Purpose Scope of Appointment (SOA)

Transcription

1 Document Number: AP-134 Document Name: Scope of Appointment Policy Business Owner/Approver: (Signatures on File) Version Date: 10/15/2012 Document History: 01/07/2009 Date Created Purpose Scope of Appointment (SOA) The purpose of this policy is to address element Scope of Appointment and Beneficiary Walk-Ins to a Plan or Agent/Broker Office or Similar Beneficiary-Initiated Face-to-Face Sales Event as described in Chapter 3 of the Center for Medicare and Medicaid Services (CMS) Medicare Marketing Guidelines. Per Section of the Medicare Marketing Guidelines: In conducting marketing activities, a plan sponsor may not market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary, and documented by the plan, prior to the appointment (48 hours in advance when practicable). The sales person is bound to only discuss those products that have been agreed upon by the beneficiary during the appointment; distinct lines of plan business include MA and PDP products. If other products1 need to be discussed at the request of the beneficiary, a second scope of appointment must be documented for the new product type and then the marketing appointment may be continued. CMS has the expectation that the scope of appointment be determined and a Scope of Appointment form be executed at least 48 hours prior to the time of the appointment. However, there is the recognition there may be scenarios where this is not possible. These scenarios are explained in Section of the Medicare Marketing Guidelines: In instances where a beneficiary visits a plan or an agent/broker office on his or her own accord, the plan sponsor or agent/broker must document the scope of appointment prior to discussing MA, PDP, or cost plans. Policy: In compliance with the passed federal law entitled Medicare Improvements for Patients and Providers Act or MIPPA, sales agents are required to obtain agreement from the beneficiary on the "scope of the appointment" of all Medicare products that will be discussed prior to the face-to-face personal appointment with a beneficiary. For all face to face appointments that are scheduled by the agent the process outlined below must be followed to maintain compliance with CMS guidelines. Please be aware that appointments set by Call Centers are all digitally recorded and therefore already comply with the requirements of documenting the agreed upon scope of the appointment. No additional documentation is required. The process outlined below addresses appointments set by the agent, e.g., referrals, beneficiaries who wish an appointment as a follow up to a marketing event. Agent use of this process and either the IVR (individual voice response) recording or the Sales Appointment Confirmation Form is effective immediately. Policy All licensed sales agents, brokers or representatives ( Agents ) must have a Scope of Appointment signed prior to any MA/MAPD/PDP appointment or product presentation. The Scope of Appointment may be completed by paper, MAPA, IVR, or by a telesales agent on a recorded line during the appointment setting process. When practicable, the scope of appointment should be determined and a Scope of Appointment be executed at least 48 hours prior to the time of the appointment Scope of Appointment forms or recordings must be stored for a minimum of 10 years and made available upon request by CMS, Humana, or any other authorized party. For agents utilizing the Humana Scope of

2 Page 2 of 10 Appointment form/process (Paper, MAPA, IVR, and Telesales) the 10 year storage requirement will be met by Humana. Agents who use a non-humana Scope of Appointment form will be responsible for the 10 year storage requirement and must make the Scope of Appointment forms available upon request. Once a Scope of Appointment is executed, it is the responsibility of the agent to complete at the time of or post appointment information on the form. This can include the reason the SOA was taken at the time of the appointment, the actual appointment date, any plans discussed during the appointment, and the enrollment application ID number if one was taken. SOA Methods A Humana Scope of Appointment can be executed one of four ways. 1. Paper Scope of Appointment Barcoded Paper Scope of Appointment forms must be ordered through the Agent Support Unit. Barcoded forms must not be photocopied, scanned, or reproduced in any way. Completed Paper Scope of Appointment forms must be mailed to the address on the back of the SOA form for scanning and processing. 2. MAPA A Scope of Appointment form can be taken in MAPA and signed with the digital signature pad. MAPA SOA s are uploaded along with any enrollment forms by the agent. Each MAPA SOA receives an MAPA SOA ID number. 3. IVR A Scope of Appointment can be taken through the IVR process on a recorded line. The IVR captures all required information through touch tone and voice recordings. Each IVR SOA receives an IVR Recording ID. 4. Lead Appointment - A Scope of Appointment can be taken through the lead setting process Any Humana lead an agent receives will contain an IVR Recording ID. Process The beneficiary must agree to the "Scope of Appointment" (SOA) and the agreement must be documented. It can be documented either via a digitally recorded call through the agent IVR line or in writing using the Scope of Appointment Confirmation Form. Each form is unique and includes a unique barcode so they should not be copied. Forms are available for order through the Agent Support Unit (Form Y0040_GNHH6CRHH)If the agent uses the form, the form is to be signed by the beneficiary and returned prior to the appointment taking place. The SOA paper form is a two-step process. The top of the form is completed prior to the appointment taking place and requires the beneficiary s signature. The remainder of the form is completed during the appointment and will require the agent s signature and SAN. After the sales presentation is complete, the Agent will need to sign and date the form and include additional information on the form including: The date of the actual appointment and presentation on the form. This may be different than the date entered during the pre-appointment phase. All carrier plans presented in the plans the agent presented box of the form (i.e. Humana and United, Humana and Coventry), etc.) The beneficiary Medicare Id if an enrollment application was taken The application number - this could be the app bar code, MAPA app ID, FASTAPP Verification ID. This is necessary to match the app to the form during CMS audit. An explanation for why the form was not documented prior to the appointment, if applicable IMPORTANT: if the beneficiary enrolled, the barcode from the enrollment application, FastAPP ID or MAPA ID will need to be included on the SOA form. IMPORTANT: if the beneficiary enrolls, the barcode from the SOA form, the IVR or Lead recording ID, or GENERICSOA will need to be placed on the enrollment application where indicated (SOA ID Number). This is necessary to match the app to the form during CMS audit. The SOA form should be submitted with the application or mailed alone if no application was completed. NOTE: The form should be sent even if the enrollment did not occur. The agent should keep a copy of the SOA form for proof of documentation.

3 Page 3 of 10 IMPORTANT: The final step of the process is to log into the Agent Portal Scope of Appointment Search tool. Agents will need to update the status of the appointment by documenting if the appointment took place Agents should make every attempt to complete the SOA form or IVR call prior to the appointment with the beneficiary. CMS s suggested time frame is 48 hours prior to the appointment. Generally, the beneficiary can NOT sign the documentation at the beginning of the sales appointment with few exceptions; the confirmation must be signed and returned to the agent prior to the in-home appointment. EXCEPTION #1 - Beneficiary walk-ins to a plan or agent / broker office or similar beneficiary initiated face-to-face sales event. The agent should complete a Sales Appointment Confirmation Form and the beneficiary must sign the form BEFORE discussing a Medicare Advantage or Part D plan. The agent must note on the form that the beneficiary was a walk-in. EXCEPTION #2 - If an agent has a properly solicited appointment with a Sales Appointment Confirmation Form in hand and unexpectedly finds that there are additional beneficiaries present that were not anticipated, the agent must have each additional beneficiary complete the Sales Appointment Confirmation Form prior to conducting the sales presentation. If any of the additional beneficiaries wish to learn about plans other than what was originally agreed to, the agent must make a separate appointment with that person to discuss their desired plans. EXCEPTION #3 - If it is not feasible for the Sales Appointment Confirmation Form to be executed prior to the appointment, an agent may have the beneficiary sign the form at the beginning of the marketing appointment. MarketPOINT s preferred method of collecting the Sales Appointment Confirmation Form is through the telephonic IVR (individual voice response) system. Please Note: The Sales Appointment Confirmation Form and the telephonic IVR option, which is available 24/7 ( ), is an acceptable form of documentation. Agents may call the beneficiary to follow-up if the Scope of Appointment Confirmation Form has not been received, but the appointment can not take place until scope of appointment is confirmed. If the agent is able to reach the beneficiary on the telephone, then it is in the best interest of all parties to call into the telephonic IVR line to confirm the scope of the appointment. Record the date of the actual appointment and presentation on the form. This may be different than the date entered during the pre-appointment phase. Record all carrier plans presented in the plans the agent presented box of the form (i.e Humana and United, Humana and Coventry), etc.) Record the beneficiary Medicare Id on the form if an enrollment application was taken Non-health products, e.g. life and annuities, may not be discussed during any MA and/or PDP appointment. CMS GUIDANCE CMS has advised that if the initial appointment was set for PDP and the beneficiary requests additional information about MAPD, the agent may discuss MAPD without having to reschedule the appointment. The agent must have the beneficiary sign a new Scope of Appointment Confirmation Form for the new product type and then may continue the presentation. A separate appointment is not required. Note: A separate appointment IS required to discuss non-health products.

4 Page 4 of 10 CMS has advised that if the Sales Appointment Confirmation Form is used to confirm the scope of the appointment and it is returned without the beneficiary having initialed the applicable boxes HUMANA CAN NOT ACCEPT THE FORM. Check marks or "X" are not acceptable notations. Beneficiaries must have put their initials in the box. If an agent receives a form that does not have initials on it, the agent must either obtain a new form WITH initials or use the telephonic IVR option to obtain a properly executed scope of appointment. Follow-up appointments to continue discussion of the same Medicare plans as the original appointment will NOT require an additional Scope of Appointment Confirmation Form; however, the agent must obtain permission to contact the beneficiary again. Permission to contact is not necessary if the agent is solely arranging to pick up a completed enrollment application. Plan lines would include MA/MAPD, PDP only and other health related products, e.g. Medicare Supplement, Dental, Vision. At no time should a Medicare appointment be conducted in conjunction with a non-health related insurance product (i.e., life, annuity, or auto). This is considered cross-selling and is prohibited by federal law. Sales Appointment Telephonic IVR Process Agents use the following process, working with the beneficiary, to record his or her agreement with the scope of appointment with the agent s upcoming appointment with the beneficiary. Appointment requests can be completed in about 4 minutes and can be made in the presence of the beneficiary or via a 3-way call. A unique number has been established for each sales channel to call the IVR system: Delegated/MECA Here Is How the System Works 1. The system leads the agent through a series of prompts to authenticate 1) you as the agent and 2) the beneficiary with whom the agent will be meeting. 2. Agents are prompted to provide the following information: Agent 7-digit Humana SAN (Agent ID Number) The Appointment Type Press 1 for an MA Appointment Press 2 for a PDP Appointment Beneficiary's Information Key in the beneficiary s 10-digit telephone number Key the last 4 digits of the beneficiary s Social Security number. 3. The system tells the agent how to walk the beneficiary through a conversation to document which products the agent will be discussing and the date, time and location of the appointment. 4. The agent puts the beneficiary on the line (calls them or conferences in) and describes to them that they will be confirming the scope of the appointment as the system asks them questions. 5. The agent discloses to the beneficiary that they are speaking on a recorded line. 6. The system tells the beneficiary to that he or she will be asked to State his or her name

5 Page 5 of 10 The appointment date The appointment time Products to be discussed during the appointment. 7. The agent asks the beneficiary to state his or her name For Example: Mr. /Mrs. /Ms., as you as you know, we are speaking on a recorded line for the purpose of documenting what we will be discussing during our upcoming appointment. Would you please say your full name for our records? 8. The agent asks the beneficiary to state his or her address For Example: Ok, can you now please say your full address, City, State, and ZIP code? 9. The agent now discloses the product(s) agreed on for the scope of appointment. For Example: And we set up an appointment for me to meet with you on _Day_, Date at _ Time at Location, for that purpose. Is that correct? 10. The agent now captures the method of introduction to the beneficiary. For Example: Lastly, according to my records, we initially met by (Say one as applicable) o You are a current Humana member that I enrolled. (Delegated) o You called in response to an advertisement/mailer. o You got my business card from a friend/neighbor/relative and called me. o You attended an appointment I had scheduled with a friend/neighbor/relative. o You attended an event that I was holding and asked me to call you. o You attended a seminar and asked me to call you. o Other... The agent asks the agent: Is that correct? 11. When the agent hears that the beneficiary is finished, the agent presses the pound (#) key to continue 12. The IVR system plays a Legal Disclaimer Statement..., then states Go ahead start now 13. The beneficiary states I Agree 14. The agent presses the # key 15. IVR system states the words to press 1 to obtain your confirmation number Note: The agent needs to write this number down and place it with the beneficiary s records in case questions arise about scope of appointment. The agent can press 1 again to have the number repeated. It is recommended that the agent write the IVR confirmation number in the upper right hand corner on the first page of the app. 16. If the agent has the number correctly written down, he or she presses the # key to end the call and disconnect.

6 Hear an Example Document: AP-134 Page 6 of 10 SOA Phone Call The preferred method for documenting a beneficiary s agreement to the meeting s scope of appoint is using the IVR system. If this is not possible, the CMC Ap-147 approved Humana paper form should be used. We will also accept any CMS approved Scope of Appointment form. Documentation Process Use the following documentation process for sales appointment confirmation: Responsibility Delegated/Independent Agent and Beneficiary Action 1. Decide what products will be discussed at the appointment (usually over the phone or face-toface at an event) 1a. If the appointment is made over the telephone, then the agent mails the Scope of Appointment Confirmation Form to the beneficiary for his or her signature prior to the appointment or calls the IVR SOA line. (It is advisable to include a postage paid self-addressed envelope to facilitate return). 1b. If the appointment is made during a face-to-face interaction, for example after a sales seminar, then the agent should complete the Scope of Appointment Confirmation Form at that time, indicating the products agreed to discuss, and have the beneficiary sign the form. 1c. If the form was mailed to the beneficiary, then the beneficiary mails or faxes the Scope of Appointment Confirmation Form back to agent, or as directed by the agent Delegated /Independent Agent 2. Completes the bottom portion to the SOA form and sends the form with or without the enrollment application to Humana at the address on the Scope of Appointment Confirmation Form in conjunction with normal Enrollment Applications processing. The form must be sent even if an enrollment did not occur. Situational Examples Example 1: While attending a seminar with your local market office, a prospect requests to set a follow up in-home appointment - Agent should call the IVR line or complete the Scope of Appointmentt Confirmation Form and have the beneficiary sign it. Example 2: Setting an appointment over the phone - Agent should call the IVR line or mail the completed Sales Appointment Confirmation Form to the beneficiary for their signature. If the form is used, the Beneficiary must return form to agent prior to appointment. Example 3: A neighbor or friend of the beneficiary attends your scheduled appointment unexpectedly explain the "scope of appointment" regulation to them, complete the Scope of Appointment Confirmation Form, have friend/neighbor sign the Sales Appointment Confirmation Form. Indicate on the form "Unexpected additional attendee" on the Initial Method of Contact line and allow them to listen to the presentation. Example 4: You have completed a presentation of the previously agreed-upon plan and the prospect would like to discuss a different product that was not included on the Scope of Appointment Confirmation Form. Have the prospect complete a

7 Page 7 of 10 new Scope of Appointment Confirmation Form indicating the additional products they requested to learn about and continue the presentation. Example 5: You have completed a presentation of the previously agreed upon PPO plan and the prospect wants to discuss another plan type in the same plan line (any MAPD plan) - the agent may present an additional MAPD product without a "48 hour cooling off" period or new Scope of Appointment Confirmation Form. Example 6: A beneficiary walks into your business office and asks you to tell them more about the Humana _? _ plan - explain the "scope of appointment" regulation to them, complete the Scope of Appointment Confirmation Form, indicate on the form that the beneficiary is a walk-in, have the walk-in beneficiary sign the Sales Appointment Confirmation Form, and present the information to the beneficiary. Documentation Retention CMS requires all documentation related to Scope of Appointment to be maintained for 10 years. All Sales Appointment Confirmation Forms received by Humana are scanned and maintained for purposes of retention for future CMS auditing. It is highly recommended that agent also retain copies of the SOAs. IMPORTANT: Agents using generic SOA forms are required to maintain the SOA form for 10 years. Please take care to PRINT legibly and fill out the forms completely and accurately. Please be sure to note how the initial contact came about in the "Initial Method of Contact" portion of the form. This should always be completed; examples would include: In-home Appointment Face to Face Appointment Outside of home Advertised Seminar Walk-In Wal-Mart Other Retail partner Other Please keep in mind that this requirement is part of federal law and as such, compliance with it is a requirement for all agents selling MA and PDP plans. Sales leadership recognizes this process is somewhat inconvenient; however; Humana is exploring other more streamlined alternatives to the process. If you have questions regarding the use of the new form, please feel free to contact your dedicated Agent Support Team at (800) or send an to: AgentSupport@humana.com. Guidance on Completing Forms It is the agent s responsibility to be aware that the scope of appointment documentation (in particular the Scope of Appointment Confirmation Form) is a required step in setting up a face-to-face appointment with a potential member. The goal of this program from CMS is not only to protect seniors from fraudulent activity but to protect you, the agent, in the event of a dispute. To that end, it is imperative that agents take the necessary steps to verify that the Sales Appointment Confirmation Forms are complete, accurate, and legible. Agents need to confirm they submit all forms on a timely basis Below are a few issues that ACS, Humana s scanning and processing vendor, has seen for paper Sales Appointment Confirmation Forms so far.

8 Page 8 of Beneficiary s Initials In Box When Selecting Products Agents need to verify that beneficiaries know to initial the form boxes beside the products they wish to talk about. Agents must remember to have their beneficiaries initial the boxes. No check marks ( ) or blank boxes ( ) are accepted by Humana per CMS. See the initials on the following example. 2. Copies of Copies of Copies of Copies Agents must work from a printed original of the Sales Appointment Confirmation Form. Do not continue to make copies from copies and present them to beneficiaries. The quality of the printing degrades with each subsequent copy. This makes the form harder for you and your customers to read, as well as making it impossible for the form to scanned or keyed by ACS. Copies of Copies make for a blurry image 3. Please Print Neatly and Accurately When completing the forms please make sure you print all required information. Keep in mind that these forms are being scanned and the data off them will be keyed into a central database. It is critical for any written information to be neat and legible in order that it may be keyed accurately. See the following examples

9 Page 9 of 10 Do This: NOT This:

10 Page 10 of 10 Sales Appointment Confirmation Form English (SAMPLE FORM, FRONT PAGE) (SAMPLE FORM, BACK PAGE) Additional Supporting Information Links: JOB AID: Accessing 2012 SOA thru Agent Portal (AP-398) JOB AID: Scope of Appointment (SOA) Training (AP-399) JOB AID: Scope of Appointment Search and Edit Tool (AP-426)