Wellcare: Regulation and Guidance Reminders for Sales and Enrollment

Sales and Enrollment Reminders

There has recently been a rise in Medicare beneficiary complaints around the topics discussed below. Please review the following Medicare Advantage & Prescription Drug regulations and guidance reminders regarding sales and enrollment. Thank you in advance for your review.

Please be sure the beneficiary has a complete understanding of the plan selected, including, but not limited to:

• Provider network status prior to the beneficiary’s enrollment into the plan.
• Confirming a beneficiary’s Providers for Network status.

Additionally, agents/brokers are to ensure beneficiaries have a complete understanding of the impact of any plan change on current coverage. Below is the language for the PECL that is being added for 2024. The best practice is to start discussing the effect on coverage as soon as possible.

• “Your current health care coverage will end once your new Medicare coverage starts. For example, if you are in Tricare or a Medicare plan, you will no longer receive benefits from that plan once your new coverage starts.”

Lastly, please be sure to verify Power of Attorney/Appointed Representative status of the person enrolling the beneficiary if the beneficiary themselves are unable to sign the application. If the beneficiary does not make their own healthcare decisions, the agent/broker must not pressure them to participate in a sales appointment or enroll into a plan.

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For Reference:

• Medicare Advantage Marketing Regulations - § 422 Subpart V - 42 CFR 422.2267(e)(4), 42 CFR 422.2274(c)(12)  
• Medicare Part D Marketing Regulations - § 423 Subpart V - 42 CFR 423.2267(e)(4), 42 CFR 423.2274(c)(12)
• MCMG - Section 422.2267(e)(4) & Appendix 1 – Standardized Pre-Enrollment Checklist (422.2267(e)(4), 423.2267(e)(4))    
• CMS Guidelines Chapter 2, Section 40.1.1
• CMS Guidelines Chapter 2, Section 40.2.1