MA plans must follow marketing regulations or risk a shutdown

AS IF OPERATING a Medicare Advantage plan weren't complex enough, MA plan sales efforts can only take place within a very short window of time-October 1 through December 7-according to federal regulations. Plans that do not adequately manage the compliance requirements for marketing can quickly find themselves in hot water with regulators from the Centers for Medicare and Medicaid Services (CMS).

In 2007, seven large plans, which had about 90% of enrollments in Medicare private fee-for-service plans, had to suspend marketing because of compliance violations. More recently, individual plans have gotten into trouble for marketing issues. For example, Universal American was sanctioned for its marketing practices and forced to suspend enrollment. The plan was charged with not monitoring its sales staff, who provided misleading information about network providers and which drugs were included in the plan's formulary.

To avoid regulatory shut down of enrollment or marketing efforts, plans must carefully develop a range of best practices for balancing compliance requirements and marketing needs.

"Regulations are there to protect Medicare-eligible people from bad actors, and because of that, they have become much more stringent about how we communicate to make sure that people are in the right plan and have a good understanding of the benefits they are using," says Margaret Martin, director of Medicare operations at MVP Healthcare in Rochester, N.Y.

CMS itself has a Medicare Part D plan finder that includes a potential member's out-of-pocket costs based on the specific drugs they take and the plans available in their area. The site also tells potential members about each plan's quality with a five-star rating system.

"We take the CMS regulations to be well-intentioned even if we don't agree with them all the time and even when they cause difficulty for us," says Hans Eckardt, vice president of marketing for SCAN Health Plan in Long Beach, Calif.

Marketing must be part of a larger strategic plan that is determined in advance of open enrollment season. The ultimate responsibility for compliance is on the plan itself.

"If you don't have a well developed and managed plan, compliance with the Medicare marketing guidelines can be daunting," says Edward L. Stubbers, the vice president of compliance for Wellpoint. "However, if you read and understand the intent behind the guidelines and design your processes accordingly, then compliance becomes second nature."

"As CMS moves toward basically scripting what they want us to say, it can be very challenging if someone asks a question that is not in the CMS script," says Mitchell. "In these cases, we need to be responsible and educated enough to explain a very layered and complicated topic in a simple way that people can use and understand. That is where we spent a lot of our training resources."

To get a sense of what issues trigger CMS action, plan executives can monitor what has gotten other plans into trouble-such as misleading information on network providers-and then take steps to avoid the same mistakes.

SCAN Health Plan is using its community van to provide education and other programs and recruits a group of senior advocates-members of Medicare Advantage plans themselves-welcome new members and provide feedback. Member retention is a goal for most plans.

"When you have a question or if there is a slip up or issue, it is important to be proactive and communicate with CMS to resolve it," says Armao.

The key is to plan ahead in order to leave time for CMS feedback or consultation. This CMS relationship can yield other benefits throughout the marketing and compliance process.

Joanne Sammer is a freelance writer based in Brielle, N.J.