FIRSTCAROLINACARE INSURANCE COMPANY
MEDICARE ADVANTAGE AGENT AGREEMENT
This Medicare Advantage Agent Agreement is made effective the 1st day of September, 2015 by and between
_________________________________ (hereinafter referred to as “Agent”) and FirstCarolinaCare Insurance
Company, a North Carolina company with offices at 42 Memorial Drive, Pinehurst, North Carolina 28374
(hereinafter referred to as “FCC”).
WHEREAS Agent desires to be appointed as an authorized agent to market FCC’s Medicare AdvantagePrescription Drug plans to Medicare eligible individuals; and
WHEREAS FCC desires to appoint Agent to market FCC’s Medicare Advantage-Prescription Drug plans to
Medicare eligible individuals; and
NOW THEREFORE FCC and the Agent agree that:
A. Agent hereby represents and warrants that Agent has all required licenses to perform the services required by
this Agreement, including but not limited to a current North Carolina issued insurance license for Life and
Health and Medicare/Long Term Care.
B. Agent’s authority hereunder shall be limited to marketing, soliciting and facilitating enrollments for FCC’s
Medicare Advantage-Prescription Drug (“MA-PD”) plans, marketing under the name of FirstMedicare Direct.
C. Agent represents and warrants that Agent has neither been, nor will be during the term of this Agreement: (i)
listed as debarred, excluded or otherwise ineligible for participation in federal health care programs; or (ii)
convicted of a felony or misdemeanor, excluding traffic violations (iii) the subject of a consent orders or other
action by a department of insurance in any state. If at any time Agent becomes aware of any violation of this
representation and warranty, Agent agrees to notify FCC in writing immediately.
D. Agent shall not delegate or subcontract any service, activity, or other obligation required of him/her under this
Agreement to any other person without the prior written consent of FCC. Any such delegation or subcontract,
if consented to by FCC, shall be performed by the delegate in accordance with FCC’s contractual obligations
to CMS and Agent’s contractual obligation under this Agreement (including this provision). Any attempted
delegation or subcontract by Agent without FCC’s consent shall be null and void and of no force or effect.
Agent agrees that any agreements of Agent with respect to a delegation or subcontract for which FCC has
provided consent shall be in writing, signed by the parties thereto, and in compliance with all applicable laws
and regulations. Such agreement must specify in writing: (1) the delegated activities and reporting
responsibilities; (2) FCC’s right to monitor on an ongoing basis the performance of the parties; and (3) that
subcontractor must comply with all applicable federal and state laws, regulations, and CMS instructions. In
the event that a delegate of Agent fails or is unable, for any reason whatsoever, to perform in a satisfactory
manner any services, activities or other obligations that have been delegated or subcontracted, then FCC or
CMS shall have the right to suspend, revoke or terminate such delegation effective upon the date set forth in a
written notice furnished to Agent. Additionally, FCC or CMS shall have the right to terminate the delegation,
institute corrective action plans, including suspension, or seek other remedies or curative measures respecting
the unsatisfactory delegation consistent with all applicable laws.
E.
Agent shall not hold a Member liable for payment of any fees or commissions that are the obligation of FCC.
F.
On MA-PD business placed by the Agent with FCC:
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1.
Agent shall submit all enrollment applications to FCC or its designee within 24 hours of receipt.
Enrollment applications must be signed by the Agent with the Agent’s number.
2.
As compensation for Agent’s services, Agent shall be entitled to the commission set forth on the
attached commission schedule (Exhibit A). Such commission schedules and any commission
payable thereunder may be modified from time to time by FCC, in its sole discretion.
If after the effective date of this agreement, the commissions paid or payable must be modified or
limited as a result of federal or state legal or regulatory requirements or new CMS requirements,
the commission schedules and any commissions paid or payable there under may be modified by
FCC to comply with such requirements. Such charges shall be automatically retroactive to the
effective date of the legal or regulatory changes even if such commissions has been paid or
earned. FCC shall compute and pay commissions within thirty (30) days after the end of the
calendar quarter in which the FirstMedicare Direct member is enrolled. If FCC shall, either
during the term of this Agreement or after its termination, refund premiums by reason of
cancellation or otherwise, the Agent shall return to FCC any commissions paid to the Agent
attributable to the premium so refunded. Moreover, FCC shall not pay for periods in which the
member is not enrolled or periods for which Agent payments may not be made under the
Medicare Managed Care Marketing Guidelines (Chapter 3 of CMS Pub. #116). Following
termination of this Agreement, the Agent may continue to service, and receive from FCC
commissions relative to, policies written by the Agent during the existence of this Agreement as
long as the agent meets all requirements (including training and appointment requirements) to
remain eligible for such payment.
3.
FCC shall not be responsible for the Agent’s expenses, such as rents, transportation, facilities,
salaries, wages, solicitors’ fees, postage, telegrams, telephone, express delivery, advertising or any
other expense whatsoever.
4.
In no event shall the Agent collect any premium or portion thereof from the applicant.
G. This Agreement shall terminate automatically without notice if the Agent’s license is terminated or suspended
by any public authority in any jurisdiction, or if the Agent is convicted in any jurisdiction for fraudulent or
dishonest acts, is excluded from participation in a federal insurance program or FCC discontinues its offering
of any MA-PD plan.
In the event either party engages in fraud or misrepresentation in the performance or nonperformance of any
action to which this Agreement applies, the other party may terminate this Agreement effective upon delivery
of written notice to the party engaged in the fraud or misrepresentation.
In the event either party fails to pay monies, if any, when due hereunder, the injured party may notify the
defaulting party of the deficiency in writing. The defaulting party shall be given 10 days after receipt of such
notice to cure the deficiency. If the deficiency is not cured within such time, the injured party may thereafter
terminate this Agreement effective upon delivery of written notice to the defaulting party.
FCC may terminate the Agreement in the event CMS or FCC determines that the Agent has not satisfactorily
performed the services set forth herein, and/or if requisite reporting and disclosure requirements are not fully
met in a timely manner.
In addition to the reasons set forth above, this Agreement may be terminated by either party at any time, for
any reason, by giving forty-five (45) days prior written notice to the other party, or the required statutory
notice, if longer.
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H. FCC shall indemnify and hold harmless the Agent against liability for damages and expenses, including legal
or other expenses reasonably incurred in defense or investigation of any claim or suit, arising out of FCC’s
negligence, error or omission, or willful misconduct in the preparation or handling of any contract of
insurance or billing procedure to which this Agreement applies, including compliance with the provisions of
the Federal Fair Credit Reporting Act of similar state acts, except to the extent the Agent has caused,
contributed to, or compounded such negligence, error or omission, or willful misconduct.
The Agent shall indemnify and hold harmless FCC against liability for damages and expenses, including legal
or other expenses reasonably incurred in defense or investigation of any claim or suit, arising out of the
Agent’s negligence, error or omission, or willful misconduct in the preparation or handling of any contract of
insurance or billing procedure to which this Agreement applies, including compliance with the provisions of
the Federal Fair Credit Reporting Act or similar state acts, except to the extent FCC has caused, contributed
to, or compounded such negligence, error or omission, or willful misconduct. Agent shall maintain
professional liability insurance in an amount reasonably sufficient to cover its professional liability, but not
less than One Million Dollars ($1,000,000) per incident/Three Million Dollars ($3,000,000) per year.
As a condition to the provision of indemnification as set forth above, each party shall promptly notify the
other party of any such claim or suit and shall cooperate with the other party in the investigation or defense
thereof. Each party shall, at its option, have the right to assume or participate in the defense of such claim or
alleged liability.
I.
General Provisions:
1. This Agreement constitutes the full, complete, and entire agreement between the parties and
supersedes all prior understandings, agreements, or arrangements between the parties with respect to
the subject matter hereof. This Agreement may be revised or modified at any time by written
agreement of the parties. FCC may unilaterally revise or modify this Agreement after giving the
Agent sixty (60) days advanced written notice of the proposed changes.
2. The only relationship between Agent and FCC shall be as an independent contractor representing
FCC. Nothing contained herein shall be construed to create an employer/employee relationship.
3. The Agent shall have no power or authority, personally or on behalf of FCC to bind or commit FCC
to any coverage.
4. The Agent shall have no power or authority, personally or on behalf of FCC, to waive any forfeiture
or to alter or discharge or waive any of the terms or conditions of any policy or contract.
5. The Agent shall not commit FCC as to any cost, expense or liability in connection with any claim or
loss, which may occur under any contract of insurance. The Agent shall promptly report all claims
and losses and turn over all legal process involving coverages placed with FCC to the nearest claims
office or to the home office of FCC.
6. The Agent shall hold and preserve all records relating to transactions by or for FCC, and all other
property of FCC (including forms and other supplies furnished by FCC) which at any time shall come
into the Agent’s possession or control, and shall surrender them to FCC upon demand. All
accounting and other records of the Agent pertaining to the business of FCC shall be subject to
inspection during normal business hours by representatives of FCC. This paragraph shall survive the
termination of this Agreement.
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7. The Agent shall not publish, broadcast, distribute, or otherwise disseminate any advertisement,
promotional material, or other like matter referring to FCC or FirstMedicare Direct without first
securing FCC’s express written approval.
8. The Agent shall notify FCC of any pending or actual significant change to the structure or business of
the Agent, including any dissolution, merger, or acquisition. Such notice shall be in writing and shall
be given to FCC as far in advance as is practicable under the circumstances.
9. This Agreement shall not be assigned or transferred and any attempt to do so shall be null and void
and of no force and effect.
10. This Agreement shall be governed by and construed in accordance with the laws of the State of North
Carolina.
11. Any disagreement of dispute between the parties to this Agreement in regard to the terms, conditions,
or performance hereof, shall by request of either party, be submitted to binding arbitration before a
panel of three disinterested arbitrators. Each party shall select an arbitrator within 10 days of the
request for arbitration. If a party fails to select an arbitrator within such time, the other party shall
select the arbitrator. The two arbitrators shall then select a third arbitrator. If the two arbitrators
cannot agree on a third arbitrator, the selection of a third arbitrator shall be made by any court of
competent jurisdiction. The arbitration shall be conducted at a mutually convenient site in the State
of North Carolina. The cost of said arbitration shall be borne by the losing party.
12. Any notice required by this Agreement shall be in writing and shall be delivered in person by United
States mail or by overnight or other priority mail service to the other party at that party’s last known
address.
13. No waiver, either direct or by operation of law or equity, of strict compliance with and performance
of any term or condition of this Agreement, or any breach of it on the part of either party, shall be
held or deemed to be a waiver of any subsequent failure of strict compliance with and performances
of any and every term of it, or any breach of it.
14. If any provision of this Agreement shall be held to be invalid, illegal, or unenforceable, such
provision shall be ineffective only to the extent of such invalidity, illegality, or unenforceability,
without rendering invalid, illegal, or unenforceable the remainder of such provision or the remaining
provisions of this Agreement.
15. The headings contained in this Agreement are provided for convenience only. They form no part of
this Agreement and shall not affect its construction or interpretation.
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IN WITNESS WHEREOF, the Parties hereto have executed and delivered this Medicare Advantage Agent
Agreement as of the Effective Date.
FirstCarolinaCare Insurance Company
By:
Name:
Title:
Date:
Agent
By:
Name:
Title:
Date:
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Exhibit A
FirstCarolinaCare Insurance Company
Medicare Advantage
2017 Agent Compensation Schedule
Compensation will be paid on a quarterly basis, based on the quarter in which the member was originally
enrolled, as follows:
$443.00 for new enrollments (defined as not an MA-PD plan replacement).
$222.00 for renewals years 2-6 and enrollments resulting from MA-PD plan replacement.
Mbr Eff Date/Anniversary
Annual Enrollment Period
Pay Date
April 15
First Quarter
June 15
Second Quarter
September 15
Third Quarter
December 15
Fourth Quarter
December 31
Commission Type
New
Renewal/Replacement
New
Renewal/Replacement
New
Renewal/Replacement
New
Renewal/Replacement
New
Renewal/Replacement
Paid Amount
In Full
Prorated*
In Full
Prorated
In Full
Prorated
In Full
Prorated
In Full
Prorated
*Pro rata share is calculated on a monthly basis.
All commission payments described herein are subject to adjustment or termination according to CMS guidelines
as set forth in the Agreement.
Exhibit B
Medicare Advantage Regulatory Exhibit
The terms and conditions contained in this Medicare Advantage Regulatory Exhibit are hereby incorporated into,
and made a binding part of, the Medicare Advantage Agent Agreement between FCC and Agent. In the event
there is a conflict between the Agreement and the MA Regulatory Exhibit, the terms and conditions of the MA
Regulatory Exhibit shall control.
A. Federal Funds. In accordance with, but not limited to, 42 C.F.R. 423.100, the Agent acknowledges that
payments the Agent receives from FCC to provide services to Medicare Advantage enrollees, are, in whole or
part, federal funds. Therefore, the Agent and any of its subcontractors may be subject to certain laws that are
applicable to individuals and entities receiving federal funds.
B. Compliance With State and Federal Laws. The Agent shall comply with all state and federal laws,
regulations, instructions, and policies relevant to the activities to be performed under the Agreement, whether
or not specifically stated in this MA Regulatory Exhibit, including, but not limited to, CMS instructions and
obligations imposed by the CMS Manual.
C. Compliance With CMS Contract Provisions. As set forth in the CMS Manual, Chapter 11 §110.1, the
Agent agrees that any services provided by the Agent to FCC’s Medicare Advantage enrollees will, to the
extent of Agent's responsibilities, comply with FCC’s Medicare Advantage contractual obligations to CMS
(the "CMS Contract Provisions") as described in this section.
1. Material Provisions. The material requirements and conditions of FCC's Medicare Advantage contractual
obligations to CMS are as follows:
a. To accept new enrollments, make enrollments effective, process voluntary disenrollments, and limit
involuntary disenrollments as provided in CMS Manual, Chapter 2;
b. Not to discriminate in regards to beneficiary enrollment;
c. To provide the basic benefits and to the extent applicable, supplemental benefits;
d. To provide access to services in accordance with the standards set forth at 42 CFR 422.112 (for a
coordinated care plan) or 42 CFR 422.114 (for a private fee-for-service plan);
e. To provide health care services in a manner consistent with professionally recognized standards of
health care;
f. To disclose information to beneficiaries in the manner and the form prescribed by CMS;
g. To operate a quality improvement program in accordance with 42 CFR 422.152;
h. To comply with all applicable provider requirements and specific physician requirements;
i. To comply with all requirements governing coverage determinations, grievances, and appeals;
j. To comply with all reporting requirements including the submission of data;
k. To accept payment;
l. To develop and submit an annual bid proposal and submit all the required information on premiums,
benefits, and cost-sharing by the due date specified in the statute, which is the first Monday in June of
each calendar year;
m. To acknowledge that CMS may not renew or may terminate its MA contract;
n. To comply with all the requirements that are specific to a type of MA plan;
o. To comply with the confidentiality, privacy, and enrollee record accuracy requirements;
p. To submit to CMS certified financial information demonstrating that the organization has a fiscally
sound operation; and
q. To submit to CMS information as CMS may require.
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2. Other Contractual Provisions Incorporated. Pursuant to the CMS Manual, Chapter 11 §110.1, in addition
to the material CMS Contract Provisions described in Section 1 above, this Medicare Advantage
Regulatory Exhibit incorporates by reference the contract language requirements set forth in the CMS
Manual, Chapter 11 §100.
D. Downstream Entities. As set forth in the CMS Manual, Chapter 9 §40 and Chapter 11 §110, in the event
Agent enters into sub-contracts to perform services pursuant to the Agreement, Agent shall require its
subcontractors, and all downstream and related entities (individually, "Downstream Entity," and, collectively,
"Downstream Entities"), be bound by the obligations set forth under the Agreement and herein. FCC reserves
the right to approve, suspend, or terminate any Downstream Entity selected by Agent, pursuant to CMS
Manual, §110.2. Producers, as defined in the Agreement, are bound by the terms herein.
E. Confidential Information. Agent, its employees, agents, assigns and downstream entities shall comply with
all state and federal laws regarding confidentiality and disclosure or medical records or other health and
enrollment information, as well as those confidentiality requirements established by FCC and CMS for the
MA-PD program. Agent acknowledges that it is a “business associate” of FCC, as that term is defined by the
Health Insurance Accountability and Portability Act of 1996 (“HIPAA”) and has entered into a business
associate agreement with FCC.
F. Inspection of Books and Records. As set forth in 42 CFR 422.504(i)(2)(i), Agent acknowledges that the
Department of Health and Human Services (HHS), the Comptroller General, or their designees have the right
to inspect, evaluate, and audit any pertinent contracts, books, documents, papers, and records of Agent, or its
Downstream Entities, involving transactions related to FCC’s Medicare Advantage contract through ten (10)
years from the final date of the contract period, or from the date of the completion of any audit, whichever is
later. For the purposes specified in this provision, Agent agrees to make available Agent’s premises, physical
facilities and equipment, records relating to FCC’s Medicare Advantage enrollees, and any additional relevant
information that CMS may require.
G. Monitoring & Oversight. As set forth in the CMS Manual, Chapter 09 §40, §50.6, and Chapter 11 §110.2,
FCC shall undertake monitoring and auditing to test and confirm compliance with Medicare regulations, subregulatory guidance, contractual agreements, and all applicable federal and state laws. Agent acknowledges
that FCC shall oversee and monitor Agent’s performance of its responsibilities set forth in this Agreement on
an ongoing basis, and shall conduct a formal review of Agent's performance at least annually.
H. Right to Revocation. As set forth in the CMS Manual, Chapter 11 §100.5 and §110.2, FCC may revoke the
Agreement in the event CMS or FCC determines that the Agent has not satisfactorily performed the services
set forth herein, and/or if requisite reporting and disclosure requirements are not fully met in a timely manner.
Furthermore, pursuant to Chapter 3 §120.2, FCC shall report the termination of the Agent, or any Producer,
and the reasons for such termination, to CMS and in accordance with state appointment law.
I. Compliance Program. As set forth in the CMS Manual, Chapter 9 §50.1-50.2, FCC shall maintain an
effective Compliance Program, including (i) written policies, procedures, and standards of conduct (the
"Policies & Procedures"), and (ii) the designation of a Compliance Officer and Compliance Committee
responsible for high-level oversight. Agent and its Downstream Entities shall comply with FCC's Policies &
Procedures. FCC shall provide a copy of its then current Policies and Procedures Manual to the Agent upon
its request. Agent shall be required to submit to FCC an annual attestation of compliance with FCC’s
compliance program and applicable CMS requirements.
J. Training and Education. As set forth in the CMS Manual, Chapter 3 §120.3 and Chapter 9 §50.1, and in
addition to the terms and conditions set forth in Section III of the Agreement, Agent agrees to complete the
requisite Training and Education in Medicare Advantage program compliance, and fraud, waste, and abuse, as
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set forth in 42 CFR 422.503(b)(4)(vi)(C). Agent also shall satisfactorily complete FCC’s annual MA-PD
training.
K. Compensation. The terms and conditions of Agent's Compensation, as described in Section V of the
Agreement, and in Exhibit A, are subject to the regulations set forth in the CMS Manual, Chapter 3 §120.4.
Under §120.4.3-120.4.7, FCC shall pay the Agent on a six (6) year compensation cycle where the aggregate
compensation amount paid for selling a beneficiary during each of the five (5) individual renewal years of a
six (6) year cycle must be fair-market value for the work performed and no more, and no less, than fifty
percent (50%) of the aggregate compensation amount paid for that beneficiary in the initial year of the six (6)
year cycle. FCC shall notify CMS annually of such amounts, which shall be no more than the adjusted fair
market value cut-off amounts released each spring by CMS. FCC shall recover compensation payments from
the Agent, and/or Producers, if (i) a beneficiary disenrolls from an FCC Product within the first three months
of enrollment ("rapid disenrollment"), or (ii) any other time a beneficiary is not enrolled in an FCC Product.
FCC shall not pay Agent a commission rate that is based upon the value of the Medicare Advantage business
generated for FCC (i.e., profitability of the Agent's book of business). Compensation for Agent's services
shall not be tied or linked in any way to a beneficiary’s health risk profile.
L. Effective Communication & Reporting Requirements. As set forth in the CMS Manual, Chapter 9 §50.4,
FCC must establish and implement effective lines of communication between high-level compliance officials,
the Agent, and Producers, including confidential, anonymous methods for the good faith reporting of potential
compliance issues as they are identified.
M. Disciplinary Standards. As set forth in the CMS Manual, Chapter 9 §50.5, FCC shall establish wellpublicized disciplinary standards by encouraging good faith participation in the compliance program by all
affected individuals. These standards shall include policies that (i) articulate expectations for reporting
compliance issues and assist in their resolution; (ii) identify noncompliance or unethical behavior; and (iii)
provide for timely, consistent, and effective enforcement of the standards when noncompliance or unethical
behavior is determined. FCC shall maintain disciplinary records for a period of ten (10) years for all
compliance violation disciplinary actions. Pursuant to the CMS Manual, §50.5.3, disciplinary records must
include (i) the date the violation was reported, (ii) a description of the violation, (iii) the date of investigation,
(iv) a summary of findings, (v) the disciplinary action taken, and (vi) the date such action was taken.
N. Ineligibility. As set forth in the CMS Manual, Chapter 9 §50.6.8, Agent warrants and represents that at the
time of entering into the Agreement, neither it, its employees, agents, nor any of its Downstream Entities, are
(i) excluded from participation in Medicare under Section 1128 or 1128A of the Social Security Act, and/or
(ii) ineligible persons identified on the General Services Administration's List of Parties Excluded from
Federal Programs, and/or the HHS/Office of Inspector General (the "OIG") List of Excluded
Individuals/Entities. In the event Agent, or any employee, agent, or Downstream Entity thereof, becomes an
ineligible person after entering into the Agreement, or otherwise fails to disclose his/her/its ineligible person
status, Agent shall have an obligation to (1) immediately notify FCC of such ineligible person status, and (2)
within ten (10) days of such notice, remove such individual from responsibility for, or involvement with,
FCC’s business. FCC retains the right to provide notice of immediate termination of the Agreement to Agent
in the event it receives notice of Agent's ineligible person status.
O. Regulatory Non-Compliance. In accordance with, but not limited to, 42 C.F.R. 423.505(i)(5), if during the
term of the Agreement, FCC concludes that it is necessary to cancel any of the activities to be performed
under this Agreement in order to comply with federal or state laws, regulations, or policies, FCC may, at its
discretion, cancel the activity and be relieved of any related obligations under the terms of the Agreement. If
FCC or Agent concludes that it is necessary to reorganize or restructure any of the activities to be performed
under this Agreement in order to comply with federal or state laws, regulations, or policies, FCC or Agent
may request to renegotiate such terms.
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P. Prohibited Remunerations. Agent specifically represents and warrants that activities to be performed under
the Agreement are not considered illegal remunerations (including kickbacks, bribes, or rebates) as defined in
§1128B(b) of the Social Security Act.
Q. Marketing.
1. Marketing Materials. As set forth in the CMS Manual, Chapter 3 § 30.5 and §120, all printed materials,
including but not limited to letters to FCC’s members, brochures, advertisements, telemarketing scripts,
or packaging that is prepared or produced by Agent or any of its subcontractors pursuant to this
Agreement must be submitted to FCC for review and approval at each planning stage (e.g. creative, copy,
mechanicals, blue lines, etc.) to assure compliance with state and federal guidelines. FCC agrees its
approval will not be unreasonably withheld or delayed.
2. Prohibition of Incentives to Beneficiaries. As set forth in the CMS Manual, Chapter 3 §70, Agent shall
not provide or offer gifts or payments, including meals, to beneficiaries as an inducement to enroll in an
FCC Product. Notwithstanding provisions contained herein, Agent may provide beneficiaries with a gift
of "nominal value," so long as such nominal gift is provided whether or not the individual purchases an
FCC Product. For purposes of this Agreement, nominal value is defined as an item having little or no
resale value and which cannot be readily converted into cash. Generally nominal value gifts are worth less
than fifteen dollars ($15.00). In addition, while Agent may describe legitimate benefits the beneficiary
may receive, Agent is prohibited from offering or giving rebates, dividends, or any other incentives,
especially those that in any way compensate for lowered utilization of health services by such beneficiary.
3. Unsolicited Contacts. As set forth in the CMS Manual, Chapter 3 §70, Agent may place a call or make a
visit to a beneficiary that it enrolled into an FCC Product, as long as such beneficiary remains enrolled
with the FCC plan ("member") or to a beneficiary who has expressly given permission for such contact
(e.g. by filling out a business reply card, or asking an FCC Beneficiary Service Representative to have
Agent contact beneficiary). Agent is prohibited from the following marketing activities:
a. Placing any outbound marketing calls to beneficiaries, unless the beneficiary requested the call;
b. Placing calls to former members who have disenrolled or to current members who are in the process
of voluntarily disenrolling, to market plans or products;
c. Placing calls to members or beneficiaries to confirm receipt of mailed information, unless otherwise
set forth herein;
d. Placing calls to members or beneficiaries to confirm acceptance of appointments made by third
parties or independent agents;
e. Approaching members or beneficiaries in common areas (e.g. parking lots, hallways, lobbies, etc.);
f. Placing calls to or visiting members or beneficiaries who attended a sales event, unless the members
or beneficiaries gave express permission for such follow-up contact; or
g. Marketing non-health care related products (such as annuities and life insurance) to beneficiaries
during any Medicare Advantage sales activity or presentation ("cross-selling").
4. Outbound Scripts. As set forth in the CMS Manual, Chapter 3 §80, any outbound call scripts utilized by
the Agent to contact beneficiaries on behalf of FCC must be submitted to FCC, and ultimately to CMS,
for review and approval prior to use in the marketplace. In addition, when conducting outbound calls,
Agent must ensure the scripts include a privacy statement clarifying that the beneficiary is not required to
provide any information to FCC or Agent and that the information provided will in no way affect the
beneficiary’s membership in a competitive Medicare Advantage plan.
5. Scope of Appointments with Beneficiaries. As set forth in the CMS Manual, Chapter 3 §70, the Agent
shall clearly identify the FCC Product that will be discussed before marketing to a beneficiary, and the
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beneficiary must agree to the scope of the appointment, and such agreement shall be documented by the
Agent. Agent shall maintain the required documentation providing the scope of the appointment and will
provide such documentation to FCC upon request.
6. Marketing in Health Care Settings. As set forth in the CMS Manual, Chapter 3 §70.12, Agent shall not
conduct sales presentations or distribute/accept enrollment applications in areas where patients primarily
intend to receive health care services, including, but not limited to, waiting rooms, exam rooms, hospital
patient rooms, dialysis centers, and pharmacy counter areas (where patients wait for services or interact
with pharmacy providers and obtain medication).
7. Marketing at Educational Events. As set forth in the CMS Manual, Chapter 3 §70.9, Agent shall not
conduct marketing activities at educational events.
8. Other Marketing Provisions Incorporated. In addition to the material CMS Contract Provisions described
above, this Medicare Advantage Regulatory Exhibit incorporates by reference all applicable contract
requirements set forth in the CMS Manual, Chapter 3.
R. Beneficiaries Held Harmless. In accordance with, but not limited to, 422.504(i)(3) and 422.504(g)(1) and
(2), both parties agree that in no event shall Agent bill, charge, collect a deposit from, seek compensation,
remuneration or reimbursement from, or have any recourse against a Medicare Advantage member,
beneficiary, or enrollee. This provision does not prohibit the collection of supplemental charges or copayments on FCC’s behalf made in accordance with the terms of the Medicare Advantage benefits.
S. Anti-Discrimination. As set forth in the CMS Manual, Chapter 3 §70, Agent shall not employ
discriminatory practices that preferentially enroll healthier beneficiaries, or mislead beneficiaries.
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Exhibit C
If Agent is a corporation, LLC, etc., please list individual brokers covered under this Agreement.
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