiaries may show their health care provider for this purpose refer to http www cms hhs gov PrivateFeeforServicePlans The leaflet must be included in all enrollment kits that prospective enrollees receive and must be available on the PFFS plan sponsor s website The leaflet must be submitted to CMS using the File amp Use certification process 50 1 17 Additional Guidance for Dual Eligible SNP Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2 422 4 a 1 iv 422 111 b 2 Gil 422 2264 423 2264 For each contract year plan sponsors offering Dual Eligible SNPs DE SNP must provide each prospective enrollee prior to enrollment with a comprehensive written statement of benefits and cost s
193. ither minimal or non medical The cost if any must be intrinsically administrative the cost must cover such items as clerical or equipment and supplies related to communication such as phone and postage or database administration such as verifying enrollment or tracking usage Note that this definition does not require that VAIS be health related A VAIS is not a benefit since no direct medical or pharmaceutical cost is incurred to the plan sponsor in providing the VAIS See Chapter 4 section 60 30 Plan Sponsor Responsibilities Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 30 1 Record Retention Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 422 504 d 422 504 d 1 i vii 422 504 e 422 504 h 1 422 504 h 2 422 504 i 1 422 504 i 2 422 504 i 3 422 504 i 4 i v 422 504 i 5 423 504 d 423 504 d 1 2 423 505 h 1 423 505 h 2 423 505 h 2 i 423 505 h 2 i ii 423 505 h 3 423 505 h i viii 423 505 h 4 i iv 4233 505 h 5 All plan sponsors must abide by CMS rules and regulations regarding record retention by retaining documents i e books records and documents etc for a period of ten 10 years The retained documents should be sufficient to include all policy and operational procedures conducted during the course of the effective period of the CMS contract with the plan sponsor Plan sponsors are responsible for
194. ity limit restrictions apply the quantity limit amount and days supply must be displayed If prior authorization or step therapy restrictions are applicable then the criteria must also be included For drugs with a Part B versus D administrative prior authorization requirement the following statement must be included This drug may be covered under Medicare Part B or D depending upon the circumstances Information may need to be submitted describing the use and setting of the drug to make the determination An explanation of how to obtain an exception to the Part D plan s formulary utilization management tools or tiered cost sharing This information or a link to this information must be included in both an introductory screen and when search results indicate a drug is not covered e An indicator to identify mail order availability excluded drugs free first fill drugs limited access drugs drugs covered in the coverage gap and drugs covered under the medical benefit for home infusion drugs only e Include the date when the search tool information was last updated In addition to the information above a plan may also choose to include search results that list formulary alternatives for the drug entered in the online search tool The Part D plan may choose to include non formulary alternatives in addition to the formulary alternatives however the formulary alternatives must be clearly marked as formulary drugs without the need f
195. ivities e Pending State or Federal legislation e Joining grassroots advocacy organizations and information about such advocacy Both written and oral communications designed to facilitate non health or non plan related activities require prior authorization 170 3 Obtaining Prior Authorization Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Following are examples of how the prior authorization required under 170 2 may be obtained With any of these examples plan sponsors must receive the member s opt in authorization prior to receiving any non plan or non health related information and plan sponsors should keep evidence of authorization for audit purposes e Plan sponsors may send at their own expense written requests to enrollees to obtain the beneficiary s authorization for the organization or sponsor to contact him her for purposes unrelated to plan benefits administration or CMS contract execution The beneficiary must sign and return the request before the plan can send non plan related materials or information This authorization may also be obtained by directing a beneficiary to a website to provide the requisite consent Note that if the plan uses a website for the opt in process the link from the plan s Medicare product website must inform the beneficiary that he or she is leaving the Medicare product website and going to the non Medicare product website as provided in 100 1 Once a beneficiar
196. kes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan Compliance criteria include without limitation the requirements in 42 CFR 422 2260 422 2276 and 42 CFR 422 111 for MA plans and 42 CFR 417 472 and 42 CFR 417 428 for cost based plans and the Medicare Marketing Guidelines I agree that CMS may inspect any and all information including those held at the premises of the Medicare health plan to ensure compliance with these requirements I further agree to notify CMS immediately if I become aware of any circumstances that indicate noncompliance with the requirements described above I possess the requisite authority to make this certification on behalf of the MA organization Signature Name amp Title lt CEO CFO or designee able to legally bind the organization gt On behalf of Name of Medicare Health Plan Date This certification form must be signed and received by the CMS Regional Office prior to submitting materials under the File amp Use Certification Process Once the File amp Use Certification form is received it is effective until further notice from CMS
197. l Voicemail may be used outside of normal business hours provided the message e Indicates that the mailbox is secure Lists the information that must be provided so the case can be worked e g provider identification beneficiary identification type of request coverage determination or appeal physician support for an exception request and whether the member is making an expedited or standard request For coverage determination calls including exceptions requests articulates and follows a process for resolution within twenty four 24 hours of call for expedited requests and seventy two 72 hours for standard requests For appeals calls information should articulate the process information needed and provide for a resolution within seventy two 72 hours for expedited appeal requests and seven 7 calendar days for standard appeal requests Provides and follows a process for immediate access in situations where an enrollee s life or health is in serious jeopardy 80 1 3 Required Scripts for Inbound Informational Calls Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 423 2262 423 2264 Inbound informational customer service telephone scripts are considered marketing materials and are subject to all requirements in this section and other relevant sections of the Medicare Marketing Guidelines Refer to 170 for more information about allowable uses of beneficiary infor
198. le how they are tracked by the plan and what happens to the money in the account if the member leaves the plan Include the following statement Enrollment is generally for the full calendar year You can disenroll from lt Plan Name gt from October 15 and December 7 of each year Your disenrollment will be effective January I of the next year You may not disenroll or make changes at other times unless you meet certain special exceptions such as if you move out of the plan s service area qualify for Medicaid or qualify for Extra Help with Medicare prescription drug costs Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan Include the following statement to explain a member s tax responsibility You must file Form 1040 US Individual Income Tax Return along with Form 8853 Archer MSA and Long Term Care Insurance Contracts with the Internal Revenue Service IRS for any distributions made from your Medicare MSA account to ensure you aren t taxed on your MSA account withdrawals You must file these tax forms for any year in which an MSA account withdrawal is made even if you have no taxable income or other reason for filing a Form 1040 MSA account withdrawals for qualified medical expenses are tax free while account withdrawals for non medical expenses are subject to both income tax and a fifty 50 percent tax penalty Include the following language with the
199. le to ensure that the following information is available for each plan benefit package PBP they offer A statement indicating that the enrollee s premium will generally be lower once he she receives extra help from Medicare The four different premium amounts An explanation that the premiums listed do not include any Part B premium the member may have to pay and A statement indicating that the premiums listed are for both medical services and prescription drug benefits MA PD plans only NOTE Even if plan sponsors offer a 0 plan premium they should still include the above information on their website 100 3 Prohibited Links Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Federal Food Drug and Cosmetic Act Part D plans may not provide links to foreign drug sales on their websites 100 4 Required Disclaimers on Websites Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 Plan sponsors must include all applicable explanatory disclaimers as referenced in 50 Applicable disclaimers should be placed directly on the web pages of the website disclaimers contained solely within various documents e g SB will not suffice 100 5 Enrollment via the Internet Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 60 422 2268 423 32 423 2268 Some plan sponsors are allowed to accept enrollment requests via the organization
200. lowing disclaimer This document includes lt Plan s Name gt partial formulary as of lt formulary date gt For a complete updated formulary please visit our lt website address gt or call lt toll free number gt lt days and hours of operation gt TTY users should call lt toll free TTY number gt e The definition of a formulary as compared to an abridged formulary 42 CFR 423 4 defines formulary as the entire list of Part D drugs covered by a Part D plan e An explanation of how to use the Part D plan s formulary document e The following statement lt Part D Plan Name gt covers both brand name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand name drug Generally generic drugs cost less than brand name drugs e A statement describing the Part D plan s general utilization management procedures as well as a statement that the formulary may change during the year NOTE As provided under 423 120 b 6 a Part D plan may not make negative formulary changes to its formulary from the beginning of the annual coordinated election period through sixty 60 days after the beginning of the contract year The document must also include the date the formulary was last updated and describe how to obtain updated formulary information An explanation of how to obtain an exception to the Part D plan s formulary utilization management tools or tiered c
201. ls 30 9 Requirements for Plans with Special Needs Populations Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Basic enrollee information must be made available to individuals with disabilities for example those with visual or hearing impairments upon beneficiary request Plan sponsors must make sure information about their benefits is accessible and appropriate for Medicare beneficiaries who have disabilities 30 10 Compliance with Section 508 of the Rehabilitation Act Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Section 508 of the Rehabilitation Act of 1973 29 U S C 794 d as amended by the Workforce Investment Act of 1998 P L 105 220 August 7 1998 and located at http www section508 gov All plan sponsors are required to have an nternet website that is compliant with web based technology and information standards for people with disabilities in addition to other requirements as specified in Section 508 of the Rehabilitation Act Refer to 100 for details 30 17 Required Materials in Enrollment Kit Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 423 128 When a beneficiary is provided enrollment instructions form for the purpose of enrollment potential enrollment the information listed below must be included This in total represents an Enrollment Kit When a plan sponsor enrolls a beneficiary online it
202. ly unwelcome marketing and other communications we also recognize plan sponsors interest in contacting their enrollees on issues unrelated to the specific plan benefit that they contract with CMS to provide to those enrollees This section contains additional guidance for plan sponsors on the distribution of other types of non plan related information 170 1 When Prior Authorization From the Beneficiary Is Not Required to Use Beneficiary Information Obtained from CMS Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 As specified in 40 14 1 plan sponsors are permitted to send current members information about health related issues without any prior authorization from the beneficiary as long as the material includes instructions describing how the individuals may opt out of receiving such communications In addition plan sponsors may send current members information about health related VAIS provided those materials contain opt out instructions Examples of health related issues plan sponsors may communicate without receiving the prior authorization of current enrollees include e Long term care insurance e Separate dental or vision policies e Value added items and services VAIS Plan sponsors may provide information to their existing enrollees about current plan coverage and other MA plan PDP cost plan or Medigap products offered by the plan sponsor without any prior authorization from enrollees Provided that the infor
203. materials all of which are defined in 20 Enrollment Materials Enrollment materials are materials used to enroll or disenroll from a plan or materials used to convey information specific to enrollment and disenrollment issues such as enrollment and disenrollment notices NOTE Refer to Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Prescription Drug Benefit Manual for model enrollment forms and notices Health Plan Management System HPMS A web enabled information system that serves a critical role in supporting the implementation and ongoing operations of MA plans MA PD plans section 1876 cost plans and PDPs HPMS and its software modules are used to collect track trend and analyze plan and CMS data Joint Enterprise A joint enterprise is a group of organizations that are State licensed as risk bearing entities that jointly enter into a single contract with CMS to offer a Regional Preferred Provider Organization RPPO plan or PDP in a multi State region The participating organizations contract with each other to create a single joint enterprise and are considered an entity for purposes of offering a RPPO or PDP Local Plans A local plan is offered by a legal entity that is not a regional or national plan Plan sponsors may choose the counties in which local plans operate Local plans may also vary benefits and premiums at the county level The uniform benefit requirement applies to local plans
204. mation Since information in Section I will conflict between MA and MA PD plans plan sponsors will need to make a hard copy change for Section I in order to reflect accurate information These side by side comparisons are eligible for a 10 day marketing review if no other changes are made to the standardized SB Side by side comparisons should be submitted to the regional office for review and approval 10 Plan sponsors offering plans with identical benefits within one contract e g one contract S H R number may display the information for these plans in the same column within the benefit comparison matrix Section II Plan sponsors using this format must include the following statement in Section I Where is lt plan name gt available If you move out of the state or county where you currently live to a state listed above you must call Customer Service to update your information If you don t you may be disenrolled from lt plan name gt If you move to a state not listed above please call Customer Service to find out if lt plan org gt has a plan in your new State or county 11 Plan sponsors may include additional information about covered benefits within a separate flyer or other material and may provide this with the SB 12 The SB header containing such information as the company name customer service telephone number only displays on the first page of the SB Section II It is acceptable for plan sponsors to display
205. mation is not confusing or misleading or includes references to information that requires prior authorization plan sponsors may provide relevant plan and health information to members including monthly newsletters information on disease management programs mailings describing rationale for benefits changes and information on Medicaid and other community or social services program 170 2 When Prior Authorization From the Beneficiary Is Required to Use Beneficiary Information Obtained from CMS Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 As specified in 40 14 5 plan sponsors are permitted to send current enrollees information about non health related services issues provided they obtain authorization from an enrollee prior to using an enrollee s protected health information to provide marketing information about an item or service that is not health related Examples of non health related issues plans may communicate after receiving prior authorization opt in of current enrollees include e Accident only policies e Life insurance policies e Annuities Other materials distributed to members that are unrelated to the administration of plan benefits or are not related to health related issues or other lines of business offered by the same organization are also subject to the prior authorization opt in requirements Examples of these types of issues include information on e Volunteer or community act
206. mation that is applicable to 80 1 3 80 1 5 At a minimum plans must develop scripts to respond to prospective and current enrollees for the situations listed below Plan sponsors must submit to CMS only scripts noted with an asterisk for review and approval all others must be maintained by the plan sponsor Make information about Best Available Evidence BAE policy available for those who contact the plan sponsor s call center Refer to 100 2 for additional information that must be made available either in writing or over the phone in the event the plan sponsor is contacted Request for pre enrollment information Request for post enrollment information inquiries on Benefits Cost sharing Formulary Network pharmacies including whether a prospective enrollee s pharmacy is in the plan sponsor s network Provider networks including whether a prospective enrollee s primary care physician is in the plan sponsor s network Out of network coverage Claims submission processing and payment Formulary transition process How to access the Part D grievance coverage determination including exceptions and appeals process How to obtain extra help Current TROOP status How to obtain needed forms How to replace a member identification card Service area NOTE Telephone enrollment scripts are not considered Informational Inbound Scripts rather they are discussed in 80 1 6 80 1 4
207. ment to offer one or all of the following Medicare Products MA plans MA PD plans PDPs and section 1876 cost plans NOTE For purposes of this guidance the term plan sponsor s will be utilized to describe all organizational plan types unless otherwise noted Post Enrollment Marketing Materials A subset of explanatory marketing materials used by a plan sponsor to convey benefits or operational information to current enrollees Post enrollment marketing materials include but are not limited to e All notification forms letters and sections of newsletters that are used to communicate with the individual on various membership operational policies rules and procedures e Annual Notice of Change ANOC e Enrollment Letters e Evidence of Coverage EOC e Pharmacy directory e Provider directory e Formulary e Member ID card e Grievance coverage organization determination and appeals letters e Exceptions process letters e Member handbook e Explanation of Benefits EOB Pre Enrollment Marketing Materials A subset of explanatory marketing materials pre enrollment materials e g sales scripts direct mail that includes an enrollment form sales presentations are generally used by prospective enrollees to decide whether or not to enroll in a plan Pre enrollment materials may contain plan rules and or benefits information Pre enrollment marketing materials include but are not limited to e Sales scripts sales presentations e Di
208. must include adjustments made as a result of adjustments made for example those based on information received from other plans reversed claims and supplemental payer adjustments e An EOB does not need to be generated by the plan sponsor when retroactive changes apply to prior benefit year prescription fills For example a plan s final EOB for CY 2010 must be sent in January 2011 for December 2010 fills Once the final EOB for CY 2010 has been sent sponsors are not required to send an EOB for any retroactive adjustments for prior benefit year fills prescription fills made prior to December 31 2010 e Notice regarding formulary changes to affected enrollees as provided in 42 CFR 423 120 b 5 and in 60 5 This includes changes to the list of excluded drugs on the plan s marketed formulary NOTE Plan sponsors are encouraged to include language promoting the LIS program on the EOB 60 7 Annual Notice Of Change ANOC and Evidence of Coverage EOC Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 a 3 422 111 d 2 423 128 a 3 With the exception of fully integrated DE SNPs section 1876 cost plans not offering Part D and employer union group plans plan sponsors must ensure their current members receive the ANOC and EOC their LIS riders and abridged or comprehensive formularies for the upcoming coverage year no later than September 30th of each year New Enrollees with an effec
209. must make these materials available electronically for example via website links to the potential member prior to the completion and submission of the enrollment request Beneficiaries must have access to enrollment materials either electronically or in hard copy to ensure this information is received prior to completion of the enrollment request Plan sponsors must ensure that all appropriate disclaimers are on the materials specified below refer to 50 for disclaimers NOTE f the information below is contained elsewhere in one of the documents of the enrollment kit plans are not required to create a separate document containing that specific information NOTE Inclusion of a cover letter including the plan s toll free customer service telephone number a TTY telephone number customer service hours of operation and a physical or post office address is optional since the contact information is included in the SB e Enrollment instructions and forms e Written notice that plan benefits and cost sharing may change from year to year Refer to 50 1 3 for disclaimers regarding benefits e Written explanation of plan s grievance coverage organization determination including exceptions and appeals processes including differences between the processes and when it is appropriate to use each e Plan ratings information on http www medicare gov must be submitted as a standalone document Refer to 30 15 for more details about pla
210. n ratings information e Summary of Benefits SB Plan sponsors have the option of including the following materials in their enrollment kits but must make them available upon request However if a beneficiary enrolls with the plan sponsor the materials below must be distributed to him her no later than ten 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the first month of enrollment whichever occurs first e Pharmacy directory Part D sponsors only e Provider directory e Combined provider pharmacy directory refer to 60 4 4 for additional requirements e Comprehensive or abridged formulary Part D sponsors only 30 12 Required Materials for New and Renewing Members at Time of Enrollment and Annually Thereafter Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 423 128 422 2264 423 2264 Within the timeframes specified by CMS plan sponsors must provide members with all necessary information outlined in Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Medicare Prescription Drug Benefit Manual In addition the materials below must be distributed to a beneficiary no later than ten 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the first month of enrollment whichever occurs first Plans should refer to the notification on the Transaction Reply Report TRR that contains the earliest notificati
211. n the past When contacting beneficiaries to establish new relationships a consent for future contact must be limited in scope short term and event specific The consent to contact may not be treated as open ended permission for future contacts However for agents contacting their own clients or plan sponsors or contracted agents contacting their current members consent for each specific contact is not required to discuss plan business NOTE All plans sponsors must comply with 170 regarding the use of beneficiary data as related to telephonic contact Also refer to 80 1 9 for information about telephonic script review and approval Prohibited telephonic activities include but are not limited to the following e Making unsolicited outbound calls to beneficiaries about other business as a means of generating leads for Medicare plans Examples of other lines of business include but are not limited to a discount prescription drug card a Medigap plan a needs assessment an educational event or a review of Medicare coverage options or any other service or product that is not an MA plan or PDP e Calls to beneficiaries based on referrals resulting in an unsolicited contact e g referrals from friends relatives neighbors or companies that collect buy or sell contact information If an individual would like to refer a friend or relative to an agent or plan sponsor the agent or plan sponsor may provide contact information s
212. nager is located Multi region plan sponsors that submit template materials are not required to send approved copies of the template to local regions since this information is already available in HPMS 90 16 Review of Materials in the Marketplace Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 423 2268 To ensure compliance with this chapter CMS periodically conducts reviews of plan sponsor materials Reviews could include but are not limited to the following activities e Review of on site marketing facilities products and activities during regularly scheduled contract compliance monitoring visits e Random review of actual marketing pieces as they are used in by the media e For cause review of materials and activities when complaints are made by any source and CMS determines it is appropriate to investigate e Secret shopper activities where CMS requests plan sponsor materials such as enrollment packets If a plan sponsor s materials are found to be non compliant CMS may enforce various compliance actions Additionally plan sponsors may be required to prepare an addendum or reissue the materials at no expense to the Government 90 17 File amp Use Retrospective Monitoring Reviews Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 b 422 2264 423 2262 b 422 2264 CMS will periodically conduct retrospective reviews of materials t
213. nal review prior to use However plan sponsors must submit each variation of the template through HPMS as a populated template within thirty 30 days of populating the materials If any changes or corrections to the bid occur after the template is approved the plan sponsor is responsible for correcting all materials to reflect the changes If a plan sponsor chooses to submit a SB for review with no section III no comprehensive written statement of benefits section IV and no hard copy changes the SB will be treated as a standardized document and reviewed using the ten 10 day timeframe However if the plan sponsor chooses to submit the SB with section II and or section IV it will be reviewed within the forty five 45 day time period Model documents used as templates may not be modified Plan sponsors should not submit SBs with variable placeholders around plan benefits and cost sharing after bids have been approved rather these SBs should be submitted as final documents 90 10 Submission of All Templates Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 Template material or model template materials must be uploaded to CMS through the HPMS marketing module and they must show how the placeholders will be populated by inserting the name of the field within greater than and less than signs e g lt date gt or populate the placeholder fields with all variables within the greater th
214. nd in addition must e Offer to send an e mail or other confirmation to the beneficiary to denote receipt of the online enrollment request or e Provide a summary of the plan for which the individual has requested enrollment or e Provide a statement that the individual will receive a notice in the mail in response to the enrollment request e g acknowledging receipt of the completed enrollment request or requesting additional information or denial of enrollment e g not eligible NOTE The only online enrollment mechanism that third party entities on behalf of the plan sponsor may make available to potential enrollees is via the plan sponsor s website The enrollment of a beneficiary utilizing an agent broker website is not permitted Furthermore allowing agents brokers including third party plan comparisons and enrollment websites that function as brokers to assist with telephonic enrollments is prohibited Plan sponsors must ensure that telephonic enrollment requests are effectuated entirely by the beneficiary or his her authorized representative and that the plan representative sales agent or broker is not physically present at the time of the request Refer to 40 1 3 of Chapter 2 of the Medicare Managed Care Manual 40 1 3 of the Medicare Prescription Drug Benefit Manual 100 5 1 Required Materials When Online Enrollment is Utilized Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42
215. nical help call center must meet the following operating standards e Average hold time must not exceed two 2 minutes The average hold time is defined as the average time spent on hold by a caller following an interactive voice response IVR or touch tone response system and before reaching a live person e Eighty 80 percent of incoming calls must be answered within thirty 30 seconds e Disconnect rate of all incoming calls must not exceed five 5 percent 80 1 2 Coverage Determinations and Appeals Call Center Requirements Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 111 b 8 423 128 d 1 423 566 a All plan sponsors must operate a toll free call center with live customer service representatives available to respond to physicians and other providers for information related to coverage determinations including exceptions and prior authorizations and beneficiary Part D appeals The call center must operate during normal business hours and never less than from 8 00 a m to 6 00 p m Monday through Friday according to the time zones for the regions in which they operate Plan sponsors are expected to accept requests for coverage determinations redeterminations outside of normal business hours but are not required to have live customer service representatives available to accept such requests outside normal business hours Additional details are available in Chapter 18 of the Prescription Drug Benefit Manua
216. ns or discussing the assistance available to them Such scripts must include a privacy statement clarifying that the member is not required to provide any information to the representative and that the information provided will in no way affect the beneficiary s membership in the plan In some instances a plan sponsor may choose to submit an outreach proposal that CMS has already approved for use by another plan sponsor or an outreach proposal that will be used by other plan sponsors in the future This is common when a plan sponsor is part of a national organization with multiple contracts each of which is conducting its own outreach but sharing the same outreach materials This is also common when a plan sponsor conducts its own outreach efforts through a subcontracting entity that provides the same services and outreach materials to multiple plan sponsors If a plan sponsor submits an outreach proposal that CMS previously approved on or after April 1 2002 that does not contain substantive changes to qualify it as an initial proposal the plan sponsor must submit the items listed above 1 8 In addition the plan sponsor must submit an attestation from either itself or its contracted outreach vendor stating 1 that the proposal has been approved by CMS 2 the date of that approval and 3 that the new submission does not contain substantive changes to the approved program 70 10 4 CMS Review Approval of Outreach Process for Dual Elig
217. nt requirement Any form developed to be used by physicians when providing a supporting statement for an exceptions request Contact numbers that enrollees and physicians can use for process or status questions Instructions about how to appoint a representative and a link to CMS Appointment of Representation form Form CMS 1696 located on CMS http www cms gov CMSForms CMSForms ist asp TopOfPage A link to the plan s Evidence of Coverage EOC and a reference to the sections on the EOC that discuss the grievance coverage determination including exceptions and appeals processes A link to the Request for Medicare Prescription Drug Determination Request Form for use by enrollees located on CMS Part D appeals webpage http www cms hhs gov PrescriptionDrugApp IGriev 13_Forms asp A link to the Medicare Part D Coverage Determination Request Form for use by provider located on CMS Part D appeals webpage http www cms hhs gov MedPrescriptDrugAppIGriev 13_Forms asp 100 2 4 Low Income Subsidy LIS Website Premium Summary Table for People Receiving Extra Help Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 128 b 2 ii and iii Plan sponsors must inform potential enrollees of what their plan premium will be once they are eligible and receive the LIS For territories this information does not need to be included Plan sponsors should use the model LIS Premium Summary Tab
218. ntended to affect a beneficiary s choice among Medicare plans Marketing by a person who is directly employed by an organization with which a plan sponsor contracts to perform marketing or a downstream marketing contractor is considered marketing by the plan sponsor Plan sponsors are responsible for all downstream activities made on their behalf 120 1 Compliance with State Appointment Laws Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2272 c 423 2272 c Plan sponsors must comply with State appointment laws In order to sell Medicare products an agent or broker must be appointed in accordance with the appropriate State s appointment law and if there are any fees required as part of the appointment law the fees must be paid Note that CMS does not dictate who should pay any such fees 120 2 Plan Reporting of Terminated Agents Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2272 c 423 2272 c 422 2272 e 423 2272 e Plan sponsors must report the termination of any brokers or agents and the reasons for the termination to the State in which the broker or agent has been appointed in accordance with the State appointment law Plan sponsors must make the report available upon CMS request until further guidance has been issued regarding designated reporting dates to CMS Plan sponsors must ferminate upon discovery and report incidences of submission
219. ntment that has already been agreed to by a beneficiary via a completed scope of appointment form Sales of Medicare health plan products are subject to our scope of appointment guidance even if conducted during a sales appointment for a Medigap policy This includes the requirement for a beneficiary completed agreement form prior to the appointment and a 48 hour waiting period Any plan sponsor or its representative that accepts an appointment to sell an MA or PDP product that resulted from an unsolicited contact with a beneficiary regardless of who made the contact will be in violation of the prohibition against unsolicited contacts If during the course of an outbound call by a Medigap issuer the beneficiary requests additional information on a MA or PDP product at this time a discussion can be held on the MA or PDP product as long as the call is being recorded Furthermore third parties may not make unsolicited MA or PDP marketing calls to beneficiaries other than to current plan members if contracted by a plan as described below to set up appointments with potential enrollees e Third parties may not make unsolicited calls to beneficiaries for non MA and PDP products for example a benefits compare meeting and provide those contacts to plans for ultimate use as an MA or PDP sales appointment e Sales of MA and PDP products are subject to CMS scope of appointment guidance even if conducted during a sales appointment for a
220. o understand Some plan sponsors choose to conduct outreach to their members to educate them and to assist them in applying for these savings programs This may be especially true because CMS capitates plan sponsors at a higher rate for some dual eligible members Because of the potential benefits to both the members and plan sponsors CMS encourages but does not require plan sponsors to assist their members with applying for State financial assistance 70 10 1 Guidance on Dual Eligibility Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 a 4 423 2264 a 3 There are several categories of dual eligibility each having specific income requirements and providing different levels of financial assistance to those who qualify at that level Specific information on categories and amounts is available at http www cms hhs gov DualEligible 70 10 2 Guidance for Dual Eligible Outreach Program Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 422 2268 423 2268 In order to assure CMS that each plan sponsor s outreach programs effectively assist members while protecting them from undue pressures or privacy violations plan sponsors including any contracted entity conducting outreach on behalf of the plan sponsor must adhere to the following guidance Plan sponsors and their contracted entities conducting outreach on their behalf must e Ensure t
221. odel document exists It is likewise incumbent on the plan sponsor to ensure that any model that has been modified in any way is not submitted for a model review Materials that are found to be non model yet are uploaded for model review will be disapproved A continued submission of non model materials as model will be viewed as a compliance issue 90 6 File amp Use Program Overview Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 b 423 2262 b Plan sponsors have the ability to utilize the File amp Use program To do so plan sponsors must submit the File amp Use certification form to the respective CMS Account Manager Materials that qualify under the File amp Use process can be distributed five calendar days after submission to CMS but no earlier than any date established by CMS for use of specific document materials All plan sponsors can use the File amp Use process for selected marketing materials as defined by CMS Plan sponsors using the File amp Use process must submit File amp Use eligible marketing materials to CMS five calendar days prior to distribution and certify that the materials comply with this chapter 90 6 1 Materials Qualified for the File amp Use Submission Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 b 423 2262 b The following materials are qualified for the File amp Use process provided they are used without modif
222. of media types are undeliverable for example an expired e mail account e Have a system in place to monitor and evaluate the effectiveness of the electronic communication process Finally if a plan elects to distribute plan information to members using media other than hard copies paper the plan is still responsible for ensuring that it is in compliance with HIPAA 40 16 Standardization of Plan Name Type Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 q 423 2268 q section 1851 a 6 of the Act Plan sponsors must include the plan type in each plan s name using standard terminology as developed by the Secretary Plan sponsors enter and maintain their plan names in the HPMS The plan name is used by internal CMS systems and in standardized marketing tools including but not limited to the SB Medicare Options Compare and Medicare Prescription Drug Plan Finder on http www medicare gov and the Medicare amp You Handbook To ensure the consistent use of standardized plan type terminology across all plan sponsors HPMS auto populates the plan type label at the end of each plan name For instance an HMO plan named Golden Medicare Plan would appear as follows Golden Medicare Plan HMO The auto generated plan type label will not count toward the fifty 50 character maximum length reserved for the plan name field In addition to standardizing the terminology in HPMS plan s
223. oices 130 Guidelines Applicable to Employer Union Group Health Plans Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 1857 1 1860D 22 b 42 CFR 422 2276 423 2276 As provided in 10 1 of Chapter 9 of the Medicare Managed Care Manual and 10 1 of Chapter 12 of the Prescription Drug Benefit Manual CMS has authority under sections 1857 i and 1860D 22 b of the Social Security Act to waive or modify requirements that hinder the design of the offering of or the enrollment in employment based Medicare plans offered by employers and unions to their members Waivers and modifications may be granted to plan sponsors offering individual PDPs or MA plans or plan sponsors offering customized employer group PDPs or MA plans offered exclusively to employer union group health plan sponsors known as employer union only group waiver plans or EGWPs CMS has issued various employer group waivers and or modifications to the Medicare Part C and Part D rules for marketing and disclosure dissemination of information to Medicare beneficiaries For specific guidance regarding these waivers or modifications of marketing and disclosure dissemination of information requirements for employer union sponsored group health plans please refer to 20 3 of Chapter 9 of the Medicare Managed Care Manual and 20 3 of Chapter 12 of the Prescription Drug Benefit Manual Plan sponsors offering employer group health plans are no longer required to s
224. omote specific benefits premiums and or services offered by the plan Plan sponsors may conduct a formal event where a presentation is provided to Medicare beneficiaries or an informal event where plan sponsors are only distributing health plan brochures and pre enrollment materials Plan sponsors may also accept enrollment forms and perform enrollment at marketing sales events Marketing Appointments Marketing appointments are individual appointments designed to steer or attempt to steer potential enrollees toward a plan or limited number of plans All individual appointments between an agent and a beneficiary are considered marketing sales appointments regardless of the content discussed Medicare Advantage MA Organization Public or private entity organized and licensed by a State as a risk bearing entity that is certified by CMS as meeting the requirements to offer an MA plan Medicare Advantage MA Plan A plan that offers coverage of Medicare Part A and Part B benefits and which may also offer other benefits including Part D coverage at a uniform premium and uniform level of cost sharing to individuals living in the service area who are entitled to benefits under Medicare Part A and enrolled in Part B Medicare Advantage Prescription Drug MA PD Plan An MA plan that provides qualified prescription drug coverage Medigap A Medicare supplemental Medigap policy is a health insurance policy sold by private insurance companies
225. on the plan sponsor s website If the specific marketing materials have not been reviewed and approved or appropriately submitted to CMS under File amp Use in accordance with this chapter an inactive link must be included on the website with a notation e g coming soon e SB e Enrollment instructions and forms e EOC e LIS Premium Summary Table Privacy Notice privacy notices are subject to enforcement by the Office for Civil Rights e Provide a link to their transition process e Information related to the plan s exception and appeals process including instructions and forms required to file and complete a coverage determination including an exception or appeal request e Provide a link on their website to the section of CMS website regarding Best Available Evidence BAE policy and make information about BAE policy readily available for those who contact the plan sponsor s call center Refer to CMS web link http www cms hhs gov PrescriptionDrugCovContra 17_Best_Available_Evidence_Policy c sp e Ifapplicable non English materials must be available as noted in 30 11 30 12 30 13 and the Part D Transition Letter available in any language that is the primary language of more than five percent of a plan sponsor s PBP service area Websites should use marketing materials that have been reviewed and approved and or appropriately submitted to CMS under File amp Use in accordance with this chapter e g
226. on to identify the start of the ten 10 calendar day timeframe e Annual Notice Of Change Evidence Of Coverage ANOC EOC or EOC as applicable except for DE SNPs refer to 60 7 for more information about these requirements e Comprehensive formulary or abridged formulary including information on how the beneficiary can obtain a complete formulary Part D sponsors only e Pharmacy directory For all plan sponsors offering a Part D benefit e Provider directory All plan types except PDPs e Membership identification card required only at time of enrollment and as needed or required by plan sponsor post enrollment 30 13 Required Ongoing Materials for New and Renewing Members Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 b 12 423 128 e Plan sponsors offering the Part D benefit must provide their enrollees an Explanation of Benefits EOB on at least a monthly basis for those months in which the enrollees use their Part D benefit Refer to 60 6 for more information about the Part D EOB Additionally CMS may require an MA organization to furnish directly to enrollees in the manner specified by CMS and in a form easily understandable to such enrollees a written explanation of benefits when benefits are provided under Part 422 The explanation of benefits will be pilot tested in CY 2012 and CMS will provide updates to all plans following the pilot 30 14 Hold Time Messages Rev 9
227. onsor loses its File amp Use Certification privileges twice it may not be reinstated under File amp Use Certification until at least one year has passed since the date the privileges were taken away the second time Following are the certification procedures for Part D sponsors e Unless the PDP sponsor requests a waiver from the File amp Use Certification process all PDP sponsors must submit File amp Use Certification marketing materials to CMS five 5 calendar days prior to distribution and certify that the materials comply with this chapter It is important to note that CMS will verify that the marketing materials submitted by the organization qualify for the File amp Use Certification process e The PDP sponsor may submit File amp Use Certification materials prior to executing a contract with CMS The CMS contract will contain a provision by which the PDP sponsor will certify that the material submitted prior to the execution of the contract as well as all File amp Use Certification materials submitted subsequent to the execution are accurate truthful not misleading and consistent with CMS requirements Thus by executing the CMS contract the appropriate officer of the PDP sponsor is attesting to his her PDP s compliance with the File amp Use Certification requirements e As each marketing material is submitted the PDP sponsor must attest to the completeness and accuracy of the material through an electronic attest
228. onsor retains all responsibility for meeting CMS requirements and must submit all documentation to the appropriate CMS Regional Office for approval per the submission guidance provided later in this section The plan sponsor must not e Conduct door to door solicitation or outreach prior to receiving an invitation from the member to provide assistance in his or her home e Share any member information financial or otherwise with any entity not directly involved in the outreach process e Store or use member financial information for any purpose other than the initial screening eligibility the submission and follow up of an application for benefits for recertification purposes and as required by law e Contact any member who has refused outreach assistance or who has not responded to the telephone call or follow up letter until at least six months following the last outreach attempt e Imply in any written materials or other contact with the member that the organization has the authority to determine the member s eligibility for State assistance programs 70 10 3 Outreach Submission Requirements for Dual Eligibility Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 In general plan sponsors either develop and conduct their own outreach or contract with an external entity to provide the expertise materials and member assistance Regardless of the approach plan sponsors mu
229. onsors are responsible for submitting final versions of templates in the HPMS Marketing Module using the associated Final Expedited Review code and will be required to enter the Template Material ID of the original MASTER template material in the Template Material ID field Changes to previously approved non variable text in the template must be submitted for review and approval by CMS Co branding information added to previously approved template materials is not subject to an additional review as long as the changes are limited to populating existing variable fields e g organization name logos or contact information If there are any changes or corrections to materials for example the benefit or cost sharing information differs from that in the approved bid the plan sponsor will be required to correct those materials for prospective enrollees and send errata sheets addenda reprints to current members by a reasonable timeframe In cases where non compliance is discovered the plan sponsor may be subject to penalties including intermediate sanctions and civil money penalties NOTE Identical materials submitted separately and not noted as template materials are subject to separate reviews 90 11 Submission of Non English Alternate Formats Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 e 423 2264 e CMS requires that plan sponsors make marketing materi
230. ont page of the plan ratings information document Plan performance summary ratings are issued in October of the previous plan contract year Until such time as the plan rating information for the following contract year is made available plan sponsors must provide the current year s plan ratings information which is generated from HPMS in their enrollment kits and on websites Once the upcoming year s plan performance rating template is available plan sponsors must download the template and submit as File amp Use as described above e g the document can be used within 5 days after submission Plan sponsors must update their websites to include the new plan performance rating and update the information in their enrollment kit no later than 30 days after the release of the upcoming year s ratings to ensure that the most recent plan performance ratings are provided to existing and prospective enrollees All marketing during the Annual Enrollment Period should use the plan performance summary rating for the upcoming year New plans that do not have any plan ratings information are not required to provide plan ratings information until the new contract year References to star ratings in marketing and or enrollment materials other than the HPMS generated plan rating information must include the year for which the plan s summary star rating applies e g xx plan is a 2011 5 Star rated plan Plans should also include the following discl
231. ontract with the state Medicaid program NOTE All other SNP types should use the following disclaimer on their marketing materials A Coordinated Care plan with a Medicare Advantage contract PDP sponsors must use one of the following contracting statements below The statements may not be modified and may either be in the text of the piece or at the end bottom center of the piece e A Federally Qualified Medicare Contracting Prescription Drug Plan e A Medicare approved Part D sponsor or e A stand alone prescription drug plan with a Medicare contract 50 1 3 Disclaimers When Benefits Are Mentioned Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 111 a 422 111 b 422 111 f 423 128 b Marketing materials may provide basic benefit information to entice a potential enrollee to request additional information When benefit information is provided the following disclaimer must be utilized on advertising and explanatory materials The benefit information provided herein is a brief summary not a comprehensive description of benefits For more information contact the plan Additionally plan sponsors must include a statement in their current contracting year marketing materials advertising and explanatory when advertising a current year benefit formulary pharmacy network premium or co payment that such information may change in the upcoming contracting year Model disclaim
232. or further navigation If not all formulary alternatives will be listed the plan must include the following disclaimer This is not a complete list of all formulary alternatives covered by the Part D plan for the drug you have selected Formulary information available on a website is subject to review by CMS Review of these materials will follow the procedures for review of websites which is described in 100 60 5 5 Other Formulary Documents Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 128 b 4 Part D plans may develop additional formulary documents provided that the comprehensive and abridged formulary documents are developed and distributed in compliance with 60 5 For example Part D plans may choose to develop a formulary that lists all of their preferred drugs or is tailored to individuals with specific chronic conditions as long as these items supplement the two required documents rather than replace them The following disclaimer must also be displayed prominently on the cover of the document This is not a complete list of drugs covered by the Part D plan For a complete listing please call lt Customer Service Phone Number gt or log onto lt website address gt 60 5 6 Provision of Notice to Beneficiaries Regarding Formulary Changes Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 120 b 5 Part D plans must provide at least sixty 60 days notice to ben
233. ormation Refer to 5 3 This also includes any mailing envelopes in which the non plan related information is sent Plan sponsors must also include a plan mailing statement on such materials as specified in 50 2 If the plan sponsor wishes to include the request for authorization in plan mailings as opposed to a separate mailing at its own expense the claimed administrative costs must reflect an appropriate reduction to reflect the share of the document preparation and mailings cost that is attributable to the sponsor s efforts to seek authorization to send non plan related materials refer to 40 14 1 and 40 14 2 Appendices Summary of Medicare Advantage And Prescription Drug Plan Technical Instructions NOTE These appendices contain only CMS technical instructions guidance related to items in this chapter CMS model documents are not included in this chapter therefore all interested parties should reference the following web links for the specific CMS model documents For Part D model documents http www cms hhs gov PrescriptionDrugCovContra PartDMMM list asp TopOfPage For Part C model documents http www cms hhs gov ManagedCareMarketing 09_MarketngModelsStandardDocumentsandE ducationalMaterial asp TopOfPage Appendix 1 Summary of Benefits Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Applies to MA PD PDP and MA plans CMS expects that the language for sections I and
234. ors that are unable to successfully complete the outbound verification on the first attempt we expect the sponsor to send the applicant an enrollment verification letter Plan sponsors must not delay processing the enrollment request including but not limited to activation of benefits and submission of enrollment request data to CMS while completing the OEV process If the sponsor makes a determination to deny an enrollment request prior to completing the OEV process the sponsor must discontinue the OEV process If the sponsor receives a TRR from CMS rejecting the enrollment prior to completing the OEV process the sponsor must suspend the OEV process and will resume the OEV process if the sponsor determines the reject to be erroneous such that the enrollment will be resubmitted to CMS Plan sponsors must send the enrollee the enrollment verification letter in addition to any other required enrollment notice such as enrollment acknowledgement and confirmation letters After the model enrollment verification letter has been sent the plan sponsor is expected to make and document at least two additional telephone attempts to successfully complete the outbound enrollment verification The minimum three attempts to conduct the verification by telephone and if applicable the mailing of the enrollment verification letter are expected to be completed no later than fifteen 15 calendar days of the plan sponsor s receipt of the enrollment request Plan
235. ost sharing and a description of the plan s drug transition policy Plan contact information for additional information or questions on the formulary A chart the approved CMS formulary of covered drugs organized by therapeutic category that includes at least two covered drugs for each therapeutic class Exceptions to this include when only one drug exists in the category or class or in the case where two drugs exist in the category or class and one is clinically superior to the other The category or class names must be the same as those found on the CMS approved Part D plan formulary NOTE While Part D plans must ensure that at least two drugs per therapeutic class are included within the abridged formulary Part D plans have the option to include the therapeutic classes as subheadings within the abridged formulary as this level of detail may be confusing for beneficiaries The row of the chart must include at least the three items described below Drug Name We suggest capitalizing brand name drugs e g LIPITOR and listing generic drugs in lowercase italics e g penicillin Part D plans may include the generic name of a drug next to the brand name of the drug The abridged formulary may only consist of drugs included on the CMS approved HPMS formulary Formulary drug enhancements described in 60 5 may not be included in the abridged formulary document Tier Placement Part D plans that provide different levels of coverage
236. otification of approval into the program Other file formats are available from CMS s Office of External Affairs upon request 150 6 1 Mark Guidelines Negative Program Mark Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act The Medicare Prescription Drug Benefit Program Mark may be reversed out in white The entire mark must be legible Medicare Prescription Drug Coverage 150 6 2 Mark Guidelines Approved Colors Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act The two 2 color mark is the preferred version It uses PMS 704 burgundy and sixty five 65 percent process black It is recommended that if the CMS mark is used in conjunction with the brand mark that the black versions of those logos be used Medicare Prescription Drug overage The 1 color version in grayscale is acceptable The mark elements are one hundred 100 percent black except for the word Medicare which is fifty five 55 percent black Viedicare Prescription Drug Coverage The 1 color version in one hundred 100 percent black also is acceptable Medicare Prescription Drug Coverage 150 6 3 Mark Guidelines on Languages Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act The Spanish version of the Medicare Prescription Drug Benefit Program Mark may be used in place
237. otnote placement Footnotes should appear either at the end of the document or the bottom of each page and in the same place throughout the document For example the plan sponsor cannot include a footnote at the bottom of page 2 and then reference this footnote on page 8 the footnote must also appear at the bottom of page 8 40 4 Reference to Studies or Statistical Data Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Plan sponsors may refer to the results of studies or statistical data in relation to customer satisfaction quality or cost as long as specific study details are given At a minimum study details need to be included in the material either in the text or as a footnote along with the source and date Plan sponsors should also disclose information on the relationship they have with the entity that conducted the study Upon submitting material to CMS for review the plan sponsor must provide to CMS the study sample size and number of plans surveyed unless the study that is referenced is a CMS study Plan sponsors should enter this information in the notes section when uploading the document that includes the reference into HPMS e Plan sponsors may distribute a study or statistical data for example Medicare Prescription Drug Plan Finder information to directly compare their plan to another plan in marketing materials to potential enrollees e Ifa plan sponsor uses study dat
238. ough unsolicited contacts refer to 70 4 While plan sponsors may mention non plan lines of health related products at the time they send a plan non renewal notice they may only do so using separate enclosures within the same envelope Plan sponsors are prohibited from mentioning non Medicare lines of business within the interim and final non renewal notices in order to ensure that the non renewal notices give beneficiaries focused information only about the plan non renewal Plan sponsors must not include enrollment applications for competing lines of business e g MA PD or MA plans and Medigap products or for other non Medicare lines of business in mailings that combine plan information with other product information 40 14 3 Multiple Lines of Business Television Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 423 2268 Plan sponsors may market other lines of business concurrently with plan products on television advertisements However they must ensure that non plan products are separate and distinct from the plan products 40 14 4 Multiple Lines of Business Internet Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2260 423 2260 Plan sponsors may market other lines of business concurrently with plan products on the Internet To avoid beneficiary confusion plan sponsors must continue to maintain a separate and distinct section of their website for Medicare
239. our statements on the mailing so that they are visible from the window of the envelope as opposed to on the outside of the envelope only if the disclaimer is prominently displayed within the display window of the envelope and is separate and distinct from the beneficiary s name address CMS expects that all plan envelopes or mailings will include one of the four statements and that the statements will be prominently displayed so that beneficiaries can easily identify the content of the mailer In addition plan sponsors must ensure that their plan name or logo is included in every mailing to current and prospective enrollees either on the front envelope through the front window of the envelope or on the mailing when no envelope accompanies the mailer Plan sponsors should not create envelopes that look like they are being sent from an official government source e g red white amp blue flags on the outside of the envelope or envelopes that are made to look like checks The review and approval of envelopes with additional information other than the four mailing statements must be submitted for a forty five 45 day review If no other information is included with one of the four mailing statements then envelopes may be submitted under the File amp Use process CMS does not require resubmission of envelopes based only on a change in the envelope size If a plan uses the same mailing statement on 3 different mailing packages e g 8 x 12 en
240. oviders of the billing rules for the plan sponsor and thus could reduce the chance for incorrect or inappropriate balance billing CMS also recommends that PPOs and PFFS plan sponsors include a statement that the provider should bill the PPO or PFFS organization and not Original Medicare CMS believes this statement will help prevent claim processing errors However use of this statement is optional In order to ensure that a provider has access to a PFFS plan s terms and conditions of payment CMS also recommends that PFFS plan sponsors include on their member ID cards 1 the web link to their terms and conditions of payment and 2 a phone number for providers to call the plan sponsor If the web link for the terms and conditions of payment is too long to fit on the member ID card then PFFS plan sponsors are encouraged to appropriately shorten the web link so that it will fit on the member ID card Inclusion of both of these items on the member ID card is optional Refer to 30 3 information regarding co branding requirements related to ID cards and 60 2 for Part D ID requirements 60 4 Directories Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 b 3 422 111 e 423 128 b 5 423 128 c 1 E 422 2260 423 2260 All plan sponsors are required to create and make available applicable provider and or pharmacy directories for their members and prospective enrollees Plan sponsors m
241. plan but one that is a like plan type following the initial year of enrollment NOTE Renewal compensation will apply whether or not the new enrollment is in a plan offered by the same or a new receiving organization e g the member moves to a different plan within the same parent organization A like plan type moves refer to moves from e A PDP to another PDP e An MA or MA PD to another MA or MA PD or e A section 1876 cost plan to another section 1876 cost plan Unlike plan type moves refer to moves from e An MA or MA PD plan to a PDP or section 1876 cost plan e A PDP to a section 1876 cost plan or an MA or MA PD plan or e A section 1876 cost plan to an MA or MA PD plan or PDP NOTE For dual enrollments e g enrollment in an MA only plan and a stand alone PDP the compensation rules apply independently to each plan However when dual enrollments are replaced by an enrollment in a single plan compensation is paid based on the MA movement e g movement from an MA only plan and PDP to an MA PD plan would be compensated at the renewal compensation amount for the MA to MA PD like plan type move 120 5 3 Compensation Cycle 6 Year Cycle Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 a 423 2274 a After a beneficiary is enrolled in an MA plan or PDP by an agent or broker a renewal compensation would be paid for five 5 years after the initial compensation year
242. plan sponsor allows online enrollment through the plan sponsor s secure website the online enrollment mechanism does not need to be available in Alternate Format materials However in addition to other requirements refer to 100 for details the online enrollment mechanism must indicate that Alternate Format materials are available by contacting the plan sponsor directly 90 12 Acceptable Formats Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 Plan sponsors must use HPMS to enter all pertinent information related to a material submission and attach the material in electronic format to this entry When submitting material include within the comments field on the Marketing Materials Transmittal screen the plan number and PBP for which materials are being submitted The following are acceptable electronic formats for submitting these materials e Zip Files ZIP e Portable Document Format PDF e Microsoft Word DOC DOCX e Joint Photographic Experts Group JPG e Microsoft Excel XLS XLSX e DOS Text TXT e Graphics Interchange Format GIF e WordPerfect WPD Other formats may be acceptable but must be agreed upon by the plan sponsor s Account Manager prior to making the submission 90 13 Submissions Outside of HPMS Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 Under extraordinary circumstances an
243. ponsors may publish separate PCP and specialty directories on the condition that both directories are given to enrollees prior to the effective date of enrollment or within ten 10 calendar days of receipt of the enrollment confirmation and at least annually thereafter Plan sponsors that use sub networks of providers must clearly delineate these sub networks preferably by listing the providers as a separate sub network and describe any restrictions imposed on members that use these sub networks This is particularly important since beneficiaries could choose their primary care physician without realizing that this choice restricts them to a specified group of specialists ancillary providers and hospitals Plan sponsors must also clearly describe the process for obtaining services in these networks and sub networks including any referral requirements as well as any out of network coverage or point of service option 60 4 4 Combined Provider Pharmacy Directory Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 b 3 G 423 128 b 5 MA PD plans and section 1876 cost plans that offer prescription drug coverage may combine the model provider and model pharmacy directories in one document If the plan sponsor chooses to use the two model directories without modification and combine them into one document the materials can be submitted either File amp Use or for a ten 10 day review period per the rules a
244. ponsors must display the plan type on all marketing materials including plan logos Plans that have previously incorporated the plan type in their plan names in a position other than at the end of the plan name must now place the plan type at the end on printed marketing materials The following exceptions to the plan name requirements apply e Plans are not required to include the parentheses with the plan type for materials that are not auto generated from HPMS CMS will allow plan sponsors to either spell out the plan name type or abbreviate on materials that are not generated from HPMS For example use of either Acme Medicare HMO or Acme Medicare Health Maintenance Organization e Operational letters or logos that do not mention the plan name are not required to include the plan type e Communication information provided verbally to beneficiaries e g scripts does not require the plan type designation e Plans that have incorporated the plan type at the end of the plan name e g Gold Plan PFFS are not required to repeat the plan type in the plan name e Inclusion of the plan type is not required throughout an entire document However plans must include the plan type on the front page or at the beginning of the document Model documents to which the only modification is the addition of the required plan name type will still be eligible for a ten 10 day review provided no other modifications are made to the document
245. ppeals processes and the procedures plan members must follow to file a grievance or request a coverage determination including an exception or appeal Quality assurance policies and procedures including Medication Therapy Management MTM and drug and or utilization management Plan sponsors must identify the conditions for which MTM programs are available inform beneficiaries that these programs may have limited eligibility criteria make clear that these programs are not considered a benefit and remind beneficiaries to contact the organization s customer service for additional information Potential for contract termination Beneficiaries and plan s rights and responsibilities upon disenrollment How to obtain an aggregate number of grievances appeals and exceptions filed with the plan sponsor Process for contacting Social Security Office or Medicaid to inquire about LIS status or level 100 2 2 Provider Access information Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 111 b 3 MA MA PD and section 1876 cost plans must include an electronic provider directory applicable for all products and defined by service areas or general geographic area This may be accomplished by e Posting a searchable master provider directory that represents the aggregate network for the plan sponsor e Posting individual provider directories by product and or service area e g mirroring those th
246. proval of the material Deviations include but are not limited to insertion of footnotes plan specific clarifications or format alterations except as indicated in the SB instructions Plan sponsors should generate their SBs via HPMS SNPs should include the required comprehensive written statement in Section IV of the SB when submitting it to CMS for review SNPs are responsible for ensuring the accuracy of the Medicaid benefits displayed in the SB by communicating with the States and or utilizing State specific materials A template is available on HPMS for plans to use and technical guidance on the Summary of Benefits can be found in Appendix 1 If a plan sponsor s bid has been approved CMS expects that plan sponsors will submit completed SBs to CMS for review Plan sponsors should not submit SBs with unpopulated brackets for cost sharing benefits etc after the bid approval Plan sponsors offering more than one plan may describe several plans in the same document by displaying the benefits for different plans in separate columns within Section II of the benefit comparison matrix Since the PBP will only print sections I and II of the SB for one plan plan sponsors will have to create a side by side comparison matrix for two or more plans by manually combining the information into a chart format Plan sponsors will also need to modify Section I of the introduction section to accurately reflect the plans that have been added to Section
247. r s plan benefit package service area NOTE the member ID card is excluded from this requirement Additionally plan sponsors must place translated versions of these materials on the plan s website For example contract ID HXXXX includes plan 001 The plan sponsor s PBP service area would be the counties that are covered by plan 001 CMS expects plan sponsors operating in areas where the five 5 percent language requirement threshold is met will provide non English materials upon beneficiary request The referenced marketing documents for CY2011 are subject to a ten 10 percent threshold CMS expects that translated versions of materials will be uploaded in HPMS and that requests for translated materials will be fulfilled within a reasonable timeframe When translating a material plans should translate the final version of the English material not a template of the English materials CMS will verify the availability of non English marketing materials through monitoring review and will also periodically conduct accuracy reviews of non English materials f materials are unavailable inaccurate or do not convey the same information as the English version plan sponsors may be subject to compliance or enforcement action and must cease use of these materials until revised materials have been approved Plan sponsors operating in service areas that do not meet the five 5 percent threshold are not required to produce any translated materia
248. r must continue to cover the drug s at the more favorable cost share or with less restrictive utilization management for the beneficiary through the end of the contract year Any drug adjudicated as a formulary drug at the point of sale must be included in the Part D sponsor s marketing materials This applies to drugs that exist on the approved HPMS formulary as well as drugs covered as Part D formulary enhancements to the approved formulary Generally these drugs are expected to relate to newly approved brand or generic drugs including new formulations and strengths that do not currently reside on the Formulary Reference File FRF but that would likely be added during subsequent FRF updates These marketed formulary drug enhancements must be added to the HPMS formulary once the drugs are represented on the FRF 60 5 1 Abridged Formulary Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 423 128 At a minimum a Part D sponsor s printed abridged formulary document must include the following information e Plan Name on cover page e lt Year gt Formulary List of Covered Drugs on cover page e PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN on cover page e The following statement Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take e The fol
249. r to being used in the marketplace Please refer to 80 Special Guidance on Telephonic Activities and Scripts for additional guidance on outbound calls 70 5 1 Specific Guidance on Third party Contact Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 d 423 2268 d Plan sponsor representatives and other third parties are prohibited from engaging in direct unsolicited contact with potential enrollees including outbound calls This guidance applies to all downstream contractors including third party organizations utilized to generate sales leads and or appointments As such plan sponsors should keep in mind that CMS views the following activities as out of compliance e Unsolicited marketing calls to beneficiaries other than to current plan members or to an agent s existing clientele e Unsolicited calls to beneficiaries for other business for example a benefits compare meeting and providing those contacts to plans for ultimate use in an MA or PDP sales appointment Independent Agents Brokers may e Contact members that they enrolled in a plan to discuss plan issues and market other plan options but cannot conduct unsolicited phone calls to other beneficiaries or plan members During an agent s outbound call to a client the agent is not required to set up an appointment to discuss other available plans products with the beneficiary e Initiate a phone call to confirm an appoi
250. r to submitting materials as outlined below plan sponsors are responsible for ensuring that materials are consistent with this chapter and all other relevant CMS issued guidance and instructions In addition it is incumbent on the plan sponsor to create materials that provide information in a manner that is clearly stated and in no way deceptive to the recipient Note that not all materials are read some are scripts 90 2 Material Submission Process Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2262 423 2262 Plan sponsors are required to submit materials for review through the Marketing Module of the HPMS The HPMS Marketing Module is an automated tool that a plan sponsor uses to enter track and maintain marketing materials submitted to CMS for review and approval HPMS can accept electronic copies of plan sponsors actual marketing materials The HPMS Marketing Module User Guide provides extensive information on how to use HPMS However plan sponsors must have a CMS plan issued User ID and password with HPMS access in order to log into the system Plan sponsors will also need to associate their User ID with the contract numbers with which they are associated in HPMS 90 2 1 Ad Hoc Enrollee Communications Submission Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2260 5 vii 6 422 2262 d 423 2260 5 vii 6 423 2262 d In our efforts to streamline the
251. re services to you except in emergencies If this happens you will need to find another provider that will accept our terms and conditions of payment Providers can find the plan s terms and conditions of payment on our website at insert link to PFFS terms and conditions of payment Clearly explain the following during SNP presentations events e Eligibility limitations e g required special needs status e Special enrollment period SEP to enroll in change or leave SNPs e Process for involuntary disenrollment if the beneficiary loses his her Medicaid or institutional status or becomes ineligible for the C SNP e A description of how drug coverage works with your plan At a marketing sales event plan sponsors may not e Conduct health screening or other like activities that could give the impression of cherry picking e Compare one plan sponsor to another by name unless both plan sponsors have concurred e Provide meals to attendees refer to 70 2 1 on exclusion of meals e Require beneficiaries to provide any contact information as a prerequisite for attending the event This includes requiring an email address or any other contact information as a condition to RSVP for an event online or through mail Plans should clearly indicate on any sign in sheets that completion of any contact information is optional e Plans sponsors may not ask beneficiaries to provide personal contact information in order to participat
252. rect mail that includes an enrollment form e Sales presentation materials e Summary of Benefits SB Promotional Activities Activities performed by a plan or by an individual or organization on a plan s behalf to inform current and potential enrollees of the products available Promotional Activities typically provide a higher level of detail than general advertising Provider For purposes of the MMG the term provider includes providers contracted with the plan sponsor non contracted providers and sub contractors including but not limited to pharmacists pharmacies physicians hospitals and long term care facilities Regional Plans e PDP Regional Plan A regional PDP sponsor offers PDP plans that serve one or more entire PDP region s but not all 34 PDP regions that include the 50 States and the District of Columbia e MA MA PD Regional Plans An MA or MA PD regional plan is a coordinated care plan structured as a Preferred Provider Organization PPO that serves one or more entire MA region s but not all 26 MA regions that include the 50 States and the District of Columbia Sales Person The term sales person is used in these Medicare Marketing Guidelines to define an individual who markets and or sells products for a single plan sponsor or numerous plan sponsors It includes employees brokers agents and all other individuals entities and downstream contractors that may be utilized to market and or sell on behalf of a plan
253. return on investments over the last two years 140 2 MSA Explanatory Marketing Materials Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264 Explanatory marketing materials as defined in this chapter created to promote MSAs must adhere to all applicable guidance found in 50 4 In addition due to the unique nature of MSAs plan sponsors must also include the following information in explanatory marketing materials for MSA plans e Explain that Medicare beneficiaries are not eligible for an MSA plan if they Have health coverage that would cover Medicare MSA plan deductibles including benefits under an employer or union group health plan 42 CFR 422 56 d Are eligible for health care benefits through the Department of Defense TRICARE or the Department of Veteran Affairs VA 42 CFR 422 56 b Are enrolled in a Federal Employees Health Benefits Program FEHBP 42 CFR 422 56 b e Are eligible for Medicaid 42 CFR 422 56 c Have end stage renal disease permanent kidney failure requiring dialysis or a kidney transplant e Are currently getting hospice care Live outside of the United States more than one hundred eighty three 183 days a year 42 CFR 422 56 a Explain the unique features of MSA plans including the MSA trustee arrangement costs to the member before and after the deductible is met what costs count towards the deductib
254. ring of an item or service paid in whole or in part by the Medicare program Any promotional activities or items offered by plan sponsors fo prospective or current members including those that will be used to encourage retention of members e Must be of nominal value refer to 70 2 for additional information on nominal value e Must be offered to all people eligible to enroll without discrimination e Must not be offered in the form of cash or other monetary rebates e May not be items that are considered a health benefit e g a free checkup e May not consist of lowering or waiving co pays should the person enroll e May not be used or included with the SB ANOC EOC e May not be structured to steer enrollees to particular providers practitioners or suppliers e May be discussed in direct mailings to enrollees as long as there is no violation of the HIPAA Privacy laws e Must be tracked and documented during the contract year e Are subject to grievances by the enrollee consequently the plan must explicitly advise enrollees of the right to grieve and the process for filing a grievance and e May not be tied directly or indirectly to the provision of any other covered item or service gt As discussed in 110 plans may provide Value Added Items and Services VAIS such as pass through discounts to their current enrollees provided the plan complies with all requirements Since the plan incurs no cost except trul
255. rior to distributing materials to its membership For further details on what CMS considers a non benefit service providing third party entity please refer to section 40 14 6 50 1 14 Additional Guidance for Preferred Provider Organization PPO and Point of Service Plans POS Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 In addition to the applicable requirements and disclaimers noted in 50 explanatory materials must include information that with the exception of emergencies or urgent care it may cost more to get care from out of network providers 50 1 15 Additional Guidance for Section1876 Cost Plans Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 In addition to the applicable requirements and disclaimers noted in 50 the following guidance is applicable to 1876 cost plans Section 1876 cost plans must describe in their explanatory marketing materials the premiums and cost sharing for services received through the section 1876 cost plan and any optional supplemental benefit packages they offer They must also indicate that premiums cost sharing and optional supplemental benefits may change each year and include information on when such benefit options may be selected or discontinued All post enrollment materials must clearly explain that members may use plan and non plan providers and also explain the benefit cost sharing differentials
256. rmation on non health related issues unless the plan sponsor has previously received prior authorization to send that particular non health related information to that member For example a request for authorization to send information about life insurance should not include a statement like Make sure your spouse s future is secure with a life insurance policy from us and or should not be sent with documents that include details about the life insurance policy e The request for authorization can be included in the same mailing as plan related or health related mailings to members as provided in these Medicare Marketing Guidelines The request for authorization may not be included on the enrollment form whether in hard copy or in electronic forms available via the plan s website or made during the processing of a telephonic enrollment e The request for authorization should not be confusing or misleading to members by purporting to have current plan benefit information or by suggesting that the content includes official information from the Medicare program e These requests for authorization are not subject to review by CMS and should not be uploaded into HPMS However per 90 21 plan sponsors are still responsible for ensuring that all materials intended for Medicare beneficiaries meet the requirements of this chapter e CMS is adopting the same requirements for these authorizations as required by the HIPAA Privacy Rule
257. rovider neither the plan nor Original Medicare will be responsible for the cost of care e For materials of short length in general materials 1 page front and back and shorter are considered to be of short length You must receive all routine care from plan providers e In all other written materials You must use plan providers except in emergency or urgent care situations lt lt or for out of area renal dialysis or other services gt gt If you obtain routine care from out of network providers neither Medicare nor lt plan name gt will be responsible for the costs 50 1 12 Disclaimer for Materials that are Co branded with Providers Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Plan sponsors that choose to enter into co branding relationships with network providers are required to include all co branded provider names and or logos on explanatory marketing materials related to the members selection of specific providers or provider organizations e g physicians hospitals Refer to 30 3 for additional information on co branding Co branding marketing materials are required to include the following disclaimer Other lt Pharmacies Physicians Providers gt are Available in Our Network 50 1 13 Disclaimer When Using Third Party Marketing Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 423 2264
258. rticular date that the pharmacy s listing in the directory does not guarantee the pharmacy is still in the network and where to obtain complete and current information about network pharmacies in the plan s areas Preferred amp Other Network Pharmacies e Part D sponsors with preferred and non preferred pharmacies must describe the features of these pharmacy types in terms of higher or lower cost sharing and must describe restrictions imposed on members that use non preferred pharmacies e Part D sponsors must indicate which of their pharmacies offer preferred cost sharing Restricted Access to Pharmacies e Part D sponsors must indicate when a pharmacy is not available to all members for example a community health center pharmacy that is available only to patients of the community health center Information about Pharmacies e Information required in the pharmacy directory for non chain pharmacies includes pharmacy name address phone number and type of pharmacy e g retail mail order long term care home infusion I T U e In lieu of providing the addresses for all locations sponsors may provide a toll free customer service number for chain pharmacies and a TTY number that an enrollee can call to get the locations and phone numbers of the chain pharmacies nearest to their home If a chain pharmacy does not have a toll free number plan sponsors should include a central number for the pharmacy chain If the chain pharm
259. rticulated below e Model provider and pharmacy directories used separately and without modification can be submitted File amp Use e Model provider and pharmacy directories combined without any modification can be submitted File amp Use e Model provider and pharmacy directories combined with the pharmacy section removed from the provider directory can be submitted for ten 10 day review e Model provider and pharmacy directories used separately or combined and otherwise modified must be submitted for forty five 45 day review 60 4 5 Mailing the Provider Pharmacy Directory to Addresses with Multiple Members Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42CFR 422 111 b 3 G 423 128 b 5 With respect to the mailing of the directory at the time of enrollment and annually thereafter plan sponsors have the option to either mail one directory to every member or to mail one directory to every address where up to four members reside Individuals in for example apartment buildings are only considered to be at the same address if the apartment number is the same Although individuals living in community residences like group homes or nursing facilities reside at the same residence each individual must receive a copy of the directory Please note that every member must still receive his or her own directory at the time of enrollment If a plan sponsor chooses to mail the directory to every ad
260. s Must include a current formulary updated Current at least monthly Formulary All MA and section 1876 cost plans must include an electronic provider directory applicable for all products defined by service areas or general Provider geographic area Directory Plans must provide applicable notices with regards to changes that occur in the provider network Subiect MustUse MustNotUse Reason For Part D and PDPs All Part D plans must include provisions for non routine access to covered Part D drugs at out of network pharmacies including limits and financial responsibility for access to these drugs Out of Network Fo Part C plans All Part C plans must include provisions with regards Coverage to Lock in Premiums Cost sharing e g co payments co insurance and deductibles Rules for obtaining out of network services Referral rules All Part D plans must include a description of the grievance appeals and coverage determination including exceptions processes and the procedures members must follow to file a grievance appeal or request a coverage determination Additionally Part D plans must Coverage include information on a Web page Determinations located as close to the plan s Organization formulary page as possible Determinations developed specifically for exceptions Grievance and appeals Appeals Processes and Ali MA plans must include a Procedures description of the gr
261. s and the regional office reviewer responsible for SB review The existing standardized SB language An explanation of why the existing standardized language is inaccurate and _A modified sentence SB for Section 1876 Cost Plans Applies to Section 1876 cost plans see information below Section1876 cost plans are not required to use the standardized Summary of Benefits If section 1876 cost plan intends to have the plan appear in Medicare Health Plan Compare and Medicare Personal Plan Finder it will need to complete the Plan Benefit Package PBP to create a standardized SB Section 1876 cost plans that create a standardized SB they should follow all instructions below All section 1876 cost plans should follow all instructions previously outlined for the SB In addition the following instructions are specific to section 1876 cost plans General Instructions The benefit description column and Original Medicare column must remain unchanged All sentences in the plan column of the matrix must be completed with applicable co pays or co insurance amounts Additional instructions provided in italicized text and in parentheses should be removed from the Summary of Benefits prior to submitting the document to CMS for review Unless otherwise indicated section 1876 cost plans should choose all of the applicable sentences in each category to describe their benefits Instructions for Section I Beneficiary Information Section
262. s Marketing in Health Care Settings Sales Marketing at Educational Events Co branding X Provision of Meals X Appointment of Agents Brokers gt lt State Licensed Reporting of Terminated Agents Brokers Agent Broker Compensation Agent Broker Training and Testing Agents must be thoroughly familiar with the products they are selling X X including the plan specific training testing details and the Medicare rules that apply to the specific products The organization sponsor is responsible for ensuring that the agents selling for them have sufficient knowledge 140 Special Guidance for Medicare Medical Savings Account MSA Plans Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 MSAs are required to abide by all applicable guidance set forth in this chapter 140 1 MSA General Advertising Materials Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 General advertisement materials as defined by these Medicare Marketing Guidelines created to promote MSAs must adhere to all applicable guidance in 50 In addition due to the unique nature of MSAs MSA plan marketing materials should e Include the standard definition of an MSA MSA Plans combine a high deductible Medicare Advantage Plan and a bank account The plan deposits money from Medicare into the account You can use the money in th
263. s differently than a Medicare supplement plan Your provider is not required to agree to accept the plan s terms and conditions of payment and thus may choose not to treat you with the exception of emergencies If your provider does not agree to accept our terms and conditions of payment they may choose not to provide health care services to you except in emergencies If this happens you will need to find another provider that will accept our terms and conditions of payment Providers can find the plan s terms and conditions of payment on our website at insert link to PFFS terms and conditions of payment For full and partial network PFFS plans A Medicare Advantage Private Fee for Service plan works differently than a Medicare supplement plan We have network providers that is providers who have signed contracts with our plan for full network PFFS plan insert all services covered under Original Medicare partial network PFFS plans should indicate the category or categories of services for which network providers are available These providers have already agreed to see members of our plan If your provider is not one of our network providers then the provider is not required to agree to accept the plan s terms and conditions of payment and thus may choose not to treat you with the exception of emergencies If your provider does not agree to accept our terms and conditions of payment they may choose not to provide health ca
264. s offered in different regions may combine their SB even if their premiums vary between plans by following the requirements below e In Section II Benefit Comparison Matrix plans must indicate the premium range for all plans listed in the SB In addition plans must include a note directing the reader to a Premium Table that reads Please refer to the Premium Table after this section to find out the premium is in your area e The Premium Table should be located after Section II and before Section III The table must include only the plan s name number service area and premium Plans may include introductory information about the table and how to use it However no other plan information may be included with the Premium Table e Regional Copay Premium Table When Organizations or Sponsors offer plans with identical benefits in multiple regions they may create a regional copay or premium table to accompany the SB that lists the copays premiums for all regions covered Include with the table should be an instruction to members explaining how to find the co pay and premium information that applies to them The regional copay premium table and SB is required to be submitted and reviewed by CMS with an attestation that the information populated in the table is identical to what is approved in the bid SBs with only Sections I II and the Premium Table are subject to a 45 day review Requests to Change Hard Copy SB Appl
265. s or employer group plans 120 5 1 Definition of Compensation Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 a 423 2274 a For purposes of this chapter compensation includes pecuniary or non pecuniary remuneration of any kind relating to the sale or renewal of a policy including but not limited to commissions bonuses gifts prizes awards and finder s fees Compensation DOES NOT include the following note that the following list represents examples but not an all inclusive list of activities that are excluded from the definition of compensation e The payment of fees to comply with State appointment laws e Training e Certification e Testing costs e Reimbursement for mileage to and from appointments e Reimbursement for actual costs associated with beneficiary sales appointments such as venue rent snacks and materials 120 5 2 Compensation Types Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 a 3 423 2274 a 3 The regulations provide for two types of compensation initial compensation and renewal compensation Initial compensation is offered for the beneficiary s initial year of enrollment in a plan Renewal compensation is equal to fifty 50 percent of the initial compensation amount and is paid in the five 5 years following a beneficiary s initial year of enrollment in a plan It is also paid when a beneficiary enrolls in a different
266. s that may be directly or indirectly involved in marketing Medicare plans Plan sponsors should ensure that their subcontractors are not using the Medicare name in a misleading manner 30 16 Referral Programs Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 The following general guidelines apply to referral programs under which a plan sponsor solicits leads from members for new enrollees These include gifts that would be used to thank members for devoting time to encourage enrollment Gifts for referrals must be available to all members that provide a referral and cannot be conditioned on actual enrollment of the person being referred e A plan sponsor can ask for referrals from active members including names and addresses but cannot request phone numbers Plan sponsors may use member provided referral names and addresses to solicit potential new members by mail only e Any solicitation for leads including letters sent from plan sponsors to members cannot announce that a gift will be offered for a referral e Plan sponsors may not use cash promotions as part of a referral program e Plan sponsors may offer thank you gifts provided they are each individually worth 15 or less and in the aggregate for the year worth 50 or less where price is based on the retail purchase price of the item e g thank you note calendar pen key chain when an enrollee provides a referral as a result o
267. s to the CMS Regional Office Account Manager If a proposal incorporates additional State s that impact another CMS Regional Office then the Regional Office Account Manager who received the request will coordinate the review with the other affected Regions and the CMS State Representative for those State s The Regional Office Account Manager will relay CMS comments back to the plan sponsor gather revisions when necessary and finish the review and approval process based upon the plan sponsor s revisions The Regional Office Account Manager will share outreach materials with the appropriate CMS State Representatives The CMS State Representatives should at a minimum share the member letters with the State Agency as a way to verify the accuracy of the information contained in the proposal and to receive input from State partners Upon final approval of the proposal and outreach materials the Regional Office Account Manager will send an approval letter to the plan sponsor The Regional Office will then contact its partners SHIPs State Medicaid Offices to notify them of the outreach effort and possible increase in beneficiary inquiries The Regional Office will share copies of outreach letters with the State Agencies to prepare them for incoming questions 70 10 6 Reviewing Previously Approved Outreach Programs for Dual Eligibility Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 422 2264 423
268. sation requirements See 120 5 5 The amount paid to the third party for other services must be of FMV and must not exceed an amount that is commensurate with the amounts paid by the plan sponsor to a third party for similar services during each of the previous two 2 years 120 6 Activities That Do Not Require the Use of State Licensed Marketing Representatives Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2274 c 423 2274 c Some plan activities typically carried out by the plan sponsor s customer service department do not require the use of State licensed marketing representatives These include the following e Providing factual information e Fulfilling a request for materials e Taking demographic information in order to complete an enrollment application at the initiative of the prospective enrollee The examples above are legitimate customer service activities that would not require using State licensed marketing representatives To further clarify when employee customer service representatives employed or contracted agents and or external agents and brokers perform customer service functions such as answering questions and or accepting enrollments on behalf of prospective enrollees who have already decided to request enrollment in a particular plan offered by the plan sponsor these functions are considered legitimate customer service representative activities and do not trigger
269. sharing e g co payments co insurance and deductibles e Any conditions associated with receipt or use of benefits e When applicable provide the notice associated with removing a Part D drug from the Part D plan s formulary adding prior authorization quantity limits step therapy or other restrictions on a drug and moving a drug to a higher cost sharing tier This information is to be maintained on the website until the next annual mailing of the updated formulary e Process for contacting Social Security Office or Medicaid to inquire about LIS status or level 100 2 1 Pharmacy Access Information Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 120 a 1 423 128 b 5 7 9 All plan sponsors that offer Part D benefits must include the following on their website Pharmacy information as defined above in 60 60 5 7 Number of pharmacies in network How the plan meets access requirements e g lt Plan Name gt has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area Description of out of network coverage Current formulary information updated monthly based on guidance provided in 60 5 4 Drug utilization management information that is easy to understand clearly marked and easy to find Information on the plan transition process An explanation of the plan s Part D grievance coverage determination including exceptions and a
270. sponsor Business cards indicating the products for example HMO PPO or PDP that he she is selling for a specific plan or plan s are not required to be submitted to CMS for review Please note that this guidance in no way precludes the application by the plan sponsors of more stringent rules or contractual obligations in order to further restrict agent or broker communication Additionally agent brokers who wish to use materials containing plan information from multiple plan sponsors can either have the piece submitted and approved by CMS for each plan sponsor mentioned prior to use 120 5 Agent Broker Compensation Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2274 a 423 2274 a Plan sponsors are not required to use independent agents and brokers but if they do they must follow CMS rules for compensating them for the sale of Medicare products CMS has established limits on agent and broker compensation in order to ensure that compensation does not create incentives for agents and brokers to assist beneficiaries with plan selection using criteria other than the beneficiaries health care needs and preferences These limits apply to MA organizations Part D sponsors and section 1876 cost plans that market through independent brokers or agents These compensation rules are designed to eliminate inappropriate moves of beneficiaries from one plan to another These compensation rules do not apply to employed agent
271. st submit the following information to their Regional Office Account Manager In electronic format using the US Postal Service or other delivery method 1 A detailed description of each step in the outreach process and the entity responsible for each step CMS recommends a flow chart showing the result of each action A timeline showing the proposed dates of outreach activities the number of members involved in each activity and the service area e g county included in the activities This is to allow CMS to more accurately coordinate outreach activities with its partners e g SHIPs State Agencies Executed contracts with all external entities involved in the outreach process This includes contracts with any subcontractors taking part in the activities Supporting documentation from the appropriate State Agency providing specific State income requirements for each savings program level and names and contacts within the appropriate State Agency agencies Internal training programs the organization is using to educate staff involved in outreach An internal plan for protecting the confidentiality of the member s financial or other personal information gathered in the outreach process Outreach letters and other materials e g brochures Authorization to Represent form going to plan sponsor members 8 Telephone scripts or other outreach assistance scripts that will guide representatives in answering members questio
272. such relationships the plan sponsor must inform its CMS Account Manager in writing of any co branding relationships at the time that the plan sponsor begins to input the co branding relationships in the Health Plan Management System HPMS The HPMS submission module will allow plan sponsors to indicate whether they are co branding with specific entities for specific services Refer to the HPMS user manual for instructions e Any changes in or newly formed co branding relationships during the year should be communicated by the plan sponsor to its CMS Account Manager The plan sponsor should also input this information in HPMS prior to marketing its new relationship The plan sponsor should also remove any references to and former co branding partner s from its marketing materials as applicable e The plan sponsor is responsible for ensuring that its co branding partner s also adhere s to all applicable CMS policies and procedures e The plan sponsor should attest that its co branding partners were provided with these Medicare Marketing Guidelines and that the co branding partners agree to follow these guidelines with respect to all marketing materials related to the plan sponsor NOTE CMS will provide additional guidance regarding the attestation requirements between the plan sponsor and the co branding partner We anticipate releasing this requirement in the HPMS contracting module for CY 2072 In addition plan sponsors are permitted
273. t plans Because VAIS are not benefits as described within CMS regulations CMS will not require prior approval of materials solely describing VAIS If the description of the VAIS is a part of a larger marketing piece plans must submit the piece in its entirety but should make the reviewer aware of the VAIS section Since VAIS is not a benefit therefore it e May not appear in the PBP SB including section 3 ANOC or EOC Plan sponsors may include VAIS along with their ANOC SB and or EOC in one bound brochure as long as the VAIS are clearly distinct from the ANOC SB or EOC such as on a different color piece of paper and the information on VAIS includes the following disclaimer The products and services described lt below above gt are neither offered nor guaranteed under our contract with the Medicare program In addition they are not subject to the Medicare appeals process Any disputes regarding these products and services may be subject to the lt Name of Plan gt grievance process The above disclaimer should be on all marketing materials if the material mentions VAIS 120 Guidance on Marketing and Sales Oversight and Responsibilities Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2272 422 2274 423 2272 423 2274 As provided in 10 marketing includes any activity of an employee of a plan sponsor an independent agent an independent broker or other similar managerial marketing position i
274. tate s counties and zip codes only if a partial service is allowed If the Part C plan is a national plan then it must identify the states For all plan sponsors Applicable conditions and limitations Premiums Cost sharing e g co payments co insurance and deductibles Any conditions associated with receipt or use of benefits Neither CMS nor the plan sponsor has any control over the actual screen size shown on individuals computer screens that can be adjusted by the user Therefore the font requirement refers to how the plan sponsor codes the font for the Web page not how it actually looks on the user s screen Non health related products or services may not be presented as benefits Subject MustUse MustNotUse Reason For Part D plans e Name addresses phone number and type of pharmacy for all non chain pharmacies For chain pharmacies a local or toll free number and a TTY number must be provided to find the nearest chain pharmacy location Number of pharmacies in network g How the plan meets access Pharmacy List requirements e g lt Plan Name gt has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area If plan sponsors use a search engine on their websites in lieu of posting the Pharmacy Directory the search engine must be in compliance with section 100 of the Medicare Marketing Guidelines All Part D plans and PDP
275. tation 5 17 11 42 CFR 422 2262 423 2262 Plan sponsors must submit all MA and PDP websites for review Plan sponsors should submit their websites via links in a Word document for a forty five 45 day review through HPMS under category code 4006 Internet web pages CMS expects reviewers to have an opportunity to review the link s provided as the information will be displayed in the marketplace Therefore the reviewer should be able to conduct the review online using the links provided in the Word document Submitting screen shots or text in a word document is not acceptable If the option to view online is not feasible the organization should contact the Account Manager prior to submission and receive permission to submit information other than through a live link Once a plan sponsor s website is reviewed and approved in entirety a plan sponsor may update specific pages of this same website by submitting only the pages to be changed using the same submission process as described above submit a link in a Word document for a forty five 45 day review Any updates to pages should be submitted with their own unique material id and date stamped accordingly Plan sponsors should submit any previously approved web pages or sites links for review if there are any changes or updates related to Medicare or plan benefit information Plan sponsors must include a date stamp on each Web page to indicate when it was last updated Plan sponsors may mak
276. terials including enrollment communications grievance and appeals and or quality assurance SB Place Holder Sentences For MA PD and MA only Plans have the option to use the prior year s Medicare premium and deductible amounts instead of waiting for CMS to release the new year s amounts MAOs that apply the Medicare defined cost sharing for Inpatient Hospital Acute Inpatient Hospital Psychiatric and Skilled Nursing Facility may also use the prior year s Medicare cost sharing amounts Based on this option for example the SB will print both the prior year s Medicare cost sharing amounts and a place holder sentence for the new year s Medicare cost sharing amounts Plan sponsors that need to go to production prior to CMS release of the Medicare cost sharing may use the prior year s Medicare cost sharing amounts and sentences and delete the new year s placeholder sentences Plan sponsors that can wait until CMS releases the new year s Medicare cost sharing should use the new year s placeholder sentences and manually update the SB with the new year s Medicare cost sharing when the amounts are released In addition these plan sponsors should delete the prior year s Medicare cost sharing amounts and sentences Medicare Options Compare will automatically display new Medicare cost sharing amounts Instructions for Use of Premium Tables in the Summary of Benefits Applies to MA PD PDP and MA only Plans with identical benefit
277. that are enclosed with post enrollment mailings provider directory pharmacy directory must be e Related to benefit or plan operations as an enrollee in the plan e g health education newsletters Medication Therapy Management Program MTMP materials and mail service forms for Part D drugs and e Distinctly separate e g folded or different color pages from the required document within the mailing envelope Additional materials enclosed in the post enrollment mailing must not include advertising materials for example materials advertising additional products such as Medigap by the plan sponsor In addition materials must comply with all relevant laws and regulations including the Federal and any State anti kickback statute 40 14 Marketing of Multiple Lines of Business Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 423 2268 Plan sponsors may market other lines of business both health related and non health related in accordance with the requirement of this section as well as 170 40 14 1 Multiple Lines of Business General Information Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 423 2268 Plan sponsor marketing materials sent to current members describing other health related lines of business must contain instructions describing how individuals may opt out of receiving such communications Plan sponsors must make every effort to ensure that all
278. that they are complying with this requirement Oversight activities conducted by CMS will verify that plan sponsors and their agents are complying with this provision Enforcement actions will be taken against plan sponsors as necessary 70 2 2 Nominal Gift Disclaimer Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2268 423 2268 Plan sponsors must include a written statement on all materials advertising promoting drawings prizes or any promise of a free gift that there is no obligation to enroll in the plan For example e Eligible for a free drawing and prizes with no obligation e Free drawing without obligation 70 3 Unsolicited E mail Policy Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 d 423 2268 d A plan sponsor may not send e mails to a beneficiary unless the Medicare beneficiary agrees to receive e mails from the plan sponsor and the beneficiary has provided his her e mail address to the plan sponsor Furthermore e Plan sponsors are prohibited from renting and purchasing e mail lists to distribute information about MA PDP or section 1876 cost plans e Plan sponsors may not e mail prospective enrollees at e mail addresses obtained through friends or referrals e Plan sponsors must provide an opt out process for beneficiaries who no longer wish to receive e mail communications 70 4 Marketing through Unsolicited Contacts Rev 96
279. the requirements in section 70 8 e Respond to questions asked at an educational event A response by plan sponsor s representative to questions will not render the event as sales marketing provided that the scope of the response does not go beyond the question asked and no enrollment forms are neither distributed nor accepted Plan sponsors or their representatives may not e Discuss plan specific premiums and or benefits e Distribute plan specific materials e Distribute or display business reply cards scope of appointment forms enrollment forms or sign up sheets e Set up personal sales appointments or get permission for an outbound call to the beneficiary e Attach business cards or plan agent contact information to educational materials however upon a request by the beneficiary a business card can be provided e Solicit prospective beneficiaries for individual appointments under the premise that the appointment is for educational purposes The following are examples of events that are not educational and are therefore subject to all guidance noted in 70 8 e A plan sponsor advertises a presentation as educational but after the presentation the agent asks if anyone would like to hear more about any specific options available to them In this situation the entire event would be considered a marketing sales event A plan sponsor may not advertise an educational event and then have a marketing sales event immediately
280. the Rehabilitation Act A TTY number must appear in conjunction with the plan sponsors customer service number in the same font size and style as the other phone numbers Plan sponsors can either use their own TTY number or State relay services as long as the number included is accessible from TTY equipment TTY customer service numbers must be toll free Exceptions e TTY numbers need not be included on ODA or banner banner like ads e In television ads the TTY number need not be the same font size style as other phone numbers since it may result in confusion and cause some prospective enrollees to call the wrong phone number As an alternative plan sponsors are allowed to use various techniques to sharpen the differences between TTY and other phone numbers on a television ad such as using a smaller font size for the TTY number than for the other phone numbers e TTY numbers are not required in radio advertisements 40 13 Additional Materials Enclosed with Required Post Enrollment Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 423 128 Plan sponsors are permitted to enclose certain additional materials as part of required post enrollment material mailings as specified below Unless specifically directed by CMS or if the documents meet the criteria specified below plan sponsors should not include additional documents with the ANOC and or EOC mailings Any informational materials
281. ties It is important to note that the marketing guidance set forth in this document is subject to change as policy communication technology and industry marketing practices continue to evolve It is the plan sponsor s responsibility to have a system in place that ensures all materials used in the marketplace meet current regulations and guidelines Moreover the examples of marketing materials and promotional activities given in these Medicare Marketing Guidelines are not all inclusive Plan sponsors should apply the principles outlined in these Medicare Marketing Guidelines to all relevant decisions situations and materials Any new rule making or interpretative guidance e g annual call letter or Health Plan Management System HPMS guidance memoranda may update the marketing guidance provided here and plan sponsors should use sound judgment and consult with CMS Account Managers in situations where new guidance updates the guidance provided in this document Specific questions regarding a marketing material or any marketing practice should be directed to the plan s Account Manager or designated Marketing Reviewer 20 Definitions Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2 422 4 423 4 422 2260 423 2260 422 2264 423 2264 422 2268 423 2268 422 22712 423 2272 The following definitions apply for purposes of these Medicare Marketing Guidelines only Ad hoc Enrollee Communications Materi
282. time of enrollment and annually thereafter as well as upon beneficiary request whichever occurs first unless the plan sponsor uses changes pages as described in 60 4 Part D sponsors must provide information about the number mix and distribution addresses of network pharmacies from which enrollees may reasonably be expected to obtain covered Part D drugs Part D sponsors may have pharmacy directories for each of the geographic areas they serve e g metropolitan areas surrounding county areas provided that all directories together cover the entire service area The pharmacy directory must contain the following information as well as any other information located within the CMS model pharmacy directory General Disclaimers e Ifa directory is a subset of a service area Part D sponsors must include the following disclaimer This directory is for lt geographic area gt Please contact lt Plan Name gt at lt phone number gt lt days and hours of operation gt for additional information e Ifaplan sponsor lists pharmacies in its network but outside the service area Part D sponsors must include the following disclaimer We also list pharmacies that are in our network but are outside lt geographic area gt Please contact lt Plan Name gt at lt phone number gt lt days and hours of operation gt for additional information e Part D sponsors must provide a disclaimer that states the directory is current as of a pa
283. tive date of November 1 or December 1 should receive both an EOC for the current contract year and an ANOC EOC for the upcoming contract year Additionally plan sponsors must send new enrollees with an effective date of January 1 or later a standalone EOC for that contract year In the instances listed above where plan sponsors are sending the standalone EOC the document may be edited to remove all references to the ANOC In addition plan sponsors doing so do not need to resubmit the standalone EOC under a new code provided they have previously submitted a combined ANOC EOC in HPMS Regardless of the effective date the document must be provided to all new enrollees no later than ten 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the first month of enrollment whichever occurs first Plan sponsors should refer to the notification on the TRR that contains the earliest notification to identify the start of the ten 10 calendar day timeframe DE SNPs may separate the ANOC from the EOC but must send the ANOC for the upcoming coverage year to current members by September 30th and send the EOC to enrollees by December 31 Beneficiaries of employer union group plans must receive their ANOC and EOCs no later than fifteen 15 days before the beginning of the employer union sponsor s open enrollment period refer to 20 3 2 1 2 of Chapter 9 of the Medicare Managed Care Manual and 20 3 2 1 2 of C
284. tive formulary changes have occurred and that affected members will receive a hard copy of such changes website updates alone will not suffice Errata sheets must include a statement explaining that the plan will continue to cover the drugs in question for enrollees taking the drug at the time of change for the remainder of the plan year as long as the drug continues to be medically necessary and prescribed by the member s physician and was not removed for safety reasons Refer to the Prescription Drug Manual Chapter 6 Sections 30 3 3 3 and 30 3 4 1 This new requirement does not extend to mid year maintenance changes defined in 30 3 3 2 of Chapter 6 of the Prescription Drug Benefit Manual Changes to previously printed formularies resulting from mid year maintenance changes may be made at the time of the next printing This is not a substitute for the required advance 60 days notice to affected beneficiaries 60 5 4 Formularies Provided on Plan Websites Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 423 128 d 2 4i In addition to the preceding print formulary requirements plan sponsors must include their current formulary and any applicable quantity limit restrictions prior authorization criteria and step therapy criteria on their website To meet this requirement Part D plan sponsors must provide an electronic copy of the comprehensive formulary prior authorization and step therapy documents that individuals may v
285. to 90 15 for additional guidance on the MCEs After the material is approved accepted for File amp Use or deemed approved the plan sponsor should enter the actual date on the material The approval date should be the date that appears in HPMS with an approved status and the File amp Use date should be the date the material is eligible for use in the market place generally five 5 days after the piece is filed in HPMS Refer to 90 3 3 for additional guidance on deemed materials These dates should appear on the material as they do in HPMS i e include month day and year If the material is deemed approved the plan sponsor will change the term CMS Approved to Deemed on its material master copy internal system and show the deemed date which is obtained from HPMS For example H1234_0021 Deemed 03152010 The plan sponsor does not resubmit the material in HPMS solely to include the CMS approval File amp Use or deemed date 40 1 1 Marketing Material Identification Number for Non English or Alternate Format Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 e 423 2264 e Non English or alternate format materials must be given a unique material ID When submitting the materials plan sponsors must utilize the proper dropdown menu in HPMS to designate that they are non English versions Refer to 90 11 and the HPMS Marketing Module User Guide for further guidanc
286. to plan sponsors by qualified State Pharmaceutical Assistance programs SPAPs and auto enrollments facilitated enrollments and reassignments effectuated by CMS Please note that if an individual with LIS makes an enrollment request that supersedes or changes a CMS generated enrollment and that election is effectuated by an agent or broker the outbound verification requirements apply Plan to plan switches within an MA or Part D parent organization both contract to contract and within contract require outbound enrollment verification if the enrollment request involves a change in plan type or plan product e g HMO to PPO SNP HMO to non SNP HMO Plan to plan switches within an MA or Part D parent organization involving the same plan type or product type e g PFFS to PFFS DE SNP to DE SNP PDP to PDP are not subject to OEV requirements Plan sponsors may continue to use existing scripts provided that they convey the information included in the most up to date model script New or revised scripts must be submitted to CMS through the normal process for approval We expect plan sponsors to make a minimum of three documented attempts to contact the applicant by telephone within fifteen 15 calendar days of receiving the enrollment request If the enrollment application is received incomplete we expect plan sponsors to concurrently conduct the outbound verification calls while obtaining completed information for the application Plan spons
287. ts products or services are Medicare approved Co branded marketing materials must be compliant with the Medicare Marketing Guidelines and must be submitted to CMS by the plan sponsor Plan sponsors may elect to submit co branded materials as template materials 30 3 2 Co Branding with State Pharmaceutical Assistance Programs SPAP Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 A plan sponsor s logo may be used in connection with the coverage of benefits provided under an SPAP and may contain an emblem or symbol indicating such a connection The decision to co brand with SPAPs resides with the plan sponsor There is nothing in the statute that requires the plan sponsor to add the SPAP emblem to its card Therefore if an SPAP approaches a plan sponsor to request that its emblem or symbol be placed on the cards as well as other marketing materials the plan sponsor may decide not to co brand States have asked if they can choose which plan sponsors to co brand with or if they must offer to co brand with all plan sponsors CMS believes that SPAPs should offer co branding of materials including the identification card to all plan sponsors covering the service area of the SPAP It is entirely the plan sponsor s decision whether or not to co brand with the SPAP If a plan sponsor approaches the State to co brand the SPAP may do so It should be noted that both the SPAP and the Part
288. ttp www cms gov manuals downloads mc86c04 pdf 70 Rewards and Incentives Promotional Activities Events and Outreach Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 70 1 General Guidance about Promotional Activities Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Promotional activities including provider promotional activities must comply with all relevant Federal and State laws Plan sponsors may be subject to compliance and or enforcement actions if they offer or give something of value to a Medicare beneficiary that the plan sponsor knows or should know is likely to influence the beneficiary s selection of a particular provider practitioner or supplier of any item or service for which payment may be made in whole or in part by Medicare Marketing representatives must clearly identify the types of products that will be discussed before marketing to a potential enrollee This includes all sales presentations events appointments and outbound calls that are designed to promote or encourage a beneficiary to enroll in a plan Additionally plan sponsors are prohibited from offering rebates or other cash inducements of any sort to beneficiaries Furthermore plan sponsors are prohibited from offering or giving remuneration to induce the referral of a Medicare beneficiary or to induce a person to purchase or arrange for or recommend the purchase or orde
289. ubmit informational copies of their dissemination materials to CMS at the time of use However as a condition of CMS providing these particular waivers or modifications CMS reserves the right to request and review these materials in the event of beneficiary complaints or for any other reason it determines to ensure the information accurately and adequately informs Medicare beneficiaries about their rights and obligations under the plan For more information about these requirements refer to 20 3 2 1 1 of Chapter 9 of the Medicare Managed Care Manual and 20 3 2 1 1 of Chapter 12 of the Prescription Drug Benefit Manual In addition to the guidance specific to marketing materials much of the procedural guidance as outlined in this chapter is also applicable to employer plans Please reference the grid below for further guidance on the applicability of the various requirements Table 130 1 Marketing Provisions Employer Union Group Plans Marketing Provisions that apply to Employer Union Group Plans these requirements are applicable for the transaction between the agent broker selling the plan to the employer union All activities conducted by the employer union or its designees to sign up individual employees to the plan s selected by the employer union are excluded from these provisions Provision Yes No Nominal Gifts X Unsolicited Contacts Cross selling PS lt Scope of Appointments Sale
290. ubsequent years the compensation amount paid to an agent or broker for enrollment of a Medicare beneficiary into a plan sponsor s plan is as follows For an initial enrollment the prior year s initial compensation adjusted by the change in MA or Part D rates announced in the Announcement of Calendar Year Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies for that contract year For renewals an amount equal to fifty 50 percent of the initial compensation The broker or agent is paid a renewal compensation for each of the next five 5 years the enrollee remains in the plan in an amount equal to fifty 50 percent of the initial year compensation amount creating a six 6 year compensation cycle Plan sponsors with plans for which they created compensation schedules in prior years can only adjust existing compensation schedules they may not create any new compensation schedules for those plans New compensation schedules no schedules existed for prior years are allowed For plans that did not exist in prior years by selecting a compensation amount that is at or below the adjusted fair market value cut off amounts For plans that existed in prior years but did not have an associated compensation schedule i e the plan chose to compensate 0 for enrollments in that particular product by selecting a compensation amount that is at or below the adjusted fair market value cut off amount Plan
291. ucation of beneficiaries and other interested parties The materials must meet the definition of educational See 70 7 for more information on educational material e Coordination of Benefits notifications as provided in 50 2 of Chapter 14 of the Medicare Prescription Drug Benefit Manual e Health Risk Assessments e Mail order pharmacy election forms e Other member surveys e VAIS refer to 110 90 22 Submission of Multi Plan Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2262 423 2262 CMS will issue guidance on a multi plan material submission process 100 Special Guidance on Plan Sponsor Websites Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 508 of the Rehabilitation Act 29 U S C 794d as amended by the Workforce Investment Act of 1998 P L 105 220 August 7 1998 All plan sponsors are required to have an Internet website that is compliant with web based technology and information standards for people with disabilities as specified in section 508 of the Rehabilitation Act For additional information please go to the following website address http www section508 gov 100 1 Plan Sponsor Website Requirements Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2264 a 423 2264 a All plan sponsors including section 1876 cost plans must have a website or web page dedicated to each product
292. uch as a business card that the individual may give to the friend or family member In all cases a referred beneficiary needs to contact the plan or agent broker directly A call from an agent or plan sponsor to a beneficiary who was referred would be considered an unsolicited contact e Calls to former members who have disenrolled or to current members who are in the process of voluntarily disenrolling to market plans or products except as permitted below Members who are voluntarily disenrolling from a plan should not be contacted for sales purposes or be asked to consent in any format to further sales contacts e Calls to beneficiaries who attended a sales event unless the beneficiary gave express permission at the event for a follow up call including a completed scope of appointment form e Calls to beneficiaries to confirm receipt of mailed information except as permitted below Plan sponsors may do the following e Contact beneficiaries who submit enrollment applications to conduct quality control and agent broker oversight activities Scripts for this purpose like all other call scripts must be submitted to CMS for review and approval e Contact their members or use third parties to contact their current members Examples of allowed contacts include but are not limited to calls to members aging in to Medicare from commercial products offered by the same sponsoring organization and calls to an organization s existing Medica
293. use the plan was not able to verify eligibility information In March the plan receives the necessary information to verify the enrollment The beneficiary is re enrolled in the plan The plan must pay the agent for the entire time the beneficiary is enrolled in the plan including when enrollment is retroactive Example Table 3 Enrollment Effective Disenrollment Effective 2 Enrollment Effective Date Date Date i March 1 Beneficiary 1 January 1 January 20 retroactive to January 1 Pays agent for entire Pays agent for entire Recovers payment due 28 Plan K ak year because the year to rapid disenrollment retroactive enrollment Beneficiar Mareh 2 Y January 1 January 20 retroactive to January 1 Pays agent for January Pays agent for first Recovers payment for Pep itlaly and March Plan K YS a8 pay and continues making month first month payments each month that the beneficiary remains in the plan Example 4 A beneficiary enrolls in Plan A with an effective date of January 1 In May the beneficiary enrolls into Plan B In October the beneficiary decides to change plans again This time the beneficiary enrolls in Plan Z Plan A is responsible for paying the agent through April Plan A must recover any payments made that cover May through December Plan B is responsible for paying compensation for May through September Plan B should not have paid anything
294. ust send a complete directory of providers pharmacists to their members at the time of enrollment and annually unless the plan sponsor uses change pages If using the change pages plan sponsors must send a complete directory of providers and or pharmacists to their members at the time of enrollment and at least every three years from the enrollment date or from the date of the last mailing whichever occurs first Plan sponsors including section 1876 cost contractors that have an Internet website must also post copies of their Evidence of Coverage SB and information on the network of contracted providers and pharmacies names addresses phone numbers and specialty on that website NOTE Employer Union only Group Waiver Plans EGWP can direct members to their employer for information on the available providers Employer Union only Group Waiver Plans EGWP must comply with both requirements to mail provider directories and post directories on their plan website Change pages constitute either the actual page being changed or a list of changes with referenced pages If a plan sponsor chooses to send change pages to members the following requirements will also apply e Change pages should be issued when there is an update to the directory e Change pages must be dated e Change pages should be submitted for forty five 45 day review e Plan sponsors may choose to disseminate an errata sheet or addendum during the year to update members
295. ution of the Part D contract PDP and MA PD entities may use the mark on submission of marketing materials consistent with this chapter 150 2 Use of Medicare Prescription Drug Benefit Program Mark on Items for Sale or Distribution Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 Section 1140 of the Social Security Act All PDP and MA PD entities may use the Medicare Prescription Drug Benefit Program Mark on items they distribute provided the item s follow s guidelines for nominal gifts as provided in 20 and 70 2 Items with the Medicare Prescription Drug Benefit Program Mark cannot be sold for profit 150 3 Approval to Use the Medicare Prescription Drug Benefit Program Mark Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 Section 1140 of the Social Security Act CMS has established the following process to grant authorized users the use and access to the Medicare Prescription Drug Benefit Program Mark on Part D marketing materials For those organizations that have received approval of a Part D plan via HPMS contract approval process CMS will distribute the Medicare Prescription Drug Benefit Program Mark licensing agreement to those entities After CMS has received the signed licensing agreement back from the organizations and the contract document for the upcoming year has been counter signed the Medicare Mark URL will be sent to the organizations After receipt of the URL organizat
296. v 93 Issued 06 04 10 Effective Implementation 06 04 10 42 CFR 422 2264 423 2264 422 2268 423 2268 In order not to be considered misleading product endorsements and testimonials must adhere to the following guidelines e Content of product endorsements and testimonials including statements by plan members must comply with the Medicare Marketing Guidelines e The speaker must identify the plan sponsor s product by name e A Medicare beneficiary may offer endorsement of a plan or promote a specific product provided the individual is a current member of the plan being endorsed or promoted If the individual is paid to endorse or promote the plan or product this must be clearly stated e g paid endorsement e If an individual such as an actor is paid to portray a real or fictitious situation the ad must clearly state it is a Paid Actor Portrayal e Product endorsements and testimonials cannot e Use any quotes including anonymous or fictitious quotes by physicians health care providers and or by Medicare beneficiaries not enrolled in the plan e Use negative testimonials about other plans CMS may ask for a list of testimonials and release forms prior to reviewing approving a material and plan sponsors are expected to comply with any requests for such information 40 11 Customer Service Call Center Hours of Operation Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 4
297. velope letter size envelope and box the envelope with each mailing statement only needs to be submitted once provided the required mailing statement remains unchanged and additional information is not included NOTE Plan sponsors are not required to include the material ID on envelopes however all envelopes must be submitted with an associated marketing material ID number 60 Specific Guidance on Required Documents Rev 93 Issued 06 04 10 Effective Implementation 06 04 10 60 1 Summary of Benefits SB Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 111 b 2 422 11 1 f 423 128 b 2 The SB is the stand alone pre enrollment document used to inform prospective as well as existing enrollees of the benefits offered by the plan sponsor The SB is a synopsis document and therefore is not intended to include benefit information in the same detail as the Evidence of Coverage The information within the SB is standardized language to allow beneficiaries to more easily compare the benefits offered by different plan sponsors and includes the following sections e Section I The introduction and the beneficiary information section which informs prospective enrollees of important aspects of enrolling in the plan This section is standardized language that should not be modified except as indicated in the SB instructions e Section II The benefit comparison matrix which is an output report o
298. via the Internet 100 5 1 Required Materials When Online Enrollment is Utilized 110 Guidance about Value Added Items and Services 110 1 Definition of Value Added Items and Services VAIS 120 Guidance on Marketing and Sales Oversight and Responsibilities 120 1 Compliance with State Appointment Laws 120 2 Plan Reporting of Terminated Agents 120 3 Agent Broker Training and Testing 120 4 Agent Broker Use of Marketing Materials 120 5 Agent Broker Compensation 120 5 1 Definition of Compensation 120 5 2 Compensation Types 120 5 3 Compensation Cycle 6 Year Cycle 120 5 4 Specific Guidance for Developing and Implementing Compensation Strategy 120 5 4 1 Additional Marketing Fees 120 5 5 Compensation Calculation 120 5 6 Specific Guidance for Recovering Compensation Payments Charge backs 120 5 7 Adjustments to Compensation Schedules 120 5 8 Third Party Marketing Entities 120 6 Activities That Do Not Require the Use of State Licensed Marketing Representatives 130 Guidelines Applicable to Employer Union Group Health Plans 140 Special Guidance for Medicare Medical Savings Account MSA Plans 140 1 MSA General Advertising Materials 140 2 MSA Explanatory Marketing Materials Requirements 150 Use Of Medicare Mark For Part D Plans 150 1 Authorized Users for Medicare Mark 150 2 Use of Medicare Prescription Drug Benefit Program Mark on Items for Sale or Distribution 150 3 Approval to Use the Medicare Prescript
299. vice Providing Third Party Marketing Materials Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Non benefit service providing third party entities are organizations or individuals that supply non benefit related information to Medicare beneficiaries or a plan sponsor s membership which is paid for by the plan sponsor or the non benefit service providing third party entity Example A A company that promotes health and wellness and develops materials targeted to the Medicare population CMS would not normally review materials created by health and wellness companies because plan sponsors are responsible for determining whether these materials meet the MMG requirements Example B An individual that provides summaries of plan sponsors or highlights plans using CMS statistical data or other research data sources available to them and offers their services and or materials to the plan sponsors The plan sponsor would distribute or allow the non benefit servicing third party individual to distribute the materials to their plan membership and or to prospective enrollee CMS would not review materials created by the individual and plan sponsors are responsible for determining whether these materials meet the MMG requirements If a non benefit service providing third party wishes to develop and or provide information to a plan sponsor s members and or prospective enrollees it must submit its mat
300. vider Directories 60 4 3 Primary Care Provider PCP and Specialty Directories 60 4 4 Combined Provider Pharmacy Directory 60 4 5 Mailing the Provider Pharmacy Directory to Addresses with Multiple Members 60 4 6 Changes to Provider Network 60 5 Formulary and Formulary Change Notice Requirements 60 5 1 Abridged Formulary 60 5 2 Comprehensive Formulary 60 5 3 Changes to Printed Formularies 60 5 4 Formularies Provided on Plan Websites 60 5 5 Other Formulary Documents 60 5 6 Provision of Notice to Beneficiaries Regarding Formulary Changes 60 5 7 Provision of Notice to Other Payers Regarding Formulary Changes 60 6 Part D Explanation of Benefits 60 7 Annual Notice Of Change ANOC and Evidence of Coverage EOC 60 8 Mid Year Changes Requiring Enrollee Notification 70 Rewards and Incentives Promotional Activities Events and Outreach 70 1 General Guidance about Promotional Activities 70 1 2 General Guidance about Rewards and Incentives 70 2 Nominal Gifts 70 2 1 Exclusion of Meals as a Nominal Gift 70 2 2 Nominal Gift Disclaimer 70 3 Unsolicited E mail Policy 70 4 Marketing through Unsolicited Contacts 70 5 Specific Guidance on Telephonic Contact 70 5 1 Specific Guidance on Third party Contact 70 6 Outbound Enrollment and Verification Calls to New all Enrollees 70 7 Educational Events 70 8 Marketing Sales Events 70 8 1 Notifying CMS of Scheduled Marketing Events 70 9 Personal Individual Mark
301. who have signed contracts with our plan for full network PFFS plan insert all services covered under Original Medicare partial network PFFS plans should indicate the category or categories of services for which network providers are available These providers have already agreed to see members of our plan If your provider is not one of our network providers then the provider is not required to agree to accept the plan s terms and conditions of payment they may choose not to provide health care services to you except in emergencies If this happens you will need to find another provider that will accept our terms and conditions of payment Providers can find the plan s terms and conditions of payment on our website at insert link to PFFS terms and conditions of payment All marketing representatives selling PFFS plans are required to verbally read or state this disclaimer during sales presentations in public venues and private meetings with beneficiaries PFFS plans are prohibited from using any materials or making any presentations that imply PFFS plans function as Medicare supplement plans or use terms such as Medicare Supplement replacement MA organizations may not describe PFFS plans as plans that cover expenses that Original Medicare does not cover nor as plans that offer Medicare supplemental benefits However it is permissible for PFFS plans to clarify that the plan does not pay after Medicare pays its share rather
302. xample Y1234_drugx38 CMS Approved MMDDYYYY This third part of the identifier must be included on the material but is not required to be included in the material ID that is submitted into HPMS The unique material ID must be printed on the front page of all materials including the SB and ANOC EOC The ID should be positioned in the lower left or right hand corner on the front page of the material and be in twelve 12 point font PDPs and MA PD plans must include the CMS contract number and PBP number on the membership identification card as well as other required information as outlined in the Medicare Marketing Guidelines The marketing material ID is therefore not needed on the member ID card Additionally envelopes television and radio ads outdoor advertisements and banner or banner like ads including Internet banner ads are not required to include the material ID All other materials should have the material ID which includes the placeholder for a CMS approval or File amp Use date Use of the contract number 1 e H R or S will allow the plan sponsor to submit marketing material that applies to only one contract while use of the MCE identifier of Y will allow the plan sponsor to submit marketing material that applies to multiple contract numbers When submitting material using the MCE identifier plan sponsors are not required to include the individual contract numbers in the material ID to which the material applies Refer
303. y opts in the plan sponsors must be clear that the beneficiary will receive additional information that may be non plan or non health related e Beneficiaries can complete authorization in person at marketing events health fairs or other public venues e Beneficiaries can complete the authorization over the telephone provided that the authorization is recorded The call must be a beneficiary initiated inbound telephone call and scripts for such calls must comply with all guidance in 80 e Beneficiaries can complete the authorization via an email to the plan provided that the authorization includes an electronic signature Regardless of the method by which the prior authorization is obtained e g written telephonic on a website the following rules apply e The request may include one or more types of information for which authorization is being sought If more than one type of information is on the form a check box or verbal agreement if a telephonic authorization needs to be assigned to each type of information Furthermore the type of information can only be described in general terms For example Check the boxes of the types of information you would like to receive life insurance long term care insurance pending State and Federal legislation grass roots advocacy e The request for authorization should not include any non plan or non health related content nor should it be included in the same mailing as info
304. y administrative costs in providing the VAIS the market value of the VAIS has no limit However if the plan links the VAIS to appreciation for the plan e g the plan when notifying current enrollee s states that the VAIS is done in appreciation for joining the plan then VAIS must be treated as a promotional item In particular the market value of the VAIS must comply with the nominal value requirements described in 70 2 70 1 2 General Guidance about Rewards and Incentives Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Plan sponsors may only offer rewards and incentives to plan enrollees to promote one of the following target activities Welcome to Medicare visit includes a referral for an ultrasound screening for abdominal aortic aneurysm for eligible beneficiaries Adult Wellness visit Any combination of the following adult Immunization influenza pneumococcal and Hepatitis B vaccination In other words a plan may target for a reward and incentive all three enumerated adult immunizations or they may chose to target for a reward and incentive only one or two of the adult immunizations Colorectal Cancer Screening Screening Mammography Screening Pap Test and Pelvic Examination Prostate Cancer Screening Cardiovascular Disease Screening Diabetes Screening Glaucoma Screening Bone Mass Measurement Diabetes Self Management Supplies and Services Medic
305. y can obtain a comprehensive formulary by contacting the Part D plan Drugs adjudicated at the point of sale as formulary drugs that are not found on the CMS approved HPMS formulary must be included in the comprehensive formulary This may include drugs that are not found on the CMS approved HPMS formulary as described in 60 5 60 5 3 Changes to Printed Formularies Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 423 128 a c Beneficiaries have a legitimate expectation that they will have access to the drugs included in marketed formularies While Part D sponsors can readily update their online formularies the same is not true for printed formularies provided to plan enrollees Given the bait and switch nature of mid year non maintenance formulary changes defined in 30 3 3 3 of Chapter 6 of the Prescription Drug Benefit Manual beginning in contract year 2010 Part D sponsors will be expected to update all impacted abridged and comprehensive printed formularies with any CMS approved non maintenance formulary changes Part D sponsors may make any necessary formulary changes via errata sheets mailed to affected members While Part D sponsors retain the flexibility to utilize other processes for notifying beneficiaries of non maintenance changes to their printed formularies CMS expects Part D sponsors to send out errata sheets with formulary changes no less than monthly to the extent that any nega
306. y 1 the plan sponsor must pay the agent broker at the initial compensation level during that calendar year but may pay either the full commission or a pro rated amount based upon the number of months the beneficiary was enrolled The plan sponsor has the discretion to provide this compensation in a single payment or multiple payments at anytime during the year Compensation of the agent broker for the remainder of the six 6 year commission cycle must be at the renewal commission level The renewal commission may also be paid at any time during each year of the cycle and may be paid in a single payment or multiple payments For the purpose of calculating compensation the movement by a beneficiary from an employer group plan to an individual plan either within the same plan sponsor or between different plan sponsors counts as an initial enrollment Plan sponsors must not pay agents who are no longer appointed to sell in the State if required agents who have not been annually trained and tested per the plan s policies and procedures with a passing score of eighty five 85 percent or agents who have been terminated for cause by the plan CMS does not differentiate between agents brokers general agents general agencies 7MOs and distribution partners It is the plan sponsor s responsibility to ensure that all of its contracted sales staff s compensation levels abide by CMS rules CMS compensation requirements do not apply to employed
307. y CMS as sales marketing events See also 70 9 However one on one appointments are not entered into the marketing events module There are two main types of marketing sales events formal and informal Formal marketing sales events are typically structured in an audience presenter style with a sales person or plan representative formally providing specific plan sponsor information via a presentation on the products being offered In this setting the presenter usually presents to an audience that may have been invited to attend Informal marketing sales events are conducted with a less structured presentation or in a less formal environment They typically utilize a table kiosk or a recreational vehicle RV that is manned by a plan sponsor representative who can discuss the merits of the plan s products NOTE If an event is scheduled as a marketing sales event then requirements for marketing sales events must be met even if only one person is in attendance at the event Plan sponsor marketing of non health care related products such as annuities and life insurance to prospective enrollees during any MA or Part D sales activity or presentation is considered cross selling and is a prohibited activity See 40 4 At marketing sales events plan sponsors may e Discuss plan specific information e g premiums cost sharing or benefits e Distribute health plan brochures and enrollment materials e Accept and perform enrollments
308. y placing the SNP affiliations at the beginning of the announcement and may include specific information about the SNP This includes providing information on special plan features the population the SNP serves or specific benefits for each SNP The announcement must list all other SNPs with which the provider is affiliated 70 12 5 Comparative and Descriptive Plan Information Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Providers may distribute printed information provided by a plan sponsor to their patients comparing the benefits of all of the different plans with which they contract Materials may not rank order or highlight specific plans and should include only objective information Such materials must have the concurrence of all plan sponsors involved in the comparison and must be approved by CMS prior to distribution e g these items are not be subject to File amp Use The plan sponsor must determine a lead plan to coordinate submission of these materials refer to 90 2 for more information on submission of marketing materials 70 12 6 Comparative and Descriptive Plan Information Provided by a Non Benefit Service Providing Third Party Rev 96 Issued 5 17 11 Effective 5 17 11 Implementation 5 17 11 42 CFR 422 2268 423 2268 Providers may distribute printed information comparing the benefits of different plan sponsors all or a subset in
309. y way unless otherwise directed by CMS Plan may use the following disclaimers in Section IV of the SB 1 Applies to all dual SNPs that cover all duals The services listed below are available only to those SNP members eligible under Medicaid for medical services 2 Applies to fully integrated SNPs that have integrated benefits in SB Section II Many of the services that are covered by Medicaid are also covered by Medicare through your Medicare Advantage SNP These services are not listed below Only the services that may continue when Medicare coverage ends or which are not covered by Medicare are shown Fully Integrated DE SNPs For fully integrated DE SNPs that meet requirements I IV CMS will allow plans to modify Section II of the SB to reflect integrated benefits applicable to each benefit category 1 Provides dually eligible beneficiaries access to Medicare and Medicaid benefits under a single managed care organization MCO 2 Has acontract with a state Medicaid agency that includes coverage of specified primary acute and long term care benefits and services consistent with State policy under risk based financing 3 Coordinates the delivery of covered Medicare and Medicaid health and long term care services using aligned care management and specialty care network methods for high risk beneficiaries and 4 Employs policies and procedures approved by CMS and the state to coordinate or integrate member ma

Chapter 3 – Medicare Marketing Guidelines

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Chapter 3 – Medicare Marketing Guidelines