Understanding the 48-Hour Rule

Center for Medicare Services 48 hour scope of appointment

The 2018 Medicare Marketing Guidelines have been published by CMS. I doubt many agents have thoroughly reviewed those 124 pages in the last two weeks. It’s not light reading. We review these guidelines carefully at SMS, especially any changes. We are ready to help if you have questions about how changes in the guidelines may affect you.

Right now there appears to be a lack of understanding about the 48-hour requirement for Scope of Appointment (Section 70.4.3.). Is it in place? Is it no longer in effect? An informal poll of agents might find answers split down the middle. That’s not good when it comes to a rule.

For 2018, the phrase “48 hours prior” is not published in the guideline for SOA. It now just says “prior to appointment” without an hour or day stipulation. That’s a relaxing of the rule.

Here are two important things to keep in mind:

First, CMS has said that 48-hour requirement is still in the Code of Federal Regulations (42 CFR 422.2268 (g)).

Second, CMS has clarified that obtaining the form is still required, and doing so 48 hours in advance of a scheduled appointment is preferred. Obtaining the form on the day of the appointment is acceptable but it requires a brief written explanation, such as “phone call” or “walk-in.”

Also keep in mind that carriers are still reviewing the updated guidelines too, and have not changed their policies and procedures yet.  You will need to comply with the Scope of Appointment policy and procedures for each carrier with whom you are appointed.

The 48-hour rule still applies to a large degree, even with that softened language. Carriers may also still require it. It’s also fair to anticipate that the 48-hour stipulation may make a return in future updates. So that makes my guidance to you pretty obvious and simple — keep operating in the same way you always have. That approach does no harm.

While the idea of more same-day scopes might be appealing, a more conservative approach means that you don’t have to change the way you’re already doing business or run the risk of your actions being scrutinized or interpreted. You also won’t have to change anything in future years if that language returns to the guidelines.

If you have questions about anything in the 2018 Medicare Marketing Guidelines, please c contact us at 585.577.1010.