Broker Medicare Advertising Material Review Checklist
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1 Broker Medicare Advertising Material Review Checklist NOTE: The material cannot be used in the marketplace until Health Net has given its express written approval. Section 1: GENERAL INFORMATION A. Material Title: B. Submission Date: C. Material Purpose: (Provide detailed explanation of how this material will be used) D. Will this material be mailed? Yes No Note: If you answered Yes and will be using an envelope for your mailing, you must use a CMS approved envelope. All envelopes require a 45 day CMS review in addition to Health Net s review timing. For your convenience, provided below is an already CMS approved envelope template ready for your use and you may populate existing placeholders to fit your business needs. Please note the following: There are four legal disclaimers listed on the envelope. Choose one that is most appropriate for your material. Note: one of four legal disclaimers MUST be included on the envelope or directly on the mailing if no envelope is used (e.g., a postcard). <Carets> = Variable data [Brackets] = Field may be removed Prior to use, remove all carets and brackets Envelope size and orientation may vary CMS approved envelope template E. Plan Type Promoted: (Check all that apply) CMS-approved Envelope Template.do HMO Plans PPO Plans SNP Plans N/A F. Distribution Period: AEP MADP SEP Year Round Other (explain in Material Purpose) G. Distribution Year: H. Geography: (Check all that apply and include counties material will be distributed in) California; County(ies): Oregon; County(ies): Washington; County(ies): Arizona; County(ies): I. Alternate/Previous Version(s): Material ID of English or Previous Version: J. Previous Version Approval/File Date: Page 1 of 5
2 K. Is material applicable to more than one plan sponsor? L. Is Health Net the Lead Plan Sponsor? M. If Health Net is not the Lead Plan Sponsor, please identify the Lead Plan Sponsor: N. List CMS contract numbers for each health plan for which the material is applicable: O. Have all other plan sponsors provided express written approval? P. Submitter Name & Title: Section 1: GENERAL INFORMATION No If No, skip to section P. Yes If Yes, you must designate one of the health plans listed in your material as Lead Plan Sponsor. The remaining health plans will be considered Non Lead Plan Sponsors. All Non Lead Plan Sponsors must review/approve the material. Lead Plan Sponsor will then do initial filing with CMS. All Non Lead Plan Sponsors will also have to file the material as an Auxiliary Material with CMS after Lead Plan Sponsor filing. No Yes If Yes, you must provide written material approval from each of the Non Lead Plan Sponsors for which the material is applicable before material can be filed with CMS (answer section O accordingly). This written approval can be provided separately from the initial material submission. However, if written approvals from all the Non Lead Plan Sponsors are not provided within 10 business days of initial submission, review timing may extend beyond 45 calendar days. No Yes Section 2: MATERIAL ATTESTATION REVIEWED FOR: ORIGINATOR Applicable CMS Marketing Guidelines Section # Material has been proofread Did not use seniors to describe Medicare beneficiaries. Did not use traditional Medicare to describe Original Medicare. Did not use free when describing benefits. (Alternatively something like included at no additional cost may be used, if applicable.) Did not use absolute superlatives. (If absolute superlatives are used, supporting documentation validating the claim must be provided.) All font, including legal disclaimers = minimum 12 point 40.2 Times New Roman in height & width or the equivalent. Correct benefit information (if applicable) Plan Type Identifier (HMO, PPO, HMO SNP, etc) is included with plan name (if applicable) (Ex: Health Net Healthy Heart (HMO)) Page 2 of 5
3 Section 2: MATERIAL ATTESTATION REVIEWED FOR: ORIGINATOR Applicable CMS Marketing Guidelines Section # Material contains phone number 40.6 Material contains TTY/TDD number (state relay may be 40.7 used as follows: TTY: 711) Phone number and TTY number are the same font, size 40.7 and style Hours of operation are included 40.6 Correct Variable Data Indicators 90.8 <Carets> = variable text (use carets to indicate variable data. Only phone numbers, hours of operations and seminar information may be submitted as variable text) [Brackets] = information can stay as is or be removed Material does not mislead or confuse beneficiaries by 40.4 words, symbols, logos or terminology that would imply or give the false impression they are endorsed/approved/authorized by Medicare or any other federal agency or program. In addition, the materials should include accurate terminology and timelines set forth by CMS or any other federal agency referenced. Material does not steer or attempt to steer an undecided potential enrollee or any Medicare beneficiary to a particular plan based on financial or any other interests of the provider Material does not provide a link to foreign drug sales 100 Applicable legal disclaimers included (see the chart , 40, 50 below with legal disclaimers and when to include them) If seminar(s) are promoted in the material, add the following: (Note: Special Needs" could range from ensuring facility is wheelchair accessible, a sign language interpreter is available for those hard of hearing, and/or materials available in Braille for those who cannot see. If you re not able to accommodate the request, please direct the beneficiary to Health Net s Member Services at (TTY: 711). If plan benefits are mentioned in the material, add the following: If plan premium information is mentioned in the material, add the following: A sales person will be present with information and applications. For accommodation of persons with special needs at sales meetings call <insert your phone number> (TTY: 711). (Note: Section 504 of the Rehabilitation Act requires all Plans/Part D Sponsors to ensure effective communication with individuals with disabilities and to provide auxiliary aids and services, such as alternate formats, to individuals with disabilities to ensure effective communication and an equal opportunity to access the agencies programs. These and other prohibitions against discrimination based on disability can be found in the DHHS Section 504 regulation at 45 CFR Part 84.) The information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. <Benefits, premiums and/or copayments/coinsurance> may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Page 3 of 5
4 If Health Net is mentioned on the material to be used from October 1 thru February 14, add the following: (Note: if more then one health plan is mentioned in an advertising material, call center hours of operation and Medicare contracting statement must be included for each health plan listed.) If Health Net Jade (HMO SNP) plan is mentioned in the material, add the following: If Health Net Jade Cardiovascular (HMO SNP) plan is mentioned in the material (Arizona only), add the following: If Health Net Amber I or II (HMO SNP) plan is mentioned in the material (California only), add the following: If Health Net Amber (HMO SNP) plan is mentioned in the material (Arizona only), add the following: If a subset of plan options are listed in the material, add the following: If a promotional item/gift is offered in the material, add the following: If the material references Star Ratings information, add the following: Calling the number above will direct you to a licensed insurance agent/broker, or call Health Net s Member Services at < (TTY: 711), 8:00 a.m. to 8:00 p.m., 7 days a week>. Health Net has a contract with Medicare to offer HMO, PPO and HMO SNP plans. Enrollment in a Health Net Medicare Advantage plan depends on contract renewal. Health Net has a contract with Medicare to offer HMO SNP plans. Enrollment in a Health Net Medicare Advantage depends on its contract renewal. You can enroll in the Health Net Jade (HMO SNP) plan at any time during the year if you meet the eligibility requirements for this Medicare Advantage Special Needs Plan. This plan is available to anyone with Medicare who has been diagnosed with a cardiovascular disorder, chronic heart failure and/or diabetes. Health Net has a contract with Medicare to offer HMO SNP plans. Enrollment in a Health Net Medicare Advantage depends on its contract renewal. You can enroll in the Health Net Jade Cardiovascular (HMO SNP) plan at any time during the year if you meet the eligibility requirements for this Medicare Advantage Special Needs Plan. This plan is available to anyone with Medicare who has been diagnosed with a cardiovascular disorder. Health Net has a contract with Medicare and the California Medicaid program to offer HMO SNP plans. Enrollment in a Health Net Medicare Advantage plan depends on its contract renewal. You can enroll in the Health Net Amber (HMO SNP) plan at any time during the year if you meet the eligibility requirements for this Medicare Advantage Special Needs Plan. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Health Net of Arizona, Inc. has a contract with Medicare and the Arizona Health Care Cost Containment System (AHCCCS) to offer HMO SNP plans. Enrollment in a Health Net Medicare Advantage plan depends on its contract renewal. You can enroll in the Health Net Amber (HMO SNP) plan at any time during the year if you meet the eligibility requirements for this Medicare Advantage Special Needs Plan. This plan is available to anyone who has both Medical Assistance from the State (AHCCCS) and Medicare. This is not a complete listing of plans available in your service area. For a complete listing please contact MEDICARE (TTY users should call ), 24 hours a day/7 days a week or consult Free gift provided without obligation to enroll, while supplies last. Medicare evaluates plans based on a 5 Star rating system. Star Ratings are calculated each year and may change from one year to the next. Page 4 of 5
5 If your marketing material is being mailed, 1 of the 4 legal disclaimers must be present on the mail panel (same side where recipient s address will appear). Choose legal disclaimer that is most appropriate for your material. This is an advertisement Important plan information Health and wellness or prevention information Non health or non plan related information Page 5 of 5
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