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The Centers for Medicare & Medicaid Services (CMS) has established guidelines and regulations that agents and brokers are required to adhere to before assisting consumers with selecting and enrolling in qualified health plans (QHPs) or Medicare products. These guidelines apply in the following areas:
CMS considers all insurance agents and brokers to be TPMOs. Agents and brokers must add the TPMO disclaimer to their website, email communications, and all marketing materials, including print and TV ads. When conducting lead-generating activities, agents and brokers must disclose to the beneficiary that their information will be provided to a licensed insurance agent for future contact, or that the beneficiary is being transferred to a licensed insurance agent who can enroll them into a new plan.
Agents should record calls (including video calls) with Medicare beneficiaries in their entirety. Examples include introductory calls to inform or educate clients about Medicare Advantage and Prescription Drug plans, subsequent calls when the beneficiary makes an enrollment decision, and post-enrollment discussions, including retention-marketing calls that influence a beneficiary to stay enrolled in a current plan. Agents do not need to record conversations when meeting with the beneficiary in person.
While agents are permitted to make unsolicited direct contact with potential enrollees via email, the email must have an opt-out option in order to remain compliant. Additionally, the content of any unsolicited email cannot intend to steer a recipient into choosing or retaining a plan — a compliant email would promote the agent's services rather than any specific plans. Agents are not allowed to approach potential enrollees in common areas, make unsolicited phone calls, or go door to door.
A Scope of Appointment (SOA) is a form outlining exactly what the agent will be presenting to a client during a meeting. The SOA ensures that potential enrollees will not be pitched plans other than those they originally requested.
Every Medicare sales appointment requires an SOA, whether the meeting occurs in person or remotely. Per CMS, agents must keep SOA forms on file for at least 10 years, even if the appointment didn't end in a sale. The SOA will be valid for 12 months or until it is utilized, and the agent will need to obtain a new one if the original expires.
The agent must wait 48 hours between obtaining an SOA from a client and the appointment. Exceptions to this rule include when a beneficiary is no more than 4 days from the end of a valid enrollment period (e.g., Annual Enrollment Period, Open Enrollment Period, Special Enrollment Period, Initial Coverage Election Period) or unscheduled in-person meetings (walk-ins) initiated by the beneficiary.
CMS regulates marketing and plan presentations, including when agents and brokers are allowed to market and how to go about it. Agents must wait until October 1 to begin marketing next year's plans to potential beneficiaries, and cannot enroll members until October 15. During presentations, agents should never attempt to mislead clients, willingly or unwillingly — for example, agents should stay away from using absolutes and superlatives to describe plans and benefits, and avoid showing favoritism between carriers or plans.
Agents typically host three types of events: educational events, sales events, or individual appointments. Educational events must be advertised as such and be designed to inform Medicare beneficiaries about the parts of Medicare in general. When holding an educational event, an agent may:
Agents must not:
Consumer-facing websites that promote a specific carrier's Medicare Advantage or Part D products must be submitted to CMS for approval.
CMS secret shoppers measure the quality of service and compliance with Medicare regulations as a way to gather specific information about products and services. These secret shoppers are looking to make sure agents are compliant not only during the annual enrollment period, but any time they communicate with customers.