COMPLIANCE CORNER
Agents contracted with GarityAdvantage are expected to review and follow the compliance policies and procedures on this page. Reach out if you have any questions: compliance@garityadvantage.com
Agent Licensure, Appointment & Certification
Scope: All agents, regardless at which level they are contracted at, must be aware and comply with CMS “Medicare Marketing Regulations,” as well as any applicable State laws and regulations. This policy applies to any agent marketing MAPD or PDP plans. These guidelines are revisited and updated annually by CMS.
Agent Oversight
It is the policy of our agencies to maintain strict and complete compliance with all laws and regulations that address the products we sell. This includes any and all Federal laws and regulations as well as any and all State laws and regulations. Furthermore, it is our intention to fully support and comply with any specific Company policies and guidelines as they relate to representing the Company and/or the products we represent on their behalf. Read more…
Agent Sales and Marketing Practices
Scope: All agents, regardless at which level they are contracted at, must be aware and comply with CMS “Medicare Marketing Regulations,” as well as any applicable State laws and regulations. This policy applies to any agent marketing MAPD or PDP plans. These guidelines are revisited and updated annually by CMS.
Code of Conduct Addendum
Last Reviewed 8/19/23
Anonymous reporting to Medicare Insurance Carriers
Downline Oversight & Monitoring
Scope: All downline entities with contracted relationships with GarityAdvantage Agencies are subject to the following oversight and monitoring.
Licensed Agent Quality Assurance Process
Overview:
Garity Advantage follows Centers for Medicare & Medicaid’s (CMS) regulatory requirements contained in but not limited to 42 CFR Part 422, and associated guidance. Garity Advantage is responsible for sales training, oversight and monitoring of licensed agents, and other processes to ensure that sales activities are compliant with CMS requirements and consistent with Garity Advantage Policies and Procedures. This policy is reviewed annually and based upon need due to regulatory and business changes. Read more…
Garity Advantage Downstream oversight Policy:
The purpose of this policy is to implement relevant provisions of 42 C.F.R. Section 422.503(b)(4)(vi), and 423.504(b)(4)(vi), Chapters 9 and 21 of the Medicare Managed Care Manual and the Prescription Drug Benefit Manual which outlines the Centers for Medicare and Medicaid Services (CMS) requirements for Part C and D sponsors and their First Tier, Downstream and Related entities (FDRs) to implement an effective compliance program, including implementation and operation of an effective system for oversight of Medicare activities and downstream entities.
GarityAdvantage Terms of Service
Please read these Terms of Service (“Terms”) carefully before using the [Garity Advantage] (the “Company”) Resources (as defined below), applying to become an insurance agent for the Company, or otherwise seeking affiliation with the Company. Read more…
Marketing Promotional Activities & Gifts
Scope: All licensed employees and independent agents must be aware of the Medicare Marketing Regulations, which are reviewed and updated each year by CMS. This policy will be amended as necessary based on changes in regulations.
Marketing Terminology and TPMO
Prohibited Terminology
Scope: All licensed employees and independent agents must be aware of the Medicare Marketing Regulations, which are reviewed and updated each year by CMS. This policy will be amended as necessary upon reviewing new Regulations. Read more…
Compliance Corner
Garity Advantage Annual Downline Compliance
Agents contracted with GarityAdvantage are expected to review and follow the compliance policies and procedures on this page. Reach out if you have any questions: compliance@garityadvantage.com
Background
The Centers for Medicare & Medicaid Services (CMS) requires that we communicate general compliance program information and requirements, as well as provide training and education and monitor specific Compliance and Fraud, Waste and Abuse (FWA) requirements to our employees, first tier, downstream, and related entities. (FDR)
Action Required
Review the following compliance and FWA requirements now to make sure you, your employees and any applicable affiliate organizations meet all the requirements. Employees are defined as hired staff, management and temporary workers for your company or subcontractors that have involvement in or responsibility for a core function in the administration or delivery of Medicare Advantage Part C, Part D, or Medicaid health plan benefits and have access to personal health information/personally identifiable information (PHI/PII).
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Code of Conduct Distribution
Downline Entities must distribute their own written policies, procedures or standards of conduct or the GarityAdvantage Code of Conduct to employees who support the administration or delivery of program benefits or services.
- Must be distributed within 90 days of hire and annually thereafter.
- Downline Entities must retain proof of distribution for each
- Resource: Generic Code of Conduct
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FWA and General Compliance Training Completion
All FDR’s are required to know, understand and follow all FWA and General Compliance regulations and requirements.
We all have the obligation to combat FWA and should be aware of how to identify and report FWA and non- compliance – if you need assistance in training, or more info on FWA and general compliance guidance, please review the information provided on these website.
- Resource: CMS Parts C and D, FWA and General Compliance Training
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OIG/GSA/State Exclusion Checks
CMS and other federal and state regulators prohibit you from hiring, employing or making payments to any person or business excluded or debarred from federal or state health care programs. You are only required to complete these pre-hire and monthly exclusion checks on your non-agent staff and Medicare Supplement only agents. This could include your administrative staff and others who are not licensed. Failure to perform checks against the Office of Inspector General (OIG), General Services Administration (GSA) federal exclusion and state exclusion lists prior to hire and monthly thereafter are not in compliance with applicable laws, regulations and guidance.If you sell products that service Medicaid program memberships (for example DSNP products), you may also be required to check additional State exclusion lists. Not all States have this requirement, however if you sell to members, or have employees who reside in a State that has this additional requirement you must check all applicable lists both prior to hire and monthly thereafter. Please note that you must check the states where both the Member and Employee reside, so if you have employees in one State, but sell to members in multiple states, you must check your employees against all States you sell in that have this requirement regardless of where your employees are located.
Resources:
- Health and Human Services Office of Inspector General List of Excluded Individuals and Entities (LEIE)
- General Services Admission (GSA) System for Award Management (SAM)
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Exclusion review requirement: is listed under Title 42 Public Health CFR §1001.1901(b). The state exclusion list requirement is listed under Title 42 Public Health CFR 1002.2; Authority also includes applicable state law and state Medicaid contracts.
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Notification of All Offshoring ‒ Requires you contact us for approval prior to sharing members’ protected health information (PHI) with an offshore third
Reporting Medicare: To report Medicare offshoring, email kfennessy@garityadvantage.com.
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Document Retention ‒ You must keep all CMS documentation a minimum of 10
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Monitoring and/or Auditing of Subcontracted Delegates/Vendors ‒ Downstream entities or subcontractors that support the delivery or administration of program benefits or services are held to the same Compliance Program requirements.
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CMS Policy Change on Site-Based Sales Activities
Please be advised there is a change to CMS policy regarding permissible sales activities at healthcare locations. Effective immediately, agents can conduct sales presentations, distribute marketing materials, and distribute/collect enrollment forms in the common area of a healthcare setting. Common areas include:
- Entryways
- Vestibules
- Waiting rooms
- Cafeterias
- Conference rooms
- Etc.
As a reminder, agents cannot market in restricted areas of a healthcare setting. Restricted areas generally include, but are not limited to:
- Exam rooms
- Hospital patient rooms
- Treatment areas where patients interact with a provider and his/her clinical team and receive treatment
- Pharmacy counter areas (where patients interact with pharmacy providers and obtain medications)
Please download the Site-Based Marketing Tool for further details on regulations.
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1099 tax Forms
As a reminder, 1099 tax forms are issued to agents who earned a wage of $600 or more from WellCare in a calendar year. Further, agents who earned less than the $600 minimum in a calendar year are responsible for filing their return. For further details on how to file a return, please reference the IRS website.
If you have further questions in relation to commissions and/or tax forms, please contact Broker Support.
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New CMS Mobile App – Did You Know?
CMS launched the, “What’s covered” App that gives consumers a more modernized way to obtain Medicare information. The App can be downloaded from any mobile device at no cost, and is a great way for you to track updates related to Medicare coverage, SEPs granted, etc.
Further, the App allows individuals with Original Medicare, caregivers and other consumers to view Medicare coverage specifics for medical items/services while at a doctor visit, hospital, general appointment, etc.
For further information, please access the CMS site.
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Medicare Beneficiary Identifier (MBI) Replacement of Health Insurance Claim Number (HICN) on Applications
Remember, the MBI has replaced the HICN for all Medicare beneficiaries and CMS has officially distributed new Medicare cards to all eligible beneficiaries.
Although some carriers continue to accept HICNs on 2019 applications, using the HICN format will delay the processing of the application and prolong coverage for the beneficiary. This is especially true if an incorrect HICN is listed on the application. Please use the MBI in place of the HICN when possible.
Additionally, please reference the following Q & As for details on understanding the MBI format.
How many characters does the MBI have?
11 characters (similar to the HICN).Do the MBI characters have any meaning?
Each MBI is randomly generated. MBI characters do not have a hidden or special meaning. Therefore, MBIs are different from HICNs (based on SSNs).What characters are used in the MBI?
Numbers and upper-case letters.How does the MBI fit on an enrollment form?
The same formatting as a HICN. You do NOT need spaces for dashes.Who has been given a new MBI?
All Medicare beneficiaries.Click here to reference more details on the MBI.
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Sales Policy Job Aid – Agent Website and Social Media Guidelines
UnitedHealthcare Medicare Solutions Agent Guide EDC
(See Section 4 for Marketing Policies)
Reporting a CMS Violation
If you suspect misconduct or identify an excluded individual, report it to us immediately so we may investigate and respond appropriately. Go to GarityAdvantage.com/compliancecorner and click on “report a CMS violation”. This is an anonymous communication and GarityAdvantage prohibits retaliation for reports made in good faith.
GarityAdvantage
Compliance Team
17 Accord Park Drive | Norwell, MA 02066