Compliance

2022 Outlook: Increased Marketing Oversight Is Top MAO Compliance Concern

While CMS guidance and oversight regarding Medicare Advantage sales and marketing was rather uneventful under the Trump administration, several recent actions by the Biden administration signal a growing focus on Medicare marketing, including MA organizations’ use of third-party entities. The most notable of those was an October 2021 memorandum that explicitly reminded MAOs that they are responsible for the activities of first tier, downstream or related entities (FDRs), including third-party marketers with which they may not directly contract. CMS in that memo clarified that MA plans must submit all marketing materials to CMS prior to use, even when certain advertisements do not mention a plan by name, and reiterated this in its latest update to the Medicare Communications and Marketing Guidelines.

Feds Take Aim at Insurers’ Compliance With Mental Health Parity

A new biannual report to Congress from HHS and the departments of Labor (DoL) and Treasury has found that carriers and plan sponsors are generally not in compliance with recent regulations requiring health plans to document the level of access plan members have to mental health care. Experts say that carriers are largely to blame, but plan sponsors also need to make a greater effort to hold insurers accountable and meet new federal reporting requirements.

Several federal laws mandate mental health care parity: Health plans are not allowed to impose benefit limitations on mental health care that are more severe than limits placed on medical and surgical benefits.

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CMS Rule Seeks More Oversight of TPMOs, ‘Chain of Enrollment’

Following up on its October 2021 “Third Party Marketing” memorandum warning of misleading tactics by some organizations, CMS in its latest Medicare Advantage and Part D proposed rule said it believes “additional regulatory oversight” is needed to protect beneficiaries from “bad actors” in this space. The agency observed that an increase in third-party marketing activities in recent years has been accompanied by a rise in marketing-related complaints from beneficiaries, such as those who do not understand how an agent or broker obtained their information.

While previous guidance and rules have focused more on MA organizations’ relationships with agents and brokers, the new proposed rule serves to address the prevalence of lead-generating entities that may not directly contract with MAOs but qualify as first tier, downstream or related entities (FDRs), explains Helaine Fingold, a partner in the Health Care and Life Sciences practice at the law firm Epstein, Becker & Green, P.C.

InnovAge Replaces CEO After CMS Imposes Second Enrollment Freeze on the PACE Organization

Shortly after Denver-based InnovAge learned that CMS suspended enrollment in the company’s Colorado programs due to noncompliance, the leading Programs of All-Inclusive Care for the Elderly (PACE) provider unveiled the resignation of its longtime CEO, Maureen Hewitt. InnovAge serves more than 6,300 PACE participants, or 12% of PACE enrollees overall, and is in the midst of a major expansion. The company on Jan. 3 said Hewitt was leaving to “pursue other opportunities” and it promoted Patrick Blair, the current president, to president and CEO.

InnovAge in March 2021 began trading on the Nasdaq Global Select under the ticker symbol “INNV,” and at the time said it planned to expand its footprint of 16 centers in five states. The company in November said it expected to open three centers in fiscal year 2023 and was looking at additional locations and eyeing acquisitions in new markets.