Surveillance, Compliance, and Marketing Christine Reinhard

1. Surveillance, Compliance, and MarketingChristine Reinhard

2. Agenda Agent/Broker Audit Annual Notice of Change/Evidence of Coverage Surveillance

3. Audit Protocol (con�t) Licensure/Appointment Was agent properly licensed/appointed prior to enrollment application Testing/Training Was agent trained and tested prior to enrollment application Did agent pass the test with at least an 85% rate

4. 2011 Agent/Broker Audit Protocol Six areas of review Licensure/Appointment Testing/Training Initial/Renewal Payment Recoupment for Rapid Disenrollment OEV Calls Complaint Resolution

5. Audit Protocol (con�t) Initial/Renewal compensation Did the sponsor pay the correct amount based on type of enrollment Did the sponsor ensure payment was not made or recouped for cancelled enrollments Rapid Disenrollment Recoupment Did the sponsor recoup the entire payment

6. Audit Protocol (con�t) OEV Calls Were the OEV calls made within the 15 day timeframe? Did a letter go out after the first unsuccessful attempt? Did the customer service rep discuss all topics?

7. Audit Protocol (con�t) OEV Calls Did the customer service representative answer member questions or transfer appropriately? Did the customer service representative cancel the enrollment, if applicable?

8. Audit Protocol (con�t) Complaints Did the sponsor fully investigate the complaint? Did the sponsor resolve the issue?

9. Audit Results Licensure/Appointment Sponsors performed well Training/Testing Sponsors performed well Quality of training/testing could be improved Ensure agent is taking online test

10. Audit Results (con�t) Initial/Renewal Payment Generally sponsors performed well When initial payment is split, ensure agent should still receive 2nd payment (member not dis-enrolled) Recoupment for Rapid Disenrollment Generally sponsors performed well Ensure entire payment is recouped

11. Audit Result (con�t) OEV Calls Calls did not address all required sections of script Member questions were not answered All three calls were not made within 15 days Letters were not sent following first failed attempt

12. Audit Results (con�t) Complaints Thorough investigation not performed Beneficiary was not �made whole� Lack of appropriate action taken against agent

13. Recommendations and Reminders (con�t) Agent Training/Testing and Oversight Ensure training and testing and testing programs are designed in a way that integrity and quality is maintained Ensure processes are in place for re-training and instances when test is failed Ensure appropriate documentation is available that agent has been trained and passed the test

14. Recommendations and Reminders Compensation CMS does not differentiate between agents, brokers, general agents, general agencies, TMOs, and distribution partners. Plan sponsor must ensure that all of its independent agent compensation levels abide by CMS rules. Plan sponsors may not pay compensation in advance (e.g., paying 5 years residuals up front)

15. Recommendations and Reminders OEV Calls Regularly listen to OEV calls to ensure quality Develop process for linking issues on OEV calls back to marketing/sales Address beneficiary needs on call Ensure calls are completed within 15 calendar days of receiving the enrollment request

16. Recommendation and Reminders (con�t) OEV Calls (con�t) Ensure letters are sent out prior to the 2nd attempt Ensure plan sponsor�s sales staff obtain the best number to be used for verification Ensure the script and verification provides cancellation process Ensure CSRs follow the CMS-approved script

17. Recommendations and Reminders (con�t) Complaints Fully investigate complaint Take appropriate action against agent/broker Track/trend complaints Ensure policy and procedures include coordination across departments within organization Perform root cause analysis

18. Annual Notice of Change/Evidence of Coverage Due to members by September 30, 2011 ANOC/EOC documents must be: Timely Accurate

19. Annual Notice of Change/Evidence of Coverage All organizations required to review materials for accuracy Submission of errata sheets timely Notification to AM of inaccuracies

20. Annual Notice of Change/Evidence of Coverage CMS will continue to review timeliness and accuracy Compliance Notices Civil Money Penalties

21. Contract Year 2012 Surveillance Marketing begins October 1, 2011 Secret Shopping Unreported Marketing Events Surveillance Marketing Allegation Response Team

22. Contract Year 2012 Surveillance HPMS Module Continuous shopping Information provided on a flow basis

23. CY2012 Surveillance Responding to Marketing Allegations Five business days to respond Detailed explanation for each individual allegation Provide HPMS Marketing ID numbers for document review Note additional materials available where appropriate

24. Contacts Camille Brown camille.brown@cms.hhs.gov 410-786-0274 marketingpolicy@cms.hhs.gov Christine Reinhard christine.reinhard@cms.hhs.gov 410-786-2987 surveillance@cms.hhs.gov