Medicare Call Center Requirements: Support Compliance and Accelerate Sales

As the US population ages, the demand for Medicare services continues to grow, and call centers have become increasingly important points of contact for beneficiaries seeking information and assistance. 

However, with this increased reliance on call centers comes a growing need for compliance with the various regulations and guidelines set forth by the Centers for Medicare and Medicaid Services (CMS). Failure to adhere to these compliance requirements can result in serious consequences, including fines and even the loss of the organization’s ability to offer Medicare services. 

In this article, we will explore the compliance requirements for Medicare call centers, including the guidelines set forth by CMS and best practices for ensuring compliance. By understanding and adhering to these requirements, call centers can help ensure that they are providing high-quality service to prospects and beneficiaries, while also mitigating the risk of penalties and other legal consequences.

The CMS Medicare Call Center Requirements in 2023

The CMS (Centers for Medicare & Medicaid Services) Medicare Marketing and Communications Guidelines are a set of regulations and best practices that govern the marketing and communication practices of organizations offering Medicare Advantage (MA) and Part D prescription drug plans. These guidelines are designed to protect beneficiaries from fraudulent or misleading marketing practices and to ensure that they receive accurate and timely information about their healthcare options.

The guidelines cover a wide range of topics related to marketing and communications, including:

• Marketing materials: All marketing materials used to promote Medicare Advantage and Part D plans must comply with CMS rules and regulations. This includes any materials that are distributed electronically, such as emails and web pages.
• Educational events: Educational events, such as seminars and webinars, must be clearly identified as educational events and not marketing events. They must also be approved by CMS in advance.
• Sales presentations: All sales presentations must be conducted in a way that is fair and impartial, and that does not mislead beneficiaries. Sales agents must not use high-pressure sales tactics or make false or misleading statements.
• Member communications: Communications sent to Medicare beneficiaries, such as plan documents and newsletters, must be clear and easy to understand. They must also include all required disclosures and disclaimers.
• Enrollment processes: The enrollment process must be clearly explained to beneficiaries, and they must be given ample time to review their options before making a decision. Agents must also follow strict guidelines when enrolling beneficiaries, to ensure that they are not coerced or misled into enrolling in a particular plan.

Crucial Requirements for Medicare Call Centers and Outbound Marketers

Within the broader guidelines, there are a number of provisions to which those operating within Medicare call centers will want to pay particular attention. Important guidelines for outreach include:

• Agents and brokers can use direct mail and email (as long as opt-out methods are offered) to make unsolicited contact with potential customers.
• No door-to-door activity and no unsolicited calls are permitted. 
• Calls are not considered unsolicited if the consumer “provides consent or initiates contact with the plan,” giving PTC, or permission to contact. (More on PTC below.)

Covering Lead Generators and Digital Marketers: The Biggest Update to CMS Guidelines in 2022

Paying attention to these guidelines only became more important for marketers, lead generators, and call center operators with the latest updates. That’s because in the 2022 edition of the MCMG, rules related to third-party marketing organizations, or TPMOs, were updated to include specific reference to independent agents and brokers as well as their referral partners (i.e., lead generators and digital marketers).

According to attorney Puja Amin of the Troutman Firm, “Carriers now have a responsibility to have oversight of every single one of their lead generators and digital marketers. That means, for you lead generators and sellers out there, you too need to be able to comply with Permission to Contact and ensure that your partners understand what measures you’re taking to be compliant with new CMS guidelines.”

New CMS Call Recording Requirements

Beyond the provisions covered above, It’s also important to note that the latest CMS guidelines also introduced a significant new call recording requirement. Under the guidelines, all sales calls must be recorded in their entirety and retained in a HIPAA-compliant manner for 10 years. This requirement applies to both new and existing Medicare clients.

According to CMS, anything that falls under the “chain of enrollment” is considered a sales call, meaning all events spanning from the time a beneficiary is made aware of a Medicare Advantage or prescription drug plan to when they complete the enrollment process. So, whether you are calling leads, scheduling appointments, or conducting enrollments and educational meetings over the phone (and Zoom!), these communications need to be recorded and retained. Only face-to-face meetings for marketing and sales are excluded from this requirement.

How often are Medicare Communications & Marketing Guidelines Updated?

The Centers for Medicare & Medicaid Services (CMS) update the MCMG on an annual basis. The updates typically occur in the fall and are effective the following year.

However, CMS may also issue updates or clarifications to the MCMG throughout the year if needed. It’s important for organizations that participate in the Medicare program to stay up-to-date on any changes to the guidelines to ensure compliance with Medicare regulations.

CMS Guideline Changes on the Way for 2023-24

Luckily, businesses may get a preview of at least some upcoming updates via proposed rules released publicly by CMS ahead of time. In a proposed rule issued in December 2022, CMS announced potential changes to several rules related to lead gen and marketing. These include:

• Reinstating a 48-hour scope of appointment (SOA) time frame: Prior to 2018, SOAs needed to be completed at least 48 hours before a personal marketing appointment could take place. The proposed rule would bring back this requirement as well as impose a 6-month window of validity for new SOAs.
• Updating disclaimers for third-party marketing organizations: Revised disclaimers will need to include state health insurance programs as well as a list of all Medicare Advantage organizations or Part D sponsors that a TPMO contracts with in a given beneficiary’s service area.
• Limiting call recording requirements: A small amount of relief from the stringent recording requirements discussed above may be in sight. Proposed rules would eliminate the need to record appointment-setting calls and check-in calls after sales. 
• Creating a 6-month rule for permission to contact: Under the rule change, permission to contact will remain valid for six months after an enrollee or prospect first asks for information.

Medicare Permission to Contact Guidelines

This last proposed rule change would limit the life of permission to contact. But what exactly is this crucial requirement for Medicare call centers?

What Is Permission to Contact in Medicare?

“Permission to Contact,” or PTC, in Medicare refers to an individual’s voluntary decision to allow certain Medicare-related organizations or agents to contact them for specific purposes related to their healthcare coverage.

Typically, this permission to contact is related to Medicare Advantage, Medicare Supplement, or Medicare prescription drug plans, and the purpose of the contact may include marketing or promotional materials, surveys or feedback, or other communications related to the individual’s healthcare coverage.

Before a Medicare-related organization or agent can contact an individual, they must obtain permission to do so. This permission can be given over the phone, in writing, or online, and the individual has the right to revoke this permission at any time.

PTC vs. Consent Under the TCPA

Although the importance of following CMS guidelines around PTC is greater than ever, lead generators, buyers, and marketers still need to keep their eye on TCPA compliance during Open Enrollment. Last year, during a webinar on creating an Open Enrollment compliance checklist, Puja Amin underlined the cases in which written consent is required under the TCPA—a more extensive regulation, with greater potential punishments for violation. These cases include:

• Any call made to a cell phone (including business cell phones) using automated or prerecorded voice technology and that contains marketing content.
• Any call made to a residential landline using a prerecorded or artificial voice and containing marketing content.
• Any call made to a residential landline on the DNC list for marketing purposes unless the caller has an established business relationship or is responding to an inquiry.
• Any prerecorded call to a residential landline in excess of the TRACED Act exemption limits. This requirement includes informational calls. TRACED Act limits commercial calls, surveys, and charitable calls to 3 per month; healthcare-related calls are limited to 3 calls per week.

Supporting TCPA Compliance for Medicare Call Centers

The complexities of consumer consent underscore the importance of TCPA compliance for Medicare call centers. While the CMS guidelines present their own level of risk, businesses can’t afford to focus their compliance efforts only on CMS—they must also be proactive about supporting TCPA compliance.

The importance of choosing the right technology partners for supporting TCPA compliance can’t be understated. In today’s tough regulatory environment, your call center is ultimately only as safe as the weakest link in your technology stack. Learn more about how to choose the best call center software, and explore the need for crucial TCPA compliance tools such as: 

• Do Not Call (DNC) scrubbing
• Workflow automation
• Dynamic scripting software
• Multiple dial modes

Dig deeper into call center compliance with this resource on how to implement TCPA best practices.

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DISCLAIMER: The information on this page, and related links, is provided for general education purposes only and is not legal advice. Convoso does not guarantee the accuracy or appropriateness of this information to your situation. You are solely responsible for using Convoso’s services in a legally compliant way and should consult your legal counsel for compliance advice. Any quotes are solely the views of the quoted person and do not necessarily reflect the views or opinions of Convoso.