Medicare Compliance & Reimbursement

Physician PDP promotion also under watch.

On the heels of the Center for Medicare and Medicaid Services' announcement that Medicare prescription drug plans will offer coverage at a lower cost than first expected, the agency has now released new guidelines for how companies can market that coverage.

Fueling the already intense competition for beneficiaries' drug-plan dollars are CMS' findings that drug plans' average monthly premium will be $32.20, about $5 less per month than previously estimated.

This means that the total cost to government should be $15 less per month for each beneficiary than was first thought, which should save taxpayers billions of dollars in the program's first year, CMS said.

"The average premium is lower than projected because the weighted average of the actual bids from stand-alone prescription drugs plans, which work with traditional Medicare coverage, and from Medicare Advantage plans are lower than had been predicted," according to an agency Aug. 9 press release.

"With robust competition, plans that do not offer low costs for high-quality benefits will have to charge higher premiums and will not attract beneficiaries," according to the CMS statement.

To protect beneficiaries in such a competitive environment, CMS unveiled Aug. 15 marketing guidelines that prohibit companies from using any potentially "unscrupulous or overzealous sales tactics." The guidelines govern stand-alone PDPs, Medicare Advantage plans, and Medicare Advantage PDPs' marketing activities. Beneficiaries can begin to enroll in the program on Nov. 15, 2005, while plans can start marketing as of Oct. 1. The PDP kicks into gear on Jan. 1, 2006.

As part of the marketing guidelines, Medicare requires PDPs adhere to the following:
  Representatives can't make door-to-door sales calls or send unsolicited emails.
  If plans use brokers or independent agents, those individuals must follow state licensing requirements.
  Plans that employ marketing representatives must ensure that those representatives meet all state requirements, including licensure and certification or registration.
  When using telephone solicitations, plans must comply with the National Do-Not-Call Registry, honor "do not call again" requests, and abide by federal and state calling hours and any other applicable requirements. Find Out What Physicians Can and Can't Do The guidelines also address physicians and other health care providers' role in selling PDPs. Providers can offer objective information about plans and coverage, and can "make available" plan marketing materials that announce contractual relationships between the plan and provider. But healthcare professionals can't steer beneficiaries to a plan to further their own financial interests.