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Medicare scope of appointment rules

The Medicare scope of appointment rules are put in place by CMS.  The SOA (scope of appointment) is a form that clients or potential clients as well as their agent must complete before meeting to discuss Medicare plan options. The scope is mandatory if you are discussing either a Medicare Advantage or Part D prescription drug plan. Although, it is a good idea to collect a SOA before any client meeting to protect both the agent and the client.  The SOA form should be kept no less than 10 years and may be collected either physically, verbally or electronically.

Watch a quick video on the scope of appointment rules for 2024

Verbal scope of appointment

When the pandemic began, it was not advisable to host in-person meetings to discuss coverage options.  Because of this, many appointments took place over the phone.  That lead to the use of verbal scope of appointments which are recorded and saved.  Many carriers offer this option as well as quoting/enrollment tools such as Sunfire and Connecture.

Click here to watch a Sunfire enrollment demonstration on YouTube 

General information about a verbal SOA

• If the client calls the agent (inbound call), the 48-hour rule does not apply.
• The scope is good for 12 months from the date it is signed.  You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
• If additional benefits are added to the discussion, a new scope is necessary.

How long is a SOA good for

As we mentioned above, a scope of appointment is good for 12 months from the date it is signed. It is important that you discuss only products that were agreed to and included in the scope.  If additional products are added, the beneficiary needs to sign a new scope.

If the client asks about Medicare Advantage plans during the 48-hour waiting period and they had not included them on the original scope, you will need to have them sign a new scope before your discussion.  This will restart the 48-hour waiting period and may move your meeting date out further.  This rule applies to any product regulated by CMS.

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CMS guidelines

In order to be complaint with CMS, agents need to have their clients complete a Medicare Scope of Appointment form. The 2024 CMS final rule went into effect September 30. 2023 and has added some changes to how agents obtain the SOA.

The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans.  The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use.  The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.

Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place.  The beneficiary has the option to opt out annually.

Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.

Find out about the proposed CMS rule 4205-P, see how it could affect agents!

Exceptions to the 48-hour rule

If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.

When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA.  This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.

How long do you need to keep a SOA

Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues.  The SOA can provide help in the event that an issue or dispute occurs.  The Scope is in place to protect the consumer, but it can also protect the agent.

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Medicare sales permission to contact

When you have a potential clients you need to keep all the CMS guidelines in mind before you begin.  You need to be compliant and use a Medicare sales permission to contact.

What is Permission to Contact:

This process helps stop agents from contacting beneficiaries through the use of dishonest sales tactics. Unfortunately, in the past, some agents have pressured Medicare beneficiaries to get a Medicare sale.  Permission to contact is one way to help deter uninvited agents to approach beneficiaries when they are not prepared.

To avoid non compliance, it is important the beneficiary gives permission for the agent to contact them before you try and meet, call or email them for Medicare Advantage or PDP sales.

Here are some ways you can contact a potential client:

1. You can return their call if they request you do so.
2. Through email as long as there is an opt-out option clearly provided.
3. If they respond to a business replay card.
4. When they fill out an online contact form.

Here are some ways you cannot contact a potential client:

1. Do not knock on a potential client’s door without an invitation.
2. You are not permitted to send texts to anyone without their permission.
3. Directly contact through social media

When is permission to contact required:

Anytime you want to contact a potential client, you should obtain permission to contact.  This is very important if they may be considering a Medicare Advantage or Prescription Drug Plan enrollment. Please note; even if you contact a potential client for a Medicare Supplement plan which does not require permission to contact, they will most likely need a Prescription Drug Plan to go with it, therefore it is always a good idea to have permission to contact.  Be sure to include the following disclaimer “This is a solicitation of insurance” on the Permission to contact form.

Please note: If you are contacting your own clients; you do not need permission to contact.

It is acceptable to email potential clients as long as you include an opt-out option.  You cannot send anything that could be considered marketing material.  Marketing material includes specific plan information such as premiums, co-pay amounts or other benefit information. All communications must meet CMS guidelines as well as  CAN SPAM Act requirements.

How long is the permission to contact good for:

Once you have collected the permission to contact, you have 12 months to contact that beneficiary.  If you do not contact them within that time, you must collect another PTC before contacting them.

A couple more things to note:

If you employ a third party marketing organization for lead generation, it is important that they are compliant with all the CMS rules.  Do not forget, it is your name on the materials they are sending so you are the one who is ultimately responsible for what goes out to the public.  Beneficiaries need to be told either verbally, in writing or electronically depending how they are contacted, that their information will be given to a licensed Medicare agent who will contact them.

Do not confuse permission to contact with a Scope of appointment.

You still need to collect a scope of appointment from the beneficiary once you are able to set up a meeting or call to go over plan options.  It is important to follow all guidelines for Medicare sales in order to maintain compliance and maintain your ability to offer Medicare plans.

Download a generic scope of appointment form

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Tips for AEP 2024

Fall is on its way, and that means that the Annual Enrollment Period, or the AEP, is fast approaching. It’s often the busiest time of the year for agents and brokers. The vast majority of Medicare sales happen in that short 54 day period, and it can be stressful. Here are four questions to ask yourself and your agency before the AEP begins so you can optimize your success:

Am I following the new compliance rules?

As you surely know by now, the new rules from the Center for Medicare and Medicaid Services (CMS) are out and they have made some changes to their categorization of agents. All insurance agents and brokers are now considered Third Party Marketing Organizations (TPMOs). This comes with some new rules, including these disclaimers, which are required by law to be on all communications (website, emails, print, etc.).

If you are marketing fewer than all of the plans available in your area, use this one: “We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.”

If you are marketing all of the plans in the service area, use this one: “Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. You can always contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) for help with plan choices.”

Am I recording phone conversations with clients eligible for Medicare?

This is another new regulation from CMS for this coming AEP season.  All calls with people who are Medicare eligible must be recorded (not just sales calls). This is to protect both the agents and the clients. There are many programs available to help make this process as streamlined as possible, like CallVault.

Who have I had the most success helping lately?

It is a good time to reflect on the last few successful client interactions you’ve had. Is there something they have in common? Did you use a certain approach with all of them, or did they share a common thread? Are they all from a certain background, of a certain age, or did the lead come from a particular source? And, are the clients you’re having the most success with also the clients that you’re spending the most time and money to access?

What does my Medicare portfolio look like?

Do the Medicare Advantage plans, prescription drug plans, and Medicare Supplement Insurance plans (or Medigap) fulfill the needs of your clients? Are they finding these plans appealing, or are they looking for something you currently don’t carry? If the products you have are what the clients are looking for in your area, that makes sales all the more simple.

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What is MACRA?

There are many acronyms in the Medicare insurance industry. So much so, that it can be hard to keep them all straight. It is helpful to focus on the vitally important ones. MACRA is one of those acronyms that any informed agent needs to know about in order to best serve their customer base.   What is MACRA stand for?

MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015. This bipartisan piece of legislation was signed into law on April 16, 2015. It created what is known as a Quality Payment Program (QPP). The Quality Payment Program is an incentive program that replaced the Sustainable Growth Rate (SGR) formula that Medicare was using. The Sustainable Growth Rate would have made payment rates for participating Medicare physicians go down significantly, which would have caused problems in the industry. Instead, the Center for Medicare and Medicaid Services (CMS) is now using the Quality Payment Program.

There are two different ways that physicians can choose to participate in the Quality Payment Program.

1. The Merit-Based Incentive Payment System (MIPS). This means that physicians would be reviewed and their payment would be based on how well they perform.

2. Advanced Alternative Payment Models (APMs). For physicians who choose this route, they may earn Medicare Incentive Payments by participating in an innovative payment model rather than have their rate based on their reviewed merit.

Other things that MACRA accomplished, other than implementing the Quality Payment Program and doing away with the Sustainable Growth Rate, are as follows:

• It changed the way that Medicare rewards physicians, which puts the onus on quality of service rather than volume of service.

• Under the Merit-based Incentive Payment System (MIPS), many quality programs are streamlined.

• Rewards physicians for participating in Advanced Alternative Payment Models (APMs).

• MACRA also required CMS to remove social security numbers from Medicare ID cards by 2019, in an effort to prevent identity theft and increase security for their beneficiaries.

Licensed Agents

Click here to see what Crowe and Associates has to offer 

Keep up with all of our current events by clicking here. 

Ready to contract?   Begin here.

Subscribe to our YouTube channel.   We provide weekly training webinars.

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