As an insurance agent, you always have your compliance radar on (or at least you should) making sure that everything you do for your clients and business is legal, fair, and according to CMS regulations. We know compliance is a daunting buzzword in the senior insurance industry, but it doesn’t have to be so complicated or overwhelming. If you are unsure about compliance or need a refresher, we’ve got your back!

What is compliance?

Compliance refers to an agent’s (or other personnel’s) ability to adhere to the rules and regulations put in place by CMS. When you are non-compliant, this means you have committed a CMS violation.

What is CMS?

CMS stands for Centers for Medicare & Medicaid Services. CMS is essentially the governing body over Medicare, Medicaid, and other Insurance programs.

What counts as a CMS violation?

There are numerous things one could do to acquire a violation. While ALL violations should be taken seriously, some are more severe than others. Infractions include, but are certainly not limited to, the following.

• Marketing Medicare Part C or Part D door-to-door, over the phone, or at unapproved seminars
• Using unapproved marketing materials
• Using “Medicare” in your job title on your business card, social media sites, brochures, etc. This is misleading as it implies that you work for Medicare.
• Failing to use or follow a Scope of Appointment form
• Writing business when you are not certified to do so (Serious Violation!)
• Writing business with an expired license (Major Violation!)
• Writing business for another agent (NO! Do not do this!)

For more specifics and questions, give us a call! 800-689-2800.

How do I know if I have a CMS violation?

The carrier will send you a notice of non-compliance, warning, corrective action notice, or any combination of the three depending on the severity and duration of the violation. This will typically be in the form of a phone call. Respond quickly and calmly to any and all requests made.

What is my punishment for non-compliance?

In most cases you will just get a warning or have to take extra training. If the problem persists or you commit a major violation, the consequences could range from intermediate sanctions, civil money penalties, non-renewal, termination, or loss of license. Appeals are generally an option.

How do I avoid non-compliance?

• If you can confidently answer “No” to these three questions, you are most likely in the clear:
  1. Will my actions cause inappropriate delay or denial of access to health services or medications for the beneficiary?
  2. Will my actions result in incorrect premiums charged or unnecessary costs incurred to the beneficiary?
  3. Will my actions result in inaccurate or untimely information provided about health and drug benefits to the beneficiary?

(Questions adapted from CMS Enforcement Actions presentation at https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Downloads/CMS-Enforcement-Actions.pdf)

• Keep detailed records of interactions with clients. In the event a carrier does contact you, they will ask specific questions.
• Utilize the Senior Marketing Specialists Compliance Team to review materials you create yourself or for questions and concerns.
• Turn to SMS marketing piece services. Choose generic, compliant, and customizable pieces from our Agent Marketing Portfolio (amp) program OR ask us to customize carrier-specific materials for you.
• Check out our compliance page on SMS University.
• Watch these SMS compliance videos!
  • Open Mike – Medicare Compliance
  • Open Mic – Mary and Mike Compliance Call
  • CMS Violation Workshop
• Give us a call! 800-689-2800.

If you still have questions or concerns regarding your compliance, don’t hesitate to let us know! We want you to stay out of trouble so your business can thrive! That’s why we are more than happy to answer your compliance questions. Reach us at 800-689-2800.