2020 Agent BrokerTraining Testing Guidelines - Final
2020 Agent BrokerTraining Testing Guidelines - Final
Introduction
Each year, the Centers for Medicare & Medicaid Services (CMS) provides Medicare Advantage
Organizations (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 individual
training 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 Marketing
Guidelines (MCMG), and regulations at Title 42 of the Code of Federal Regulations, Parts 417, 422, and
423).
Plans/Part D sponsors (including 3rd party vendors, if applicable) must ensure that all their agents and
brokers (including employed, subcontracted, downstream, and/or delegated entities) that sell Medicare
products are trained and tested annually on Medicare rules and regulations and on the specific plan
types their agents and brokers sell. Plans/Part D sponsors must ensure the integrity of their training and
testing program to include that all agents and brokers are tested independently. Finally, Plans/Part D
sponsors must maintain information on their training and testing programs and make this information
available to CMS upon request. This includes tools, exams, policies and procedures, and evidence of
completion.
The suggested training topics are outlined below. Plans/Part D Sponsors also should ensure that their
agents/brokers can speak to these general topics and their relation to the types of plan products they
sell (i.e., Part C, Part D, Cost Plans, etc.)
1. Medicare Basics
a. Overview of Medicare
i. Medicare Parts and covered services
1. Medicare Part A: Original Medicare - Hospital Insurance
2. Medicare Part B: Original Medicare - Medical Insurance
3. Medicare Part C: Medicare Advantage
4. Medicare Part D: Prescription Drug Coverage – Stand-alone PDP and
MA-PD
b. Eligibility requirements and premiums
i. Original Medicare (Part A and Part B)
ii. Part C
iii. Part D
1. including applicable premiums, cost-sharing subsidies for low-income
individuals
iv. Section 1876 Cost Plans
c. Overview of Medigap
2. Enrollment and Disenrollment (Part C, Part D, and Section 1876 Cost Plans – where applicable)
a. Enrollment Procedures
i. Format of enrollment requests (use of approved enrollment mechanisms)
ii. Appropriate use of short enrollment forms or model plan selection forms (Part C
and D) or Simplified (Opt-In) Enrollment Mechanism (Part C)
3. Communication and Marketing Requirements and Other Regulations (Part C, Part D, and
Section 1876 Cost Plans – where applicable)
a. Agent and Broker Responsibilities
i. HIPAA privacy
ii. Other responsibilities required by plan
b. Communication and Marketing Overview
i. Overview of each term including the activities and materials that apply
ii. Description of general rules and requirements for Communication and
Marketing
iii. Provision of Star Ratings information, including instructions on how to access
and use the information
iv. Information on how to access and use the Summary of Benefits,
Provider/Pharmacy Directory, Evidence of Coverage, Annual Notice of Change,
and formulary, as applicable
c. Standards for Communication and Marketing - Inappropriate/Prohibited
Communication and Marketing Activities
i. Conducting health screenings
1) A prospective beneficiary asks an agent if plan XYZ has an urgent care benefit and if so, what the
benefit includes. Where would the agent find this information for plan XYZ?
A. Summary of Benefits
B. Provider Directory
C. Evidence of Coverage
D. None of the above
2) 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. If
you see your specialist without this referral, the plan may not pay for your visit.
B. Call and make the appointment
C. You do not need to see a specialist
D. All of the above
3) True or False? Once a beneficiary is enrolled in an MA plan and has paid his plan-specific monthly
premium, he no longer needs to pay his Part B premium.
A. True
B. False
4) Match the Medicare Part in the first column with the correct description in the second.
Medicare Part Description
A. Part A 1. Physician services, outpatient hospital care, lab tests, mental health
B. Part B services, some preventative services, and medical equipment
C. Part C considered medically necessary to treat a disease or condition
D. Part D 2. Prescription Drug Benefit
3. Hospital inpatient care, some SNF care, and home health and hospice
care
4. An option for beneficiaries to receive private health plan coverage in
lieu of Original Medicare (i.e., Parts A and B) through MA Plans
5) Mrs. Doe will turn 65 at the end of March and signed up for an MA plan in January during her Initial
Coverage Election Period (ICEP). When will her coverage begin?
A. On February 1
B. On March 1
C. On April 1
D. On May 1
6) Which of the following periods provide an opportunity for a beneficiary to move from Original
Medicare to an MA plan?
A. October 15 through December 7
B. January 1 through April 15
C. January 1 through March 31
D. The month when the beneficiary turns 65 years of age
E. All of the above
7) Which of the following conditions would qualify an MA plan member to switch plans during a
Special Enrollment Period (SEP)? (more than one may be correct)
A. The member recently moved into a nursing home
B. The member’s plan was terminated
C. The member does not like his/her doctor
D. The member is not satisfied with the plan
E. The member has moved to another state
F. The member was recently admitted into the hospital
8) During a formal sales event held on October 5, an agent tells attendees, “You can enroll in Acme’s
Traditional Medicare Advantage HMO plan between October 15 and December 7, but the plan
won’t take effect until January 1. However, if you don’t like the plan after you enroll, you have until
March 31 to switch back to Original Medicare.” Following the presentation, the agent assists a
couple in filling out an enrollment form for Acme’s Traditional HMO plan, and tells the couple that
she will ”hold on to it” until the October 15 enrollment date. Which of the following statements are
true? (more than one may be true)
A. The agent is not allowed to assist beneficiaries in completing their enrollment form
B. The presenter provided incorrect Annual Election Period (AEP) information
C. The agent is not allowed to accept an enrollment prior to October 15
D. The presenter provided incorrect Medicare Advantage Disenrollment Period (MADP)
information
9) Mrs. Doe has decided to file a grievance because she feels that she was treated with disrespect
while communicating with a plan’s customer services representative (CSR). What is the first step
Mrs. Doe should take to file a grievance?
A. File an appeal with the plan
B. File an appeal with an Administrative Law Judge
C. Contact the plan in writing or by telephone to file a grievance
D. Contact her lawyer
10) For all MA plans, an enrollee that chooses to join a PDP will be automatically disenrolled from
his/her current plan.
A. True
B. False
Part IV: Communication and Marketing Regulations and Materials for Sales
Agents/Brokers
12) True or False: A state insurance department would like to investigate a sales agent that they suspect
is violating Medicare communication and marketing regulations. The plan does not need to allow
the investigation because the agent is licensed and has followed the guidelines to date.
A. True
B. False
14) True or False: CMS requires plans to record the names of all attendees attending their plan-
sponsored marketing/sales events.
A. True
B. False
15) At a formal marketing event that occurred on December 1, an agent provided factual information
on the MA/MA-PD plans available from Acme Health Plan, and noted that compared to all other
16) A beneficiary enrolled into Acme Health Plan in 2012 as an initial enrollment and has remained in
the plan since. How much should Acme pay in CY2015 to the agent that facilitated the enrollment?
A. 50% of CY2012 fair market value
B. 60% of CY2012 fair market value
C. Up to 50% of CY2015 fair market value
D. Up to 60% of CY2015 fair market value
17) A beneficiary enrolls into Acme Health Plan in November 2014 as an initial enrollment. Assuming
the beneficiary remains enrolled in the plan in 2015, in what month does their first renewal cycle
begin?
A. December, 2014
B. January 2015
C. November 2015
D. December 2015
18) If a beneficiary makes a plan change to a plan offered by another organization, and the new
organization does not use agent and brokers, what happens to the payment?
A. The new organization would continue to make payments to the enrolling agent from the
previous organization.
B. The initial organization would continue to pay the enrolling agent for one full renewal
cycle.
C. The new organization would not make payments and the initial plan would have to recoup
for the number of months the member was not in the plan.
D. None of the above
19) Mr. Smith, an agent with ACME Health Plan, is giving a sales presentation and wants to provide
some food for his guests. What can Mr. Smith provide?
A. A sit down meal offered in a separate room, before or after the promotional portion of the
event
B. A buffet dinner
C. Snacks such as cheese and crackers
D. None of the above
20) In which of the following settings is a Scope of Appointment form NOT required to be collected?
A. A formal marketing event that a beneficiary did not pre-register to attend
B. A one-on-one appointment occurring in the beneficiary’s home
C. An unscheduled meeting with a beneficiary who arrives at an agent’s office without an
appointment and requests information
D. All of the above scenarios require a Scope of Appointment form be collected.
5 Enrollment and B The ICEP coverage begins the first day of the month of
Disenrollment entitlement to Medicare Part A and Part B, OR the first
of the month following the month the enrollment
request was made (if after entitlement has occurred).
6 Enrollment and A The Annual Election Period (AEP) for enrolling in an MA
Disenrollment Plan is October 15 through December 7. Answer B is
incorrect because there is no enrollment period during
these dates. Answer C is the enrollment period for
enrolling in an MADP, but this period only allows a
beneficiary to change from an MA plan to Original
Medicare (with/without a stand-alone PDP). Answer D is
incorrect because the beneficiary is already enrolled in
Original Medicare, so there is no Initial Coverage Election
Period (ICEP) that is applicable.
7 Enrollment and A, B and If an individual moves into, resides in, or moves out of a
Disenrollment E long-term care facility (such as a nursing home) / s he is
eligible for a SEP. S/he would also be eligible for an SEP
as a result of moving out of the plan’s service area or if
his/her current plan is terminated.
13 Marketing and C Plan sales agents include those employed by the plan
Communication itself and those who are contracted with the plan
Regulations and through direct or downstream contracts. They do not
Materials for Sales necessarily have to be an employee of the plan but they
Agents and Brokers must be contracted with the plan.
15 Marketing and B Plans may make direct plan comparisons provided the
Communication information is factual and they have supporting data.
Regulations and However, plans are prohibited from using “scare tactics”
Materials for Sales or pressuring beneficiaries into enrolling.
Agents and Brokers
16 Agent and Broker C Renewal compensation should be paid up to 50% of the
Compensation current fair market value (FMV), regardless of whether
the member is new to the organization or not. The
initial rate when the member first entered the plan will
no longer be utilized to determine the renewal rate.
17 Agent and Broker B The compensation year is January through December.
Compensation “Rolling years” are not permitted. In this example, the
beneficiaries first initial year ends December 31, 2014,
and their first renewal year would be January 1, 2015
through December 31, 2015.
18 Agent and Broker C When a switch happens across organizations, and the
Compensation new organization doesn’t use agents and brokers, the
new MA organization would not make payments. The
initial plan would have to recoup for the number of
months the member was not in the plan.
19 Medicare Marketing C Meals (either provided or subsidized) are prohibited at
Activities marketing events where plan-specific benefits are
discussed and plan materials are distributed.
Refreshments and light snacks are permitted, however
agents and brokers should use their best judgment on
the appropriateness of food products provided and
should ensure that items provided could not be
reasonably considered a meal and/or that multiple items
are not being “bundled” and provided as if a meal.