Medicare Call Center Requirements: Support Compliance and Accelerate Sales

Medicare Call Center Requirements: Support Compliance and Accelerate Sales

August 12, 2024 | Convoso

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 and third-party marketing organizations (TPMOs), 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 provide high-quality service to prospects and beneficiaries while mitigating the risk of penalties and other legal consequences.

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CMS Medicare Marketing And Communications Guidelines

CMS Medicare Marketing and Communications Guidelines are 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 protect beneficiaries from fraudulent or misleading marketing practices and ensure 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 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. 
  • Sales presentations: All sales presentations must be fair and impartial to avoid misleading 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: You must clearly explain the enrollment process 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.

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The CMS Medicare Call Center Updates in CY2025

CMS updates for contract year 2025 (CY2025) introduce new definitions and stricter rules on top of the existing guidelines, particularly focusing on areas like consent management and data sharing by TPMOs. The new guidelines go into effect on October 1, 2024. 

Here’s an overview of the major CMS updates: 

  • Expanded Definition of TPMOs: The definition of Third-Party Marketing Organizations (TPMOs) now includes a broader range of entities, such as lead generators, independent agents, brokers, and any organization involved in Medicare marketing, sales, or enrollment activities.
  • One-to-One Consent for Data Sharing: TPMOs must obtain prior express written consent from beneficiaries before sharing their personal data with other entities. The Medicare enrollee must consent to each entity rather than giving broad consent.
  • Prior Express Written Consent Required for Manual Dialing: Unlike FCC regulations, which only require consent for autodialed calls, the new CMS rules mandate that TPMOs must obtain prior express written consent before making any sales-related calls, even if they are dialed manually. 
  • Standardized Compensation for Agents and Brokers: CMS has introduced a uniform compensation rate for all agents and brokers, eliminating variations in pay that could influence which plans they recommend to beneficiaries.
  • 10 Days to Honor Opt-Outs: TPMOs must keep a record of any opt-out requests from Medicare enrollees and must ensure that these requests are honored within 10 business days.

TPMOs now need to get prior express written consent from Medicare beneficiaries before sharing their personal data with other entities. Unlike before, where broad consent might have been enough, beneficiaries now need to consent to each specific entity that will access their information.

While the CMS rule is similar to the FCC’s new one-to-one consent rule, it’s actually stricter. The CMS update applies one-to-one consent even for manually dialed calls. This means that you can’t just follow FCC guidelines and assume you’re compliant—if you’re dealing with Medicare, you must follow CMS’s stricter consent rules.

This change protects beneficiary privacy and prevents unauthorized data sharing. By requiring one-to-one consent, CMS ensures that beneficiaries know exactly who has access to their personal information. 

Using Online Forms to Collect Consent

For most Medicare call centers and TPMOs, the easiest way to collect this consent will be through checkboxes on an online form. CMS specifically mentions how to use checkboxes to collect one-to-one consent. 

“In the rule, it states that the TPMO can use a consent method where the default selection is that the beneficiary chooses to not share their data,” Michael Peronto, Director of Professional Services at ActiveProspect said. 

“Basically, what it’s saying is that if [the enrollee is] encountering a form, and there are multiple entities that are listed, that you cannot actually pre-check the box before that form is submitted.”

How Does This Impact Transfer Calls?

There’s an exception to the prior express written consent rule for warm transfers. If a beneficiary verbally agrees during a live phone call, a TPMO can transfer them to another TPMO without needing prior express written consent. 

This only applies if the beneficiary will immediately speak with the next TPMO. If the beneficiary’s personal data is shared with someone they won’t directly interact with right away, prior express written consent is still required.

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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.

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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: 

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


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.

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