AEP Agent Compliance Guide

Agent Compliance Guide for AEP Success

Overview: The Annual Enrollment Period (AEP) is a high-stakes time for Medicare insurance agents. Balancing the pressure to meet enrollment goals with the critical importance of staying compliant with Medicare Communications and Marketing Guidelines (MCMG) can be challenging.

This guide provides the compliance essentials, practical tips, a checklist, and resources to help agents stay compliant and ensure a smooth AEP.

Why Compliance Matters During AEP

Compliance is essential for protecting both your reputation and your clients. As CMS Administrator Seema Verma emphasized, “Medicare beneficiaries must be able to trust the information provided to them and feel confident that they’re making informed decisions.” Remaining compliant protects you legally, builds trust, and helps ensure your clients make well-informed healthcare choices.

Statistic: In 2023, CMS reported that nearly 18% of agent compliance infractions occurred during AEP. Ensuring compliance reduces your risk and supports a smooth AEP season.

Key Compliance Areas for AEP

1. Understanding “Marketing” vs. “Communications” Activities

• Communications are general information-sharing activities and do not need CMS review.
• Marketing includes any material or activity that influences enrollment in a specific plan. All marketing materials must be CMS-approved.

Quick Tip: If in doubt, ask yourself if the content has the intent of “selling” or steering a client toward a specific plan. If so, it’s marketing and requires approval.

2. Scope of Appointment (SOA) Forms

• Requirement: Obtain a signed SOA form from clients before discussing specific Medicare plans.
• Retention: SOA forms must be kept on file for 10 years.

“SOA forms ensure clients are aware of the conversation scope, reducing misunderstandings and supporting a compliant sales environment.”

3. Event Compliance: Educational vs. Sales Events

• Educational Events: Must be purely informational without specific plan details.
• Sales Events: Plan details can be discussed only if an SOA is completed.

Statistic: CMS reports that more than 20% of compliance errors are related to improperly run events. Clarify event type to clients and follow guidelines to avoid compliance infractions.

4. Permissible Language and Advertising Rules

• Permitted: Objective information, like costs, benefits, and factual plan details.
• Prohibited: Urgency phrases like “limited time” or “government-endorsed” statements.

“Keeping language clear and neutral helps clients make informed choices without feeling pressured.”

5. Plan/Part D Sponsor Activities in Healthcare Settings

• Agents may distribute materials in common areas of healthcare settings, but patient rooms and treatment areas are off-limits for sales.

6. Digital Communication & Unsolicited Contacts

• Permitted: Email contact with an opt-out option.
• Prohibited: Unsolicited text messages and social media DMs.

Compliance Checklist for AEP

Download and print this checklist to stay organized and compliant throughout AEP:

1. Scope of Appointment (SOA)

   • Obtain SOA before discussing specific plans.
   • Retain SOA forms for 10 years.

2. Marketing Material Approval

   • Confirm all marketing materials are CMS-approved.
   • Avoid unapproved, non-compliant language in communications.

3. Event Type Declaration

   • Clearly label events as “Educational” or “Sales.”
   • For educational events, refrain from discussing specific plans.

4. Healthcare Setting Compliance

   • Limit sales activities to common areas.
   • Avoid patient rooms and treatment areas.

5. Digital Contact Compliance

   • Use email with opt-out options for outreach.
   • Refrain from unsolicited text or social media messages.

6. Client Communication and Follow-up

   • Document all client interactions related to plan discussions.
   • Regularly review your compliance practices and procedures.

7. Referral Procedures

   • Follow CMS guidelines when using referral programs.
   • Ensure all rewards meet CMS “nominal gift” standards.

Agent Tips for a Smooth, Compliant AEP

1. Double-Check Your Materials: CMS can update compliance requirements, so it’s wise to review materials frequently.
2. Prepare a Compliance Binder: Keep SOA forms, event documentation, and CMS-approved materials in an organized binder for easy access.
3. Stay Updated on CMS Rules: CMS regularly updates compliance rules. Visit the CMS website regularly or sign up for updates.
4. Use Digital Tools Wisely: Platforms like LinkedIn can be excellent for connecting, but ensure all outreach aligns with CMS guidelines on unsolicited contact.

"A smooth AEP season means fewer headaches and greater client trust. Compliance isn’t just about rules; it’s about giving clients the confidence that they’re in the best hands.” 

Resources for Continued Compliance

For personalized support, feel free to reach out to our compliance team. With the right tools, strategies, and understanding of compliance, you can make this AEP your most successful yet while delivering value to every client.

Stay Compliant, Stay Confident!