Cigna 2025 final rule TPMO updates

2025 final rule TPMO distribution of beneficiary data and reporting requirements

The release of the Centers for Medicare & Medicaid Services (CMS) 2025 final rule has brought about some important updates to Third-Party Marketing Organization (TPMO) distribution of beneficiary data and reporting requirements.

Please review the guidance below to ensure you stay compliant during this AEP season.

‍

What is a TPMO?

TPMO is defined as all organizations and individuals, including independent agents and brokers, who are compensated to perform lead generation, marketing, sales, and enrollment related functions as a part of the chain of enrollment. TPMOs may be a first tier, downstream, or related entity (FDR).

‍

‍

Distribution of personal beneficiary data by TPMOs

Per 42 CFR 422.2274(g)(4)

The 2025 final rule included a new lead generation rule requiring TPMOs to obtain prior express written consent from beneficiaries for each party that can contact a beneficiary. Please review this guidance to ensure you understand and can implement this rule.

Beginning on October 1, 2024, personal beneficiary data collected by TPMOs for the purpose of marketing or enrolling a beneficiary into a MA or Part D plan may not be shared with other TPMOs, unless the beneficiary gives prior written consent. Prior written consent from the beneficiary must be obtained through a clear and conspicuous disclosure that lists each entity receiving the data and must allow the beneficiary to consent or reject to the sharing of their data with each individual TPMO.

‍

‍

Reporting of agent/broker non-compliance with marketing regulations

§§422.2272(e) and 423.2272(e), §§422.2274(c) and (g) and 423.2274(c) and (g)

CMS requires MA plans and Part D sponsors to have a mechanism for oversight of all agents, brokers, and other TPMOs who engage in sales and marketing on their behalf. MA plans and Part D sponsors must ensure that this mechanism is robust enough to capture and report violations of CMS requirements by agents, brokers, and other TPMOs (such as repeat violations and those that have the potential to harm beneficiaries) to the organization's CMS account manager at least monthly.

In response to this guidance released by CMS in June, Cigna's Medicare sales oversight program will be modified to include the new reporting requirement. Their teams will continue to capture and address matters of sales and marketing non-compliance, issue agent/agency notices of violation, and follow-up on corrective measures, as applicable. In addition, the names and actions of any agents/brokers, and other TPMOs violating CMS requirements will be reported to CMS monthly in accordance with this new guidance.

Examples of non-compliance that CMS expects to be reported include, but are not limited to:

• Credentialing issues
  • Licensing
  • Appointment situations (e.g., failure to obtain Scope of Appointment (SOA))
  • Testing requirements (e.g., failure to achieve 85% on annual testing)
  • Termination for cause
• Failing to comply with CMS's marketing requirements
  • Misleading information
  • Cherry picking
  • Unsolicited contact
• Fraudulent enrollment
  • Enrolling beneficiaries without their consent
  • Failing to record telephonic enrollments
• Repeat offenses
  • SOA issues (e.g., SOA missing or not completed prior to a scheduled personal marketing appointment)
  • Permission to contact documentation (e.g., agent could not produce documentation of valid permission to contact)
  • Cross-selling (e.g., marketing non-healthcare related products)
  • Failing to record sales calls with beneficiaries

‍

‍