Agent and Broker Training & Testing GuidelinesIntroductionEach year, the Centers for Medicare & Medicaid Services (CMS) provides Medicare AdvantageOrganizations (MAOs)/Part D sponsors training and testing requirements for their agents and brokers.Plans/Part D sponsors should at a minimum use the criteria outlined below in developing their individualtraining and testing.The agent and broker training guidelines are based on CMS’ Medicare Managed Care Manual (MMCM),CMS’ Medicare Prescription Drug Benefit Manual (MPDBM), Medicare Communications and MarketingGuidelines (MCMG), and regulations at Title 42 of the Code of Federal Regulations, Parts 417, 422, and423).Plans/Part D sponsors (including 3rd party vendors, if applicable) must ensure that all their agents andbrokers (including employed, subcontracted, downstream, and/or delegated entities) that sell Medicareproducts are trained and tested annually on Medicare rules and regulations and on the specific plantypes their agents and brokers sell. Plans/Part D sponsors must ensure the integrity of their training andtesting program to include that all agents and brokers are tested independently. Finally, Plans/Part Dsponsors must maintain information on their training and testing programs and make this informationavailable to CMS upon request. This includes tools, exams, policies and procedures, and evidence ofcompletion.The suggested training topics are outlined below. Plans/Part D Sponsors also should ensure that theiragents/brokers can speak to these general topics and their relation to the types of plan products theysell (i.e., Part C, Part D, Cost Plans, etc.)1. Medicare Basicsa. Overview of Medicarei.Medicare Parts and covered services1. Medicare Part A: Original Medicare - Hospital Insurance2. Medicare Part B: Original Medicare - Medical Insurance3. Medicare Part C: Medicare Advantage4. Medicare Part D: Prescription Drug Coverage – Stand-alone PDP andMA-PDb. Eligibility requirements and premiumsi.Original Medicare (Part A and Part B)ii.Part Ciii.Part D1. including applicable premiums, cost-sharing subsidies for low-incomeindividualsiv.Section 1876 Cost Plansc. Overview of MedigapAgent and Broker Training & Testing Guidelines1

d. Options for receiving Medicarei.Original Medicare onlyii.Original Medicare with a stand-alone PDPiii.MA-PDiv.MA or Cost Plan without stand-alone PDPv.Cost Plan with a stand-alone PDPvi.Private Fee-for-Servicee. A high level description for each of the Plan Typesi.Original Medicare (Parts A and B)1. Benefits and beneficiary protections (1-800-Medicare, FFS appeal rights,etc.)2. Individual enrollment and entitlement for supplementary medicalinsurance (SMI)ii.Part C1. Description of coordinated care plans (e.g., HMO, PPO, RPPO, SNP, etc.)2. Description of Private Fee-for-Service Plans3. Benefits and beneficiary protections (grievance and appeal rights, priorauthorization, step therapy, benefit limitations)4. Out of Pocket costs (e.g., premiums, cost-sharing,copayments/coinsurance, MOOP limits)5. Network requirements (in and out of network providers)6. Disease Treatment plan7. Description of how doctors are paid8. Description of Medical Savings Accounts (MSA)iii.Part D1. Description of plan types (MA-PD, Prescription Drug Plan)2. Benefits and beneficiary protections (grievance and appeal rights)3. Standard benefita. TrOOP, coverage gap, catastrophic coverageb. Medicare Coverage Gap Discount Program4. Pharmacy Networksa. In-network versus out-of-network coverageb. Preferred and standard cost-sharing for network pharmaciesiv.Other Plan Types1. Employer Group Plans2. Cost Plans3. Optional: Programs of All-Inclusive Care for the Elderly (PACE)2. Enrollment and Disenrollment (Part C, Part D, and Section 1876 Cost Plans – where applicable)a. Enrollment Proceduresi.Format of enrollment requests (use of approved enrollment mechanisms)ii.Appropriate use of short enrollment forms or model plan selection forms (Part Cand D) or Simplified (Opt-In) Enrollment Mechanism (Part C)Agent and Broker Training & Testing Guidelines2

iii.b.c.d.e.Requirement that enrollment mechanism capture beneficiary’sacknowledgement and consent to required key elementsEnrollment Processingi.Enrollment effective datesii.NotificationsNon-discrimination requirements for enrollmentPart C and D Enrollment periodsi.Description of the limited circumstances for making a mid-year change inenrollmentii.Initial Coverage Election Period (ICEP)iii.Annual Election Period (AEP)iv.Initial Enrollment Period for Part D (IEP for Part D)v.MA Open Enrollment Period (MA OEP)vi.Open Enrollment Period for institutionalized in individuals (OEPI)vii.Special Enrollment Periods (SEP)1. 5-Star Special Enrollment Period2. Provide other examples of SEPs (e.g., moving to a different servicearea, change in dual/LIS status, CMS/State Assignment, etc.)3. Limitation on dual/LIS SEP for “potential at-risk” or “at-risk”individualsviii.Section 1876 Cost Plan open enrollmentDisenrollmenti. Voluntary disenrollmentii. Involuntary disenrollment (i.e., when a member must be disenrolled formoving out of service area, loss of dual eligible status, etc.)3. Communication and Marketing Requirements and Other Regulations (Part C, Part D, andSection 1876 Cost Plans – where applicable)a. Agent and Broker Responsibilitiesi.HIPAA privacyii.Other responsibilities required by planb. Communication and Marketing Overviewi.Overview of each term including the activities and materials that applyii.Description of general rules and requirements for Communication andMarketingiii.Provision of Star Ratings information, including instructions on how to accessand use the informationiv.Information on how to access and use the Summary of Benefits,Provider/Pharmacy Directory, Evidence of Coverage, Annual Notice of Change,and formulary, as applicablec. Standards for Communication and Marketing - Inappropriate/ProhibitedCommunication and Marketing Activitiesi.Conducting health screeningsAgent and Broker Training & Testing Guidelines3

d.e.f.g.h.i.j.ii.Providing cash or monetary rebatesiii.Making unsolicited contactPotential Consequences of Engaging in Inappropriate or Prohibited Communication andMarketing Activities (prohibited activities, include but not limited to: conducting healthscreenings, providing cash or monetary rebates and making unsolicited contact)i.Report requirementsii.Disciplinary actionsiii.Terminationiv.Forfeiture of future compensationMarketing/Sales Eventsi.Definition of marketing/sales eventsii.Appropriate promotion of sales eventsiii.Examples of dos and don’ts, including but not limited to:1. Provision of refreshments, snacks, and meals2. Soliciting enrollment applications prior to the start of the AEP3. Requiring information as a prerequisite for events (e.g., contactinformation)iv.Notification of events to the plan, as applicablePersonal/Individual Marketing Appointmentsi. Scope of appointmentii. Examples of dos and don’ts, including but not limited to:1. Discussion/marketing of non-health care products2. Discussing products not agreed upon by the beneficiaryEducational Eventsi. Appropriate promotion of educational eventsii. Sponsorship, promotioniii. Example of dos and don’ts, including but not limited to:1. Topics (Medicare, plan-specific premiums and/or benefits, etc.)2. Displaying and/or distribution of marketing materials3. Marketing activities4. Provision of refreshments, snacks, and mealsNominal Giftsi. Examples of dos and don’ts, including but not limited to:1. Eligibility (e.g., all potential enrollees, regardless of enrollment inspecific plan(s))2. Value (e.g., 15 or less, no more than 75 per year)3. Refreshments, snacks, and meals4. Cash, charitable contributions, and gift certificates/cards that can bereadily converted to cashCross-selling – definitioni. Health care related products – definition and “dos and don’ts”ii. Non-health care related products – definition and “dos and don’ts”Unsolicited contact, outside of advertised sales or educational events or mailingsAgent and Broker Training & Testing Guidelines4

k. Referrals – solicitation of leads from members for new enrolleesi. Any solicitation for leads – all communication types (requirements andrestrictions)ii. Gifts for referrals (requirements and restrictions)l. Marketing in Health Care Settingi. Examples of dos and don’ts, including but not limited to:1. Conducting sales activities in common areas2. Conducting activities where patients get careii. Conducting activities in long term care facilitiesm. Agent and Broker Compensationi. Compensation Eligibility1. Independent agent (eligible)2. Employed agent (agent/broker who only sells for one Plan/Part Dsponsor are exempt from compensation requirements)3. Referral fee (applicable to anyone)ii. Definition of compensationiii. Compensation types and definitions1. Initial Compensation2. Renewal Compensation3. Referral Feesiv. Definition of “like plan type” and “unlike plan type” changesv. Guidance on compensation payments1. Compensation year is Jan. 1 through Dec. 31, regardless ofbeneficiary enrollee date2. Initial members are paid either a pro-rated amount or the fullcompensation3. Payment must be pro-rated for mid-year renewals4. Recoupment must occur for months a member is not in the plan5. Recoupment for rapid disenrollmentAgent and Broker Training & Testing Guidelines5

Appendix: Associated ReferencesContentReference(s)Original Medicare Basics42 CFR- Subpart B, General ProvisionsMedicare Advantage Basics42 CFR Part 422 Subpart A—General Provisions Subpart B—Eligibility, Election, and Enrollment Subpart C—Benefits and Beneficiary ProtectionsMedicare Managed Care Manual(MMCM) Ch. 1 & 2Part D Basics42 CFR Part 423 Subpart A—General Provisions Subpart B—Eligibility and EnrollmentMedicare Prescription Drug Benefit Manual (PDBM) Ch. 1 & 31876 Cost Plans and OtherPlan Types42 CFR Part 422: Subpart A—General Provisions42 CFR Part 423: Subpart A—General ProvisionsMMCM Ch. 1 & 2; PDBM Ch. 1 & 2Extra Help42 CFR Part 423 Subpart P—Premiums and Cost-sharing Subsidies for LowIncome Individuals Subpart S—Special Rules for States-Eligibility Determinationsfor Subsidies and General Payment ProvisionsPDBM Ch. 13Election Periods42 CFR §422.62- Election of coverage under an MA plan42 CFR §423.38- Enrollment periodsMMCM Ch.2 Section 30; PDBM Ch. 3 Section 30Enrollment andDisenrollment Process42 CFR Part 422; Subpart B—Eligibility, Election, and Enrollment42 CFR Part 423; Subpart B—Eligibility and EnrollmentMMCM Ch.2; PDBM Ch. 3Beneficiary Protections42 CFR Part 422; Subpart C—Benefits and Beneficiary ProtectionsMMCM Ch. 17f; PDBM Ch. 5Part C OrganizationalDeterminations and Appeals,Part D CoverageDeterminations andRedeterminations, andGrievances42 CFR Part 422; Subpart M—Grievances, OrganizationDeterminations, and Appeals42 CFR Part 423; Subpart M—Grievances, Coverage Determinations,Redeterminations, and ReconsiderationsMMCM Ch. 13; PDBM Ch. 18Overview of Marketing42 CFR Part 422; Subpart V—Medicare Advantage MarketingRequirements42 CFR Part 423; Subpart V—Marketing RequirementsMedicare Communications and Marketing Guidelines (MCMG)Overview of MarketingMaterials Requirements42 CFR §422.2260 - 422.226642 CFR §423.2260 - 423.2266MCMGAgent and Broker Training & Testing Guidelines6

ContentReference(s)Agent/Broker Compensation42 CFR §422.2274- Broker and agent requirements42 CFR §423.2274- Broker and agent requirementsMCMG Section 120.4Marketing EventRequirements42 CFR Part 422; Subpart V—Medicare Advantage MarketingRequirements42 CFR Part 423; Subpart V—Marketing RequirementsMCMG Sections 40 and 50Marketing Event Type42 CFR Part 422; Subpart V—Medicare Advantage MarketingRequirements42 CFR Part 423; Subpart V—Marketing RequirementsMCMG Section 50Agent and Broker Training & Testing Guidelines7

Agent and Broker Training & TestingSample TestBelow are sample test questions that may be used by Plans/Part D sponsors.Part I: Medicare Basics1) A prospective beneficiary asks an agent if plan XYZ has an urgent care benefit and if so, what thebenefit includes. Where would the agent find this information for plan XYZ?A. Summary of BenefitsB. Provider DirectoryC. Evidence of CoverageD. None of the above2) If a beneficiary enrolled in an HMO tells you that she wants to see a specialist, you should tell her:A. You will likely need a referral from your primary care physician (PCP) to see a specialist. Ifyou see your specialist without this referral, the plan may not pay for your visit.B. Call and make the appointmentC. You do not need to see a specialistD. All of the above3) True or False? Once a beneficiary is enrolled in an MA plan and has paid his plan-specific monthlypremium, he no longer needs to pay his Part B premium.A. TrueB. False4) Match the Medicare Part in the first column with the correct description in the second.Medicare PartDescriptionA. Part A1. Physician services, outpatient hospital care, lab tests, mental healthB. Part Bservices, some preventative services, and medical equipmentC. Part Cconsidered medically necessary to treat a disease or conditionD. Part D2. Prescription Drug Benefit3. Hospital inpatient care, some SNF care, and home health and hospicecare4. An option for beneficiaries to receive private health plan coverage inlieu of Original Medicare (i.e., Parts A and B) through MA PlansAgent and Broker Training & Testing Guidelines8

Part II: Enrollment and Disenrollment5) Mrs. Doe will turn 65 at the end of March and signed up for an MA plan in January during her InitialCoverage Election Period (ICEP). When will her coverage begin?A. On February 1B. On March 1C. On April 1D. On May 16) Which of the following periods provide an opportunity for a beneficiary to move from OriginalMedicare to an MA plan?A. October 15 through December 7B. January 1 through April 15C. January 1 through March 31D. The month when the beneficiary turns 65 years of ageE. All of the above7) Which of the following conditions