Medicare Collective

Mission Statement

• To support insurance and financial professionals specializing in Medicare and healthcare solutions.
• To provide resources, advocacy, and education to help them navigate the complexities of healthcarerelated products and regulations.
• To collaborate within the healthcare ecosystem to establish best practices.
• To inform policymakers based on our firsthand observations, often in the home, with tens of millions of everyday Americans.

The following principles will guide us as broad and enduring guidelines and organizational approaches to consider as we serve our clients. These principles are mutually reinforcing of existing federal, state, and local regulations, as well as the code of ethics upheld by each state’s Department of Insurance.

1. Client-Centric Service: We will empower the American people with personalized solutions and ongoing support so they can better manage their health and navigate the complex health care system.
   1. Prioritize the needs and goals of clients: ensuring the beneficiary is enrolled in a plan that fits their health needs, financial situation, and personal preferences. The primary focus for brokers in plan selection should consider out-of-pocket expenses, in-network access to preferred providers, and that prescription drugs are covered under the plan’s formulary. Supplemental benefits may also be important to the client, but they must be considered holistically in conjunction with the core benefit structure.
   2. Transparency, accountability, and aligned incentives: Transparency and accountability are essential to maintaining integrity in the Medicare program. Equally important are aligned incentives. Bad actors who employ aggressive sales tactics or circumvent CMS regulations must be identified, retrained, or removed from the system. Such practices erode trust, compromise the accuracy of needs analyses, and disrupt beneficiaries’ care plans—potentially leading to adverse health outcomes.
2. Compliance and Regulatory Integrity: Compliance sets the standards around quality, which upholds confidence in the Medicare program. The elimination of fraud, waste, and abuse is also a part of compliance and regulatory integrity.
   1. Adhere to CMS rules, HIPAA, and insurance regulations. Specifically, when it relates to broker performance, we should look closely at these five areas: accretion, rapid disenrollment, annual retention, complaints to the health plan, and complaints to Medicare. These five lagging indicators taken together will expose broker opportunism and malfeasance. Carriers independently have immediate access to all this data and can compile and publish lists revealing both the best and worst performers. Some carriers already do this.
   2. Maintain ethical marketing and sales practices. Specifically, carriers should not heap commissions because it circumvents the existing rules around commission payments, incentivizes bad behavior, and does not promote ongoing service of the client.
   3. Collaborate with regulators: Work with NAIC and DOI to help identify, reduce, and eliminate broker malfeasance.
3. Knowledge and Expertise: We equip beneficiaries with better information by maintaining a deep understanding of Medicare Advantage, Part D, Medigap, and supplemental products.
   1. Implementing known best practices: Known best practices that are leading indicators of quality, such as conducting a 10-day post-enrollment call to confirm that the member received their proof of coverage.
   2. Ongoing broker education: Keeping brokers informed through regular updates on program changes, plan benefits, coverage modifications, and eligibility requirements is essential to maintaining compliance and ensuring accurate guidance for beneficiaries.
4. Accessibility and Responsiveness: Clients deserve accessibility and responsiveness from both their broker and the overall healthcare system.
   1. Ongoing service and communication: Brokers must maintain ongoing communication with their clients to monitor their experiences when interacting with the healthcare system.
   2. Responsiveness and action: Brokers respond promptly to questions, observations, and other assistance requests. Brokers work with their Broker Resource Integration Organization (BRIO) when they are unable to resolve the situation.
5. Continuous Improvement: The healthcare industry is rapidly evolving due to unprecedented advances in science, technology, and human behavior. Overall, these forces are creating new models of care, and the broker distribution and service elements must evolve too. Value-based care and personalized medicine are the future direction of healthcare.
   1. Regularly analyze client feedback, retention metrics, and market trends to identify patterns, uncover opportunities, and proactively address challenges in service delivery.
   2. Continuous Process Improvement: Implement process improvements to enhance client experience
   3. Establish a common vocabulary: To effectively collaborate with rule makers, legislators, carriers, and other industry stakeholders, we must establish a shared vocabulary grounded in clear and appropriate definitions. This common language enables us to accurately describe and evaluate the actions, tactics, techniques, procedures, and operations—both desirable and undesirable—within our industry. It also fosters meaningful dialogue among ourselves and with other professionals, enabling us to evolve and adapt our collective body of knowledge, including our guiding principles and core tenets.
6. Collaboration and Partnership: Healthcare is a team effort and a complicated value stream. We must work together to map out the lifecycle of a beneficiary and define what actions should be taken on that journey, by whom, and to what extent.
   1. Stakeholder collaboration: Work effectively with carriers, brokers, and other stakeholders to improve the beneficiary’s experience and confidence with the Medicare program.
   2. Brokers and BRIOs are an additional resource in a resource-constrained industry: Brokers must be viewed as industry professionals and more tightly coupled into the tools and processes of other industry participants.
7. Decision-making support tools: Artificial intelligence and other technologies are rapidly evolving to allow new levels of productivity and analytical capability. As we integrate these tools into our workflows, it is essential to use them as decision support systems to enable a human being to perform higher-order tasks, such as building trust and rapport.
   1. Public safety net: Carriers will continue to automate processes, and brokers and BRIOs must serve as a safety net, especially when automation creates barriers to care.
   2. Enhancing Performance Through Data-Driven Tools: Leverage data to develop and deploy decision support tools that improve industry performance and elevate client satisfaction. These tools should empower professionals with actionable insights, streamline operations, and support informed, personalized guidance for beneficiaries.
8. Consumer Protection: Brokers and Broker Resource Integration Organizations (BRIOs) should work as a single unit to represent beneficiaries when the system does not work for them, specifically:
   1. Guide to Quality: Brokers guide people towards high-quality care and away from low-quality care, which prevents harm to the beneficiary from happening in the first place. Brokers and BRIOs help beneficiaries understand, unlock, and access plan benefits. Evidence of Coverage documents can unintentionally create obstacles to ongoing care, making it difficult for individuals to maintain access to the services they need. Brokers identify and remove barriers that beneficiaries may not be equipped to navigate alone.
   2. Grievances and appeals: There is room for improvement: Despite over 50 million denials annually, only about 11% are appealed. Yet, of those appeals, an impressive 87% are successful.
   3. Additional Resources: Brokers and BRIOs help beneficiaries obtain additional resources available beyond the plan’s benefit structure. For example: Qualify for Medicaid and apply for Medicaid redetermination; apply for state pharmaceutical assistance programs and access community-based resources (such as transportation).