New Medicare Opt-Out Provision: What’s Included

The Centers for Medicare & Medicaid Services (CMS) recently released the 2024 Rate Announcement and Final Rule, including a provision requiring Medicare Advantage (MA) plans to “notify enrollees annually, in writing, of the ability to opt out of phone calls regarding MA and Part D plan business.” The overall requirement is not new, but what is new is the requirement to provide the notification in writing. As plans operationalize this provision, there are several things to take into consideration and ensure staff understands and can articulate.

Can members opt out of all calls from the plan?

No. This annual, written notification only applies to calls regarding plan business as defined by CMS in the Medicare Advantage Program Communication Requirements. The definition is actually quite narrow.

How does CMS define plan business?

Calls regarding plan business are calls related to helping a beneficiary choose a Medicare Advantage plan.

42 CFR §422.2264(b)/42 CFR §423.2264(b) of the Code of Federal Regulations defines plan business for this purpose as contact of current, and to a more limited extent former members, including those enrolled in other products offered by the parent organization to discuss plan business across products. Some examples include:

• Calling current enrollees in non-Medicare products about aging into Medicare from commercial products.
• Calling members in a Part D plan to discuss other Medicare products.
• Calling members submitting enrollment applications to discuss enrollment business.
• Agents or brokers calling clients about other projects they sell, such as auto or home insurance.
• Medicare Advantage Organizations making unsolicited calls about other lines of business as a way to generate Medicare plan leads.

What types of calls do not fall under the opt-out provision?

Calls that don’t meet this definition of plan business are not subject to the annual opt-out requirements. This means that, unless an MAO structures their opt-outs too loosely, the new requirements do not apply to calls intended to manage member care, coordinate coverage or meet member needs.

Operational Considerations

As your plan works to structure and execute the required annual opt-out of phone calls for plan business, it is important to carefully structure the wording used when giving members the ability to opt-out so that you do not mistakenly allow members the option of opting out of quality, Stars, and non-regulated outreaches.

Here’s a checklist to help you jumpstart your review:

• How do you currently notify members of the new opt-out option and how do you accept requests?
• Do you have member materials that explain the extent of the opt-out, including what it applies to and what calls they may still receive? Can this be leveraged for the written notification, or do you need to develop new content?
• Who typically receives the member’s initial request? Sales teams, customer service, appeals and grievances, care management or another department?
• Do all internal and external partners know what to do when they receive a request and how to differentiate the opt-outs for plan business from Stars, quality, care management, onboarding and other calls?
• How is the request documented? Who updates the information and what is the source of truth? Is there a centralized data repository (operational data store or enterprise data warehouse) in which the member choice is maintained?
• How is the information disseminated to appropriate departments?  How are opt-outs for plan-business coded differently from other opt-outs?
• How is staff trained regarding the Do Not Call List, member opt-out of phone calls, and any other member-imposed restrictions on communication?
• What is the schedule and mechanism for the annual notification? Do you include it with the Annual Notice of Change or Evidence of Coverage documentation, welcome kit, or as a separate mailing at the beginning of each year?
• What instructions are you providing to the member? Do they have to return something to the plan? Can they opt out by phone? Is there an option on the member portal for the opt-out?

Complying with CMS’ heightened communications requirements will require adjustment to processes, data storage, and member communication approvals. Our team has expertise in all aspects of this process and can help. For more information, please contact me at Cherie.shortridge@healthmine.com.