Did you know that the Centers for Medicare & Medicaid Services (CMS) have established stringent requirements to protect consumers from fraudulent practices during the health plan enrollment process through the Marketplace?
These regulations ensure that consumers are fully informed and have authorized the use of their information for enrollment purposes. Here’s a concise guide to understanding these requirements and how to comply with them.
- Attestation at the Beginning of the Call: Agents must obtain explicit consent from consumers at the start of the enrollment call. This includes:
- Conducting a search for consumer applications.
- Helping the customer apply for Marketplace coverage or financial assistance.
- Enrolling a customer in a Qualified Health Plan (QHP).
- Checking the status of the customer’s coverage and making updates throughout the year.
- Review of Plan Information at the End of the Call: Agents must review the selected plan information with the consumer to ensure they understand and agree to the plan details. This review must be documented and kept on file for ten years.
Consent and Documentation
To comply with CMS requirements, agents must secure and retain proof of consumer consent. Consent must be obtained before any enrollment actions occur and should be documented clearly. This can be done through audio recordings or written consent, including:
- The individual’s name.
- The date consent was given.
- The name of the agents to whom the consent was given.
It is also wise to include the plan name, subsidy, and premium information while obtaining a record of consent whenever there is an enrollment into any plans, changes made to an application, or cancellation of a plan to avoid misunderstandings.
Agents must also keep a "Review of Eligibility Application Information" on file for 10 years. The attestation document cannot be used for this purpose. HealthSherpa provides an email option to help agents comply with this requirement.
Third-party means such as online forms or lead-generators do not constitute proper consent according to CMS standards. It’s recommended that agents speak directly with clients to obtain consent.
To mitigate any confusion or regulatory issues, always follow up with consumers who have provided their information through online forms, social media, or surveys. Personally confirm their review of the eligibility application and consent before submission.
Inform Consumers about AOR
If you utilize the "NPN Override"/Agent of Record (AOR) feature, where commissions are assigned to someone other than yourself within HealthSherpa, it's crucial to inform the customer at both the beginning and end of the conversation. A simple statement like the following can suffice:
Hi [Customer Name], my name is [Your Name]. I am a licensed agent in [State] and am appointed with the major insurance carriers which offer ACA plans in [State]. As an FYI, when we are done you may see documents which refer to [Name of AOR]. [Name of AOR] is the Agent of Record here at [Name of agency], or as some call the principal agent. I wanted to let you know in case you see his/her name on documents you might receive.
This information should also be included in emails and text messages you send. This practice ensures transparency and avoids confusion if another agent interacts with the customer. It's important to reiterate that any agent communicating with a customer must be licensed in the customer's state and appointed with the carrier they are enrolled with.
Agent Best Practices
We have compiled a list of recommended best practices for complying with CMS requirements regarding proof of consent based on information from CMS and our ACA partners:
- Clear and Accurate Communication: Ensure that consumers understand the actions you are taking on their behalf and for which plan year.
- Form of Consent: While CMS doesn't mandate a specific format, written consent or voice recordings are recommended to prevent misunderstandings. Third-party consent methods like online forms or lead generators are not considered compliant.
- Content of Consent: The consent record should include the individual's name, date of consent, agent(s)/broker(s) names, acknowledgment of the agent/broker's role, and permission for specific actions (e.g., conducting application searches, assisting with enrollment).