Compliance Outlook For 2022

By: Chalen Jackson

Compliance Officer

2022 looks to be a banner year for increased compliance measures in our industry. As we saw Medicare Advantage grow to now cover 45% of all Medicare eligibles, heavy scrutiny of payment models, particularly risk adjustment rates, has been on the rise. Add to that a drastic increase in CMS filed complaints, representing nearly 40,000 beneficiary issues, and it is safe to say we can expect to see many changes in the coming year. Below I have outlined a few key trends I am seeing develop and a couple action items for your agency.

Increased Audit Activity

Based on updates from CMS as well as current carrier communications, we can expect increased general and compliance audits from carriers. Some may only occur at the top of hierarchy level (Senior Marketing Specialists), but some may occur on an agency level as well. I will be sending out compliance audit/attestations to roughly 10% of our agents/agencies each year to maintain our required downline oversight. It will be vital to ensure that you have proper policies and procedures in place to meet compliance guidelines and maintain control of your business.

Major Changes to Leads and Marketing

Due to a drastic increase (up 255%) in complaints in 2021, CMS is examining several major changes to marketing rules, primarily focused on requirements for third-party marketing (lead vendors) but will also affect any agent created marketing materials. These critical changes will likely occur early second quarter and we will keep you apprised of any updates! It is recommended that ALL marketing materials be reviewed by our office and those requiring CMS approval can be submitted on your behalf to HPMS.

Overuse/Misuse of Certain SEP’s

Several carriers have expressed concerns over the misuse of certain SEP codes, especially the FEMA-declared Disaster (DST) code. In addition, the improper use of other codes such as Other Creditable Coverage (OCC) and Maintaining Dual Status are under increased scrutiny by carriers and CMS alike. I recommend using the Election Period Assistant on the SMS website and for the most thorough representation of SEP availability and applicability with clients and prospects, the UnitedHealthcare SEP guide.

Communications Compliance

2021 saw an increase in oversight under several regulatory acts, including CANSPAM, TCPA, CCPA, and the implementation of STIR/SHAKEN, all aimed at curbing unwanted and unsolicited calls, texts, and emails. Even though this is not exclusive to Medicare or insurance, as a business owner, you are still subject to these laws and regulations. Please ensure that you are considering state and federal laws regarding outbound marketing and that you have a retention system for all forms of marketing and communications with clients and prospects.

Even with this stark uptick in compliance measures, there is still fantastic growth potential in the Medicare arena that can be captured without running afoul of these guidelines.

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