Policies and Procedures Manual

Version 1

Table of Contents

1.    Commitment to Compliance

  • Compliance Charter

2.    Organization Chart

  1. Policy on Policies
    • Policy Statement
    • Policy Purpose (Scope)
    • Policy Provisions and Exhibits (Procedure)
      • Development and Review
      • Approval and Communication
      • Restriction on Distribution of Policies and Procedures

4.    Company Compliance and Regulatory Affairs

  • State License
  • Carrier Appointments
  • Carrier Certification
  • Disaster Recovery
    • Temporary Displacement
    • Permanent Displacement or Restructuring

5.    Internal Employees

  • New Hires
  • Employee Files
  • The Violent Crime Control and Law Enforcement Act
  • Office of Inspector General Exclusions
  • System for Award Management (SAM) Exclusion List
  • Code of Conduct
  • Corrective and Disciplinary Action
  • Reporting of Disciplinary Action
  • Employee Separation 5.10.In-House Licensed Agents

5.11.Distribution of Carrier Documents

6.    Internal Employee Training

  • Telesales Agents
  • Administrative Staff
  • Enrollment Staff
  • In-House Licensed Agents

Table of Contents

  1. Agent Compensation
    • Payment Guidelines and Compliance for External Agents
    • Payment Guidelines and Compliance for Internal Agents
    • Chargeback Process
    • Rapid Disenrollments
    • Agent Files
      • Agent Contracting
      • Required Tax Forms

8.    HIPAA Compliance

  • Personal Health Information (PHI) and Personally Identifiable Information (PII)
    • Member Files
    • Agent Files
    • Employee Files
  • Email
  • Passwords
  • Secure Areas
  • Logical Access

9.    Privacy and Security

  • Personal Health Information (PHI) and Personally Identifiable Information (PII)
    • Access to Personal Health Information or Personally Identifiable Information
    • Personal Health Information or Personally Identifiable Information Policies and Procedures
  • Collection of Personal Health Information or Personally Identifiable Information
    • Sensitive Personal Health Information or Personally Identifiable Information
  • Use and Retention of Personal Health Information or Personally Identifiable Information
  • Disclosure and Cross-Border Transfers
    • Disclosures of Personal Health Information or Personally Identifiable Information
    • Transfer of Personal Health Information or Personally Identifiable Information
  • Security of Personal Health Information or Personally Identifiable Information
  • Data Quality
  • Monitoring and Enforcement
    • Reporting
    • Review
    • Disciplinary Actions

Table of Contents

  1. MIPPA Compliance
    • External Agent Contracting
    • External Agent Certification and Training
    • Sales and Marketing Events
    • Scope of Appointment Forms
    • Agent Code of Conduct
    • MIPPA Rules and Regulations
    • Prohibited Practices

11. Agent Oversight

  • Agent Licensing and Contracting 11.1.1.Agent Contracting

11.1.2.Records Retention and Maintenance 11.2.Reporting of Terminated Agents 11.3.CMS Approved Material

11.4.Downline Oversight

12. Agent Violations

  • Carrier Originated Complaint Process 12.2.Agent Violations Uncovered Internally 2.1.Documentation of Violation(s)

12.2.2.Agent Re-Training 12.2.3.Reporting of Violation to Carriers 12.2.4.Corrective and Disciplinary Actions 12.2.5.Termination of Agents

12.3.Agent Violations Uncovered by FMO (External Source) 12.4.Agent Reporting of Violations

13. Telesales

  • Telesales Code of Conduct and Ethics
  • Telesales Contracting and Appointment Process
  • Telesales Certification and Training Process
  • Call Recordings
  • Call Scoring and Retraining
  • CMS Approved Materials
  • Telesales Agent Code of Conduct and Ethics

Addendums

PP – 5.1a “Code of Conduct”

PP – 10.5a “Agent Code of Conduct”

PP – 12.2.1a “Agent Violation Report”

PP – 12.2.1a “Agent Counseling Report”

Table of Contents

PP – 13.1a “Telesales Code of Conduct and Ethics”

PP – 13.7a “Telesales Agent Code of Conduct and Ethics”

Appendixes

PPA – 1 “Insider Trading and Fair Disclosure Policy”

PPA – 2 “Policy on Maintaining a Safe, Healthy and Affirmative Workplace” PPA – 3 “Corporate Contribution Policy”

PPA – 4 “Foreign Corrupt Practices Act (FCPA) Policy” PPA – 5 “Public Relations/Media Inquiries Policy”

 

Forms:

 

Acknowledgment of Receipt

 

Our Commitment to Compliance

American Exchange’s Policies and Procedures Manual forms the basis of our Compliance Program. The purpose of this program is to ensure the highest standards of morals and compliance by all employees, Downstream Call Centers and Subcontracted Agents, and to provide guidance on conducting business in an ethical manner.

Our policies and procedures apply to all employees, Downstream Call Centers and Subcontracted Agents. They do not create any contractual agreement between the Company and its employees or the aforementioned entities, nor does it guarantee any promise of employment.

This manual and the code found within may be changed or amended by American Exchange at any time.

Compliance Charter 

Introduction

The principle purpose of the Company’s Compliance Program is to promote and facilitate corporate governance of operations and services rendered in accordance with established laws, regulatory requirements, and the Policies and Procedures of the Company.  The Compliance Program ensures the business operations, of every individual who conducts business for or on behalf of the Company, reflect the values, integrity and commitment to compliance that the Company strives to meet.

Responsibilities and Obligations

The Company’s Compliance Program is guided by the principles contained within the Company’s corporate responsibilities.  It includes the 7 key elements of an effective compliance program (see below) which will foster a culture that promotes prevention and detection of conduct that does not conform to the laws, regulations and company policies associated with government-funded healthcare programs. These 7 key elements include:

  1. Written Policies and Procedures – The policies and procedures of the Company should serve as guide for its employees, contracted agents and business partners in regards to compliance standards and the procedures and practices relating to complianc
  1. Compliance Officer and committee – An effective compliance program must have a compliance officer to oversee the entire program. The compliance officer’s responsibilities include developing, operating and monitoring the compliance program; along with reporting to management on a periodic and as needed basis. The compliance officer will also be responsible for coordinating and participating in the training of all employees, independently investigating compliance matters and ensuring that any necessary corrective action is
  1. Effective training and education – A necessary component of an effective compliance program is the proper and periodic education and training of all Company personnel and contracted agents at all levels. The Company’s compliance organizations must administer training specific to requirements to ensure understanding of applicable laws, regulations and policies.  This training should be in addition to mandatory annual certification training/testing

requirements. All employees will be trained to ensure they’ve gained the necessary knowledge of all laws, regulations, and best practices of a successful Compliance Program.

4.    Effective lines of communication (including anonymous reporting function)

– The compliance officer must effectively create and maintain effective lines of communication.  It is crucial to the success of the program that all employees and staff have an effective way to ask questions and report concerns or violations when the need arises.  This may include a process, such as a hotline or other reporting system, to encourage questions and complaints and procedures to protect the confidentiality or reports and anonymity of the complainants and to protect employees against retaliation.

  1. Internal monitoring and auditing – There will be ongoing evaluation and monitoring of the compliance program to ensure its effectiveness. The Company will utilize multiple avenues for internal monitoring and auditing purposes. The information gathered from monitoring efforts may result in the correction and/or modification of our internal processes; re-coaching and re-training efforts of employees and/or contractors or; disciplinary action taken by the Company. The Company’s compliance organizations must immediately notify the appropriate carrier(s) of any egregious compliance failure
  1. Disciplinary enforcement – Depending on the severity of violations, re-training and disciplinary actions up to and including termination may be taken if the monitoring and auditing process uncovers any egregious compliance
  1. Mechanisms for responding to and reporting detected problems – All reports and/or indications of suspected noncompliance will result in an immediate investigation to determine whether there has been a violation of law or other requirements; and, if so, make sure all affected parties are notified of the breach, and do everything possible to correct/minimize the severity of the violation. All suspected incidents or breaches will be reported to the appropriate carrier(s) Privacy Department, Legal Department or Compliance Department upon

Structure and Membership of The Company’s Compliance Organizations

The Chief Administrative Officer (CAO) will be the head of the Compliance Program. They will be responsible for everything regarding compliance. It is their responsibility to  keep  the  lines  of  communication  open  and  fluid,  not  only  with

employees, but with senior management as well. The CAO is also responsible for training and educating all employees regarding compliance. However, the success of any compliance program depends on the diligence of everyone involved to be aware of all rules and regulations and adhere to them, as well as help monitor for possible breaches and violations, and if any are found report them immediately.

Knowledge of Regulations and The Company’s Policy

The Company’s Compliance Program will establish and maintain an inventory of applicable policies and procedures, regulations and guidance documents applicable to the day-to-day duties of the Company’s employees and contracted agents. Additionally, broader, more general compliance requirements pertaining to, but not limited to, Information Security, Records Management, and Privacy and Security Awareness will be addressed in these policies and procedures. These will include, but are not limited to, Health Insurance Portability and Accountability Act (HIPAA) regulations; the Center for Medicare and Medicaid Services (CMS) guidelines; and federal, state, and/or local laws and regulations.

Oversight of the Company Compliance Program

To help ensure the success of the Compliance Program, the Company will conduct periodic reviews and audits of compliance operations and performance. The goal of this internal monitoring is to uncover any non-compliance issues, so they can be addressed internally, and remediated before any actual breach of compliance occurs. This internal checks and balances system will help ensure the success of the         Compliance Program. The Company’s Compliance organizations will immediately notify each affected carrier of any egregious compliance failure by reporting such incidents or breaches to the carrier(s) Compliance Department or Legal Office.

American Exchange

Code of Compliance and Ethics

American Exchange, here after used interchangeably with the Company, is committed to excellence in providing insurance coverage options to licensed agents and in conducting its business affairs. Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us. Each American Exchange employee subscribes to this Code of Compliance and Ethics as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” means the plans or services available from a private insurance company through the Company, “consumer” means a person who may purchase a product; “member” means someone who has purchased such a product and “agent” means any downline agent contracted through American Exchange with a private insurance carrier.

  1. I shall conduct myself in an ethical manner with courtesy and dignity and with respect for the rights and reasonable requests of consumers and members at all times
  1. I will not make statements or engage in activities that could mislead or confuse consumers, members and/or agents or misrepresent the Company, insurance carrier products or the Centers for Medicare & Medicaid Services (CMS).
  1. I will use no form of coercion, deception, sympathy appeal or other high-pressure tactics to entice agents to enroll consumers in a I will always give clear and accurate information regarding my relationship with the Company and avoid the use of false, contextually misleading or exaggerated statements.
  1. I will protect the privacy of consumers, members and agents and preserve the confidentiality of their records in accordance with the Company’s Policies and I will handle the enrollment application and any other consumer or member health information in my possession in a professional and confidential manner. I will maintain only such consumer or member information required to conduct business and will do so in a secure and compliant manner and in accordance with the Company’s Privacy Policies and Procedures.
  1. I shall observe the Company’s Policy of Nondiscrimination by reason of race, creed, color, sex, age, national origin or economic Enrollments in any product shall not be predicated on age or medical condition, except as provided by federal rules of access to Medicare. I understand that discrimination based on health status or disability is prohibited.
  1. I am aware that marketing activities in connection with the sales of products to consumers are strictly regulated by both state and federal law and rules and regulations promulgated by the Centers for Medicare & Medicaid Services (CMS) and I agree to comply with these
  1. I understand that agents must use sales and marketing materials that have been approved by the required entities (CMS, Departments of Insurance and the Company, as applicable) in all sales and marketing to consumers
  1. I understand that I cannot use the Company’s logos or carrier logos (including but not limited to: letterhead, business cards, websites, shirts or other use) without prior written permission from the Company or the
  1. I understand it is my responsibility to comply with all applicable federal and state regulations including but not limited to HIPPA.
  1. I have reviewed and understand the Company’s Policies and Procedures and agree to abide by them.
  1. I understand that any breach of the above pledge could result in the immediate unilateral termination of my employment with the Company.

 

PP – 2.0 Organizational Chart

American Exchange (“Company”) will have an Organizational Chart available upon request. It is the responsibility of the Human Resources Director to update the Company’s Organizational Chart by the 15th of each month.

3.1  Policy on Policies

American Exchange has established a Compliance Committee to create, review and implement the policies and procedures of the organization.  It is the policy of the Company that all employees and downline agents and agencies adhere to the policies and procedures found within this manual, and are subject to review and disciplinary action by the Compliance and Oversight Board of upline MGAs, FMOs, or Carriers should any deficiencies be found.

3.2  Policy Statement

It is American Exchange’s policy to develop and maintain policies and procedures that provide guidance and demonstrate the Company’s commitment to compliance.

3.3  Policy Purpose (Scope)

This document outlines the process of development, review, approval and communication of sales operations, policies and procedures.

3.4  Policy Provisions and Exhibits (Procedure)

Policies and procedures are developed and maintained to provide guidance to ensure compliant and ethical conduct, professionalism and knowledge of required business processes and responsibilities.

3.4.1  Development and Review

All policies and procedures are developed and reviewed by the Compliance Committee of American Exchange The Compliance Committee is notified of potential policy issues as they arise by other individuals within the Company.  The Compliance Committee then meets to assess the issue and develop a process addressing the issue. American Exchange will conduct quarterly and annual audits to ensure proper implementation and address any deficiencies. The audits will assess the following areas: Internal Employee Training, HIPAA and MIPPA Compliance, Agent Oversight and Agent Violations.

3.4.2  Approval and Communication

All policies and procedures are approved by the President of American Exchange Once approved, the new or amended policy is distributed to all employees in memo form. The new or amended policy should also be distributed to any carrier, vendor or other entity as needed.

3.4.3  Restriction on Distribution of Policies and Procedures

American Exchange’s Policies and Procedures are for “Internal Use Only”.

All policies and procedures are kept in electronic format on a secure server that can only be accessed by American Exchange’s employees.

PP – 4.0 Company and Regulatory Affairs

American Exchange has developed set policies on how to manage and maintain its state licenses and appointments with each carrier as well its Day-to-Day operations. Additionally, all downstream entities are required to apply the following policies to their internal regulatory processes.

PP – 4.1 State Licenses

The Company agrees to hold all appropriate resident and non-resident licenses in each state, and with each carrier, in which a particular product is being represented.  The Company will also pay all necessary licensing fees and complete any required CE to maintain state appointments.

It is the responsibility of the Chief Administrative Officer to update each and all licenses and fees with all carriers, as needed.

PP – 4.2 Carrier Appointments

It is the responsibility of the Chief Administrative Officer of American Exchange

to ensure that they are appropriately licensed and appointed with each carrier in all states where plans are represented.

PP – 4.3 Carrier Certification

American Exchange and its representatives agree to annually comply with each carrier’s individual certification guidelines as well as any additional CMS requirements.

Only the President will be responsible for completing certification on behalf of the agency.

PP – 4.4 Disaster Recovery

The Company will have set policies in place to govern the steps taken to ensure day-to- day operations can continue in the fullest capacity possible in any instance where the normal business processes may be interrupted.

PP  4.4.1 Temporary Displacement

If, for any reason, natural disaster or otherwise, employees and executive staff are unable to enter the building, or are required to leave the premises for a length of time deemed to be “temporary”, business operations will resume in a minimal capacity as considered necessary by the President. This may include accessing email from a secure, backup, email server or forwarding phone calls and voicemails to employee cell phones.  Access to the main server will not be available in these circumstances.

PP – 4.4.2 Permanent Displacement or Restructuring

In the event of a natural disaster or other event which results in permanent abandonment of the building, the Company will have a Business Continuity Plan (BCP) which outlines the procedures necessary to resume the organization’s normal operations. The BCP includes issues such as permanent loss of the main IT server and relocation of the office. The BCP will also address issues not resulting in displacement but instead restructuring of the organization such as loss of a key employee.

PP – 5.0 Internal Employees

American Exchange views internal employees as any person holding a permanent full-time or part-time position with the Company.  American Exchange does not view its independent, telesales and/or captive downline agents as employees and are therefore not addressed within this section.  The policies found within this section will also apply to any internal employees of the Company.

PP – 5.1 New Hires

All new hires will complete compliance orientation and agree to all compliance rules and regulations. This includes HIPAA, the Policies and Procedures Manual and Employee Handbook. All new hires must sign American Exchange s Code of Conduct (Please refer to document PP – 5.1a).

PP – 5.2 Employee Files

All personnel files will be managed and maintained in accordance with HIPAA and the guidelines outlined in the Employee Handbook.

PP – 5.3 The Violent Crime Control and Law Enforcement Act (18

  • 1033 et seq)

The Violent Crime Control and Law Enforcement Act (18 U.S.C. 1033 et seq.) makes it a crime for individuals convicted of certain felonies to willfully engage in the business of insurance.  The Company will comply by terminating employment with any individual who falls under this category.

PP- 5.4 Office of Inspector General Exclusions

Sections 1128 and 1156 of the Social Security Act prohibit certain individuals and entities from participating in federally funded healthcare programs, including Medicare, Medicare Advantage and Medicare Part D plans.  The Office of the Inspector General (OIG) maintains a list of excluded individuals and entities.  The list is available on the internet at:

http://oig.hhs.gov/fraud/exclusions.asp

American Exchange will comply by screening all new employees against the OIG exclusion list prior to hire and all current employees against the OIG exclusion list on a monthly basis.  A screenshot of the result from the check will be saved in PDF format and available upon request.  Employees will be immediately removed from all activity related to Medicare products if found to be on the OIG listing.

Should a potential employee appear on the OIG exclusion list, employment will be denied.  In the event an existing employee is added to the OIG exclusion list, their employment with American Exchange will be terminated citing the sections of the Social Security Act listed above.

PP – 5.5 System for Award Management (SAM) Exclusion List

It is the policy of American Exchange that all new employees are screened against the SAM exclusion list prior to hire and all current employees against the SAM exclusion list on a monthly basis. A screenshot of the result from the check will be saved in PDF format and available upon request.  Agents will be immediately removed from all activity related to Medicare products if found to be on the SAM listing.  This list is available on the internet at:

www.sam.gov

Should a potential employee appear on the SAM exclusion list, employment will be denied. In the event an existing employee is added to the SAM exclusion list, their employment with American Exchange will be terminated.

PP- 5.6 Code of Conduct

All employees of American Exchange must sign and agree to maintain the Company’s Code of Conduct.  (Please refer to document PP – 5.1a)

PP- 5.7 Corrective and Disciplinary Actions

CMS maintains regulations governing the sale of all insurance products.  It is the Company’s policy that all employees abide by these regulations without exception. Failure to do so will lead to disciplinary action up to and including termination.

PP 5.8 Reporting of Disciplinary Action

Employees that face disciplinary action as a result of non-compliance or fraud, waste or abuse will be reported up to the carriers and/or the Compliance and Oversight Board of American Exchange or any of our partners as required. The report will include the following information:

  • The steps taken by the Company in response to the violation
  • The information uncovered during the investigation process
  • The completed report on the findings of the investigation
  • Copies of any disciplinary warnings (if issued)
  • A list of all violations and consequences uncovered

PP 5.9 Employee Separation

In the event of employee separation, American Exchange will ensure all HIPAA and sensitive information remains secure.  Upon separation, all company passwords the separated employee had access to will be changed immediately. Passwords that were assigned specifically to the terminated agent will be deactivated immediately upon termination. The separated employee’s manager will be responsible for ensuring that the employee does not have access to his/her work space, computer or E-mail.  The manager will be responsible for escorting the said employee off the property.

PP 5.10 In-House Licensed Agents

All agents that are in a captive relationship with the Company will be held to the same monitoring and disciplinary standards as other internal employees.  This includes monthly verification against the OIG and SAM Exclusion Lists, annual background checks, training and corrective action.  In addition, all licensed agents are also expected to comply with individual carrier guidelines in regard to licensing, certification and oversight.  All in-house agents are trained on Fraud, Waste and Abuse and general compliance upon initial contract with the Company.

PP – 5.11 Distribution of Carrier Documents

The Company will comply with all carrier specific guidelines in regard to the distribution of documents pertaining to that individual carrier.  These documents may include Codes of Conduct, carrier generated Fraud, Waste and Abuse training materials, Conflict of Interest policies, etc.  The Company will distribute these within 90 days of hire and periodically thereafter to all employees and vendors who conduct business on behalf of that carrier.

PP – 6.0 Internal Employee Training

American Exchange has established and is committed to maintaining on-going compliance training for all staff. This includes, but is not limited to, General Compliance, HIPAA, MIPPA, Policies and Procedures and Fraud, Waste and Abuse Training.  All aforementioned training must occur within 30-days of initial hire, and annually thereafter, for all employees dealing with Medicare Advantage, Medicare Prescription Drug Plans, under 65 Health Plans, and Life Policies. Internal Employees of Downstream Call Centers must also follow the same training schedule in addition to any training offered by individual carriers specific to the call center structure.

All employees and agents of the Company will complete a compilation of the following trainings based on their job function with the Company:

  • MIPPA regulations including prohibited marketing practices
  • PHI and PII data
  • Sales presentations and outlines; call scripts and guidelines
  • Comparison of Medicare Advantage plans to Original Medicare
  • Plan rules and member responsibility
  • Election periods
  • Enrollment and disenrollment processes
  • Benefits (Out-of-Network coverage, emergency services, etc.)
  • Eligibility and LIS eligibility

PP – 6.1 Telesales Agents

All Telesales Agents will be responsible for ensuring marketing and sales compliance through on-going training.  This includes maintaining current knowledge of the CMS Marketing Guidelines. Telesales Agents are responsible for completing annual certification when applicable as well as Fraud, Waste and Abuse Training and other carrier specific training as required.  Telesales agents must complete all licensing, certification, training and any other requirements specific to the telesales channel prior to writing business.

PP – 6.2 Administrative Staff

Administrative Staff will be required to participate in on-going training on compliance rules and regulations.  This includes HIPPA, Fraud, Waste and Abuse Training, Policies and Procedures and all applicable federal and state guidelines.

PP – 6.3 Enrollment Staff

Any individual handling enrollment applications will participate in on-going training on compliance rules and regulations.  This includes HIPPA, Policies and Procedures and all applicable federal and state guidelines.  In addition, they will also be trained on carrier and CMS guidelines regarding submission timelines and guidelines, document retention and proper handling of PHI/PII.

PP – 6.4 In-House Licensed Agents

In-House, captive agents will be required to participate in on-going training on compliance rules and regulations.  This includes HIPPA, Fraud, Waste and Abuse Training, Policies and Procedures and all applicable federal and state guidelines.

In addition, they will be required to complete all training specific to each individual carrier they are licensed and appointed with.

Addendums                                                                                              None

PP – 7.0 Agent Compensation

In instances where American Exchange pays agent compensation out of its internal accounting office, policies are enforced to ensure compliant and accurate payments to agents.

PP – 7.1 Payment Guidelines and Compliance for External Agents

It is American Exchange’s policy to have commissions paid directly to brokers whenever possible.  In the event American Exchange is requested by an insurance carrier to pay broker commissions, American Exchange will pay according to insurance carrier commission schedules.  The Company will comply with all CMS rules and regulations regarding the amount of commissions that can be paid to a given individual or agency.

PP – 7.2 Payment Guidelines and Compliance for Internal Agents

Internal agents such as telesales and captive agents may receive a different compensation schedule than agents that are contracted directly with the carrier(s).                             It is the Company’s policy that all agent payment compensation and/or bonus schedules are available for review by the carriers and my up line upon request to ensure CMS compliance regarding agent compensation.

PP – 7.3 Chargeback Process

It is American Exchange’s policy to charge back commissions according to each insurance carrier’s policy and CMS guidelines. The Company will comply with all carrier guidelines regarding chargebacks.

PP – 7.4 – Rapid Disenrollments

It is the Company’s policy to track rapid disenrollment trends in downline and captive agents when made available to the Company by the insurance carrier. The Company will charge back all rapid disenrollments when applicable.

PP – 7.5 – Agent Files

Agents licensed under the Company are required to be licensed, appointed, certified and have the correct tax forms on file with American Exchange

PP – 7.5.1 Agent Contracting

Agents must complete the carrier specific contracting, certification and be appointed prior to soliciting business and/or receiving commission.

PP – 7.5.2 Required Tax Forms

Agents must have a W-9 on file with the American Exchange

PP – 8.0 – HIPAA Compliance

It is American Exchange’s commitment to the protection and integrity of all personal and health information. It is American Exchange’ policy to comply with the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) as well as other laws aimed at safeguarding privacy.  The

Company is required to maintain, at a minimum, the following policies and procedures regarding HIPAA.

PP – 8.1 – Personal Health Information (PHI) and Personally Identifiable Information (PII)

All written PHI/PII shall be placed in an appropriately secured file.  Paper files (members, agents and employee) containing such information shall be kept in a secure place at all times within the resources available other than when being updated or used by authorized personnel as a necessary function of their work.  All applicable physical and electronic documents will be retained for a minimum period of ten years.

PP – 8.1.1 – Member Files

Privacy regulations protect the confidentiality of the member’s individual medical information with respect to others. These privacy regulations apply to all forms of PHI/PII, including but not limited to, paper, verbal and electronic.  Members’ files will be kept in a secure place at all times.

PP – 8.1.2 – Agent Files

American Exchange’s HIPAA Policies and Procedures ensure that all identifiable health information encountered by our staff as a result of processing is protected from unauthorized access and/or release as defined in the privacy regulations.  The Company is to take necessary measures to ensure all agent files are in compliance with HIPAA standards.

PP – 8.1.3 – Employee Files

The Company will protect all health-related records and make sure they are secure in a separate area from employment files and available only to those with the proper authority to see them. Employee files will be managed and maintained in accordance to HIPAA guidelines.

PP- 8.2- E-mail

The Company will ensure all emails containing PHI/PII are transmitted in a secure manner and in accordance with HIPAA guidelines.

PP- 8.3- Passwords

Each Company employee will have a set of unique passwords to access computers, e- mail, networks and client and agent management software.  These passwords are assigned on a need to access basis and are to remain confidential and should not be shared with anyone.  In the event of employee separation, pertinent passwords will be changed.

PP- 8.4- Secure Areas

All areas that may contain PHI/PII will be deemed secure areas. Secure areas must maintain a strict level of compliance.

PP- 8.5- Logical Access

The Company grants logical access to employees on a Need-to-Access basis.  All forms of PHI and PII, both physical and electronic, are housed in secure areas and assessable only to those employees who utilize the information to conduct normal and necessary business practices.  Access is granted by the employee’s manager and all high-levels approved by the President of the Company.  Should an employee be found in violation of any of the policies found within this section or should a breach occur, access to all forms of information is immediately suspended for all employees involved in said violation.

PP – 9.0 Privacy and Security

American Exchange relies on information for their success. Managing personal information responsibly and legally serves our business objectives and helps build trust with stakeholders, partners and brokers. The policies outlined below operate in conjunction with other privacy policies laid out by either American Exchange or its affiliates.

PP – 9.1 Personal Health Information (PHI) or Personally Identifiable Information (PII)

All individuals who conduct business for, or on behalf of, American Exchange are responsible for understanding and complying with applicable laws and regulations that protect the privacy and security of Personal Health Information (PHI) or Personally Identifiable Information (PII) pertaining to members, customers, employees and business partners.  American Exchange employees must collect, maintain, use and disclose PHI and PII in a manner consistent with all applicable laws in the all areas in which American Exchange conducts business.

All managers at the executive and administrative levels are responsible for monitoring and ensuring compliance in regards to any privacy laws and/or policies set forth within this manual.

PP – 9.1.1 Access to Personal Health Information or Personally Identifiable Information

Access to PHI and PII is granted on a need-to-access basis determined by the individual’s direct manager.  All written PHI and PII will be kept in a secure file accessible only to those employees deemed necessary.  Paper files (members, agents and employee) containing such information shall be kept in a secure place at all times within the resources available other than when being updated or used by authorized personnel as a necessary function of their work.  Electronic PHI and PII will be stored on a secure server and password protected.

PP – 9.1.2 Personal Health Information or Personally Identifiable Information Policies and Procedures

American Exchange is responsible for identifying the applicable laws and regulations relating to PHI and PII and relaying that information to its employees, brokers and any other individual conducting business on their behalf. The Compliance Committee will review all pertinent rules and regulations and develop and enforce policies and procedures for meeting the requirements of state and federal laws.

PP – 9.2 Collection of Personal Health Information or Personally Identifiable Information Policies and Procedures

American Exchange will collect PHI and PII lawfully and will require the same of third party entities collecting information on their behalf. The collection of PHI and PII should be limited to that which is relevant and appropriate for purposes of providing a service, employment or that which is required by law.

PP – 9.2.1 Sensitive Personal Health Information or Personally Identifiable Information

The definition of Sensitive PHI or PII varies across jurisdictions and can included information regarding race, ethnic origin, political opinions, religious beliefs, trade union membership, physical or mental health, sex, commission or alleged commission of offenses, court proceedings, financial information, government-issued identification numbers (i.e. Social Security numbers), etc.  American Exchange will limit the collection of sensitive PHI and PII to that related to a legitimate business purpose. Where required by law, American Exchange will collect Sensitive PHI and PII only with the consent of the individual.

PP – 9.3 Use and Retention of Personal Health Information or Personally Identifiable Information

American Exchange will use and retain PHI and PII only for legitimate business purposes consistent with the policies and procedures outlined in this manual, documented legal requirements and/or any applicable privacy notices provided to the individual. American Exchange will retain all PHI and PII in accordance with federal and state guidelines and only that which is required by law or necessary to satisfy operational needs. All written PHI and PII will be kept in a secure file accessible only to those employees deemed necessary.  Paper files (members, agents and employee) containing such information shall be kept in a secure place at all times within the resources available other than when being updated or used by authorized personnel as a necessary function of their work. Electronic PHI and PII will be stored on a secure server and password protected.

PP – 9.4 Disclosure and Cross-Border Transfers

Disclosures of PHI and PII to vendors, contractors, service providers and other third party affiliates must be consistent with applicable privacy notices, contracts, agreements and laws.  It is the policy of American Exchange that such disclosures will be limited to the minimum amount of PHI and PII necessary for the intended purpose. American Exchange is also responsible for identifying their legal obligations and for determining those obligations are met in regards to the handling, protection and transfer of PHI and PII to recipients outside the borders of the United States.

PP – 9.4.1 Disclosure of Personal Health Information or Personally Identifiable Information

Prior to disclosing PHI or PII, American Exchange will ensure the following procedures are adhered to: the transfer of all forms of PHI is completed in a secure manner, through a secure outlet; the employee, system or entity that is receiving the PHI and PII is clearly identified; and, when required by law, the third party is contractually committed to protecting the PHI and PII and limiting is usage and disclosure.

PP – 9.4.2 Transfer of Personal Health Information or Personally Identifiable Information

American Exchange will allow the transfer of PHI or PII to, or allow access by, entities in foreign countries for the sole purpose of conducting legitimate business transactions and only when assured the information will be lawfully processed and protected.

PP – 9.5 Security of Personal Health Information or Personally Identifiable Information

It is the policy of American Exchange to establish, implement and monitor administrative, physical and technological security and safeguards to protect all forms of PHI or PII from unauthorized access, unintended disclosure, corruption or loss.

PP – 9.6 Data Quality

It is American Exchange’s policy to maintain accurate and complete PHI and PII in all instances when required to do so either by state and/or federal regulations or carrier guidelines.

PP – 9.7 Monitoring and Enforcement

American Exchange requires all employees to comply with the privacy laws set forth in this manual as well as all other state and federal regulations, and has set procedures in place to monitor and enforce these policies.

PP – 9.7.1 Reporting

Any possible breach of PHI or PII privacy must be reported to the Compliance Committee immediately and reported to each carrier affected by the breach.  In addition, the Compliance Committee has the responsibility for investigating each individual situation and reporting those findings to any additional entities that are deemed necessary.

PP – 9.7.2 Review

It is the policy of American Exchange to review and audit all policies related to privacy and security on a quarterly basis to ensure proper implementation. The Compliance Committee is responsible for conducting the quarterly audits as well as addressing any privacy complaint that may arise.

PP – 9.7.3 Disciplinary Actions

If the Compliance Committee of American Exchange determines that an employee or third party entity has, either knowingly or unknowingly, violated any policy related to privacy and/or security, disciplinary action will be taken up to, and including, verbal and written warnings, suspension with or without pay, or termination. Several factors will be taken into consideration when assessing the disciplinary measures taken including, but not limited to, severity of the violation; nature of the violation (accidental, inadvertent or purposeful misconduct); potential risk created by the disclosure to the individual; whether the employee in violation self-reported and was cooperative with the investigation and if the employee in question is a repeat offender.  All violations will be reviewed on a case-by-case basis and disciplinary measures issued accordingly.

Addendums                                                                                     None

PP – 10.0 MIPPA Compliance

It is the policy of American Exchange to comply with all guidelines set forth by the Medicare Improvements for Patients and Providers Act (MIPPA). The President, CEO and Vice President of Senior Services along with the Director of Operations oversee each portion of this policy.

PP – 10.1 External Agent Contracting

American Exchange follows all state and federal guidelines, as well as any carrier specific requirements, regarding agent licensing and appointments.  All agents must be fully appointed, when applicable, prior to marketing Medicare Advantage and/or Medicare Prescription Drug Plans for which they will be representing.  Any agent acting on behalf of a Downline Call Center must also hold all applicable licenses and appointments prior to submitting business. Telesales agents must also adhere to specific contracting requirements as covered in PP – 13.0 of this manual.

PP – 10.2 External Agent Certification and Training

It is the policy of American Exchange that all downline agents certify annually for each carrier they represent for Medicare Advantage and/or Medicare Part D plans. Each agent must complete and pass all certification, general compliance and Fraud, Waste and Abuse training required by each carrier prior to engaging in any sales activities with said carrier. This training can include, but is not limited to, certifications administered by America’s Health Insurance Plans (AHIP), Gorman and CMS. Employees of American Exchange will not assist agents in any way, shape or form with answers to certification test(s).  Telesales agents must also adhere to specific certification and training requirements as covered in PP – 13.1 of this manual.

PP – 10.3 Sales and Marketing Events

American Exchange adheres to all MIPPA guidelines related to sales and educational events. American Exchange requires all independent downline agents to report all sales events to the carrier and CMS per each carrier’s specific guidelines as well as notify them of any changes made once the event is filed.  It is also the policy of American Exchange and its downline agents to comply to with all

CMS and MIPPA rules regarding the prohibiting of methods of coercion during sales and marketing events, including, but not limited to, gifts valued more than $15, foods other than light snack and monetary rewards of any kind.

PP – 10.4 Scope of Appointment Forms

It is the policy of American Exchange that its Downstream Call Center agents comply with all carrier requirements pertaining to the obtaining, submission and storage of Scope of Appointment Forms. In addition, all Downstream Call Centers must adhere to any and all CMS specific rules and regulations regarding these documents.

PP – 10.5 Agent Code of Conduct

Downstream agents will be requested to sign the Agent Code of Conduct for Medicare Advantage and Medicare Part D Sales upon contracting stating that they agree to abide by all rules set forth by CMS and the MIPPA document prior to entering into a relationship with the Company.  The Agent Code of Conduct also states that independent agents are responsible for monitoring the Medicare and CMS websites, reviewing all agent updates distributed by the company and completing all required certification and training annually. (Please refer to document PP – 10.5a)

PP – 10.6 MIPPA Rules and Regulations

In addition to the policies referenced above, the Company also requires all agents selling on their behalf to:

  • Provide written mandatory compensation language to each Medicare beneficiary to whom a health plan is presented
  • Present all information in a fair and accurate manner so that each beneficiary is fully informed to make a decision
  • Provide each enrollee with written information of the complete benefit package and confirm that the individual understands the program, the grievance and appeal procedure and their disenrollment rights
  • Ensure that all potential enrollees receive a clear explanation of the plan’s networks’ provisions which include proper utilization of the urgent care and emergency benefits
  • Utilize only marketing materials that have been approved by CMS and/or American Exchange
  • Enroll only qualified Medicare beneficiaries that reside in approved service areas; using only approved enrollment applications and enrollment methods as set forth by CMS, the carrier and/or the Company
  • Provide the enrollee with a copy of the signed enrollment form including the proposed effective date

PP – 10.7 Prohibited Practices

Agents are expected to refrain from performing prohibited sales and marketing practices in accordance with Chapter 3 of the Medicare Marketing Guidelines.  These activities include but are not limited to:

  • Conducting activities that may cause potential enrollees to feel pressured, compelled or coerced in any way
  • Conducting activities that mislead or misrepresent potential enrollees
  • Claiming that the Company or the agent is recommended, endorsed, affiliated with or employed by CMS, the state Department of Insurance or Medicare
  • Making statements or claims that contradict or conflict with information found in CMS approved materials
  • Using definitive statements that cannot be supported by facts and data
  • Inducing providers or provider groups to:
    • Distribute printed information comparing benefits to different health plans unless the materials have received prior CMS approval
    • Accept enrollment applications
    • Persuade individuals to enroll into specific health plans
    • Offer anything of value to induce plan enrollees to select them as a

provider

  • Conducting presentations, distributing or accepting enrollment applications or soliciting potential enrollees in health care settings with the exception of designated common areas permitted under CMS guidelines
  • Conducting plan sponsored specific presentations or distributing and accepting enrollment applications at designated educational events
  • Presenting or selling non-health related products during MA, MAPD or PDP appointments
  • Presenting or selling products beyond the scope agreed upon by the beneficiary prior to the appointment
  • Offering gifts, payments or remuneration of any kind to induce enrollm This includes cash gifts, charitable donations or contributions made on behalf of the individual, gift certificates or gift cards that can readily be converted into cash or offering meals (regardless of value) at sales events.
  • Practicing discriminating activities which may deny eligible beneficiaries of their right to enroll
  • Requiring an in-home appointment
  • Falsifying or participating in false signatures
  • Ignoring or delaying an enrollee’s request for cancellation or disenrollment
  • Overstating plan benefits
  • Implying permanent coverage
  • Using any form of unsolicited contact including but not limited to:
    • Sending e-mails to beneficiaries that have not given their permission
    • Making outbound marketing calls without written permission by the

individual or calling disenrolled members with the purpose of re-enrolling

  • Soliciting door-to-door or leaving information on doors, cars, etc.
  • Bait-and-switch practices
  • Any other sales or marketing practice prohibited by CMS or the carrier

Addendums

PP – 10.5a “Agent Code of Conduct for

Medicare Advantage and Medicare Part D Sales”

PP – 11.0 Agent Oversight

American Exchange utilizes several methods in an attempt to prevent, detect and correct fraud, waste and abuse as well as other compliance issues.  Using these tools, American Exchange can take a proactive approach to compliance and help ensure a high standard of business ethics.

PP – 11.1 Agent Licensing and Contracting

American Exchange will monitor all subagent’s state license status on a monthly basis including but not limited to continued professional education and state exam results. American Exchange will monitor all agent certification results that are made available by the carrier.

PP – 11.1.1 Agent Contracting

Once received, all agent contracts are reviewed for accuracy and missing information prior to being submitted to the company for approval.  All agent information is documented in the Company’s database system including name, phone number, address, social security, and date of birth. The contract is then submitted to the upline per each individual guideline.

PP – 11.1.2 Records Retention and Maintenance

All agent records are scanned into our secure server and are retained for no less than a minimum of ten (10) years.  All agent information is also documented in the Company’s database system, updated as needed and retained indefinitely. Designated employees will be able to view and maintain records as needed.

PP – 11.2 Reporting of Terminated Agents

In the event a downline agent is terminated with cause by a Medicare Advantage and/or Medicare Part D Plan, the terminated agent will be reported to the internal Compliance Committee.

PP – 11.3 CMS Approved Material

It is American Exchange’s policy to provide agents with supplies for Medicare Advantage and Medicare Part D plans that are current and approved by CMS.  American Exchange ensures agent use of updated materials during “Ride-A-Longs” and Secret Shopper audits.  Telesales agents must utilize CMS approved scripts on all sales calls.

PP – 11.4 Downline Oversight

It is the Company’s policy that all independent agents within its downline adhere to the same compliance and ethics guidelines as its internal employees and agents.  American Exchange does the following to ensure all agents within our organization receive, understand and follow the compliance guidelines set forth by this manual, the carriers and CMS.  The Vice President of Senior Services and Assistant Director of Senior Services are responsible for the oversight of the Company’s agents.

Some examples of agent oversight we provide are:

  • Weekly Meetings with Agents
  • Ride-a-Longs with new and existing Agents
  • Web Conferences

PP – 12.0 Agent Violations

American Exchange takes all agent violations extremely serious and has detailed policies and procedures in place to handle such instances.  These policies and procedures apply to all downline agents regardless of their appointment level as well as Downstream Call Centers and any agent appointed under them.

PP – 12.1 Carrier Originated Complaint Process

In the event that American Exchange receives a complaint directly from a carrier, immediate action is taken to ensure a response is received in the designated time frame. The Company will assist the carrier in obtaining the agent’s response to the complaint within the designated time frame.

PP – 12.2 Agent Violations Uncovered Internally

American Exchange takes any violation of MIPPA, HIPAA, carrier policies and procedures and all other federal and state rules and regulations very seriously and has policies in place should an internal employee or downline agent uncover a breach of any of the above.

PP – 12.2.1 Documentation of Violation(s)

All violations will be reported to the Company’s Chief Administrative Officer who will then submit a summary of the violation to the Compliance Committee and to the Chief Administrative Officer at American Exchange. These summary reports may be submitted in any of the following manners:

Email:

Phone:

Anonymous reporting can be done through the carrier or CMS.

An Agent Violation Report (AVR) will be completed for each violation and kept in the agent’s personal file. (Please refer to document PP – 12.2.1a)

PP – 12.2.2 Agent Re-training

It is the policy of American Exchange to re-educate downline agents in all areas where policies and/or rules and regulations were misinterpreted or misunderstood.  Retraining can include, but is not limited to: webinars, one-on-one coaching with Company employees, carrier sponsored training, ride-a-longs and recertification.  An Agent Counseling Report will be completed after any retraining occurs.  (Please refer to document PP – 12.2.2a)

PP – 12.2.3 Reporting of Violation to Carrier

It is American Exchange’s policy to report all violations to the appropriate carrier in accordance with their individual guidelines.

PP – 12.2.4 Corrective and Disciplinary Actions

American Exchange and/or American Exchange reserves the right to enact corrective actions whenever a violation occurs up to and including termination of contract through American Exchange  Disciplinary actions may include but are not limited to retraining and/or recertification, carrier mandated compliance training, reporting of the violation to carrier(s) and/or CMS and termination of agent contract.  All corrective and disciplinary actions are document using the ACR and AVR and added to the agents’ personal file.

PP – 12.2.5 Termination of Agents

For agents that are deemed repeat offenders or are found to be acting maliciously and with intent, American Exchange and/or American Exchange reserves the right to terminate agents from any or all appointments, and may opt to deny agent future appointments with American Exchange. Actions that may result in agent termination include, but are not limited to, three failed “Ride-A- Longs”, three (3) failed Secret Shopper Reports or two (2) or more sales allegations within a calendar year.  In the event either party terminates an agent’s contract(s), the applicable carrier(s) will be notified within five business days.

PP – 12.3 Agent Violations Uncovered by FMO (External Source)

In the event a member grievance against an agent or a sales allegation is received directly by American Exchange, the applicable carrier will be notified within 24 business hours of receipt. American Exchange follows all carrier rules and regulations regarding the handling of any and all sales allegations and will comply with individual requirements. The Agent Violation Report will be filled out by the employee working with the agent in question and will be submitted to the Compliance Committee for review.

PP – 12.4 Agent Reporting of Violations

The Company has in place several methods for agents to report any compliance violations they uncover as well as seeking answers to compliance questions they may have. Agents may utilize any of the following methods to reach the Compliance Committee:

Email:

Phone:

Anonymous reporting can be done through the carrier or CMS.

Addendums

PP – 12.2.1a “Agent Violation Report”

PP – 12.2.2a “Agent Counseling Report”

PP – 13.0 Telesales

American Exchange understands that the guidelines surrounding call centers and telesales agents may be different than those for agents that conduct business in a face-to-face scenario. The policies outlined in this section are specific to telesales channels and agents only and supersedes all other policies within this manual.

PP – 13.1 Telesales Code of Conduct and Ethics

The principal of this Company’s call center has reviewed and agreed to American Exchange’s Telesales Code of Conduct and Ethics. (Please refer to document PP – 13.1a)

PP – 13.2 Telesales Contracting and Appointment Process

It is the policy of American Exchange that no sales will be conducted via the telesales channel until the agency has been licensed and appointed as an official call center by each carrier they represent.  All downline telesales agents must also be appointed and designated as a telesales agent (as required by carrier) prior to submitting business in this manner.

PP – 13.3 Telesales Certification and Training Process

The Company’s policy is that all telesales specific training and certification be completed prior to the agency or downline agents engaging in marketing or selling via the call center channel. This training may be in addition to the annual, CMS required certification. The Company is responsible for ensuring all downline telesales agents are trained on each carrier’s enrollment process as well.

PP – 13.4 Call Recordings

It is the policy of the Company that all calls are recorded and made available for review upon request.  All requests for call recordings will be submitted to the requesting entity within 48 hours unless otherwise noted. The Company agrees to submit call recordings to their upline based on carrier guidelines.

PP – 13.5 Call Scoring and Retraining

Telesales calls will be scored in accordance with carrier guidelines by the upline and/or the carrier(s).  It is the policy of American Exchange that two (2) calls per agent per week are scored internally as well.  The results of the scoring may result in retraining or disciplinary action as deemed necessary.  Retraining will be documented in the agent’s file and logged for trending patterns.

PP – 13.6 CMS Approved Materials

It is the policy of the Company that only CMS and/or carrier approved materials and scripts are used by telesales agents.

PP – 13.7 Telesales Agent Code of Conduct and Ethics

In addition to the Agent Code of Conduct, it is the policy of the Company that all telesales agents also review and sign the Telesales Agent Code of Conduct and Ethics prior to engaging in telesales activities.  (Please refer to document PP – 13.7a)

Addendums

PP – 13.1a “Telesales Code of Conduct and Ethics”

PP – 13.7a “Telesales Agent Code of Conduct and Ethics”

Addendums

American Exchange

Code of Compliance and Ethics

American Exchange, here after used interchangeably with the Company, is committed to excellence in providing insurance coverage options to licensed agents and in conducting its business affairs. Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us. Each American Exchange employee subscribes to this Code of Compliance and Ethics as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” means the plans or services available from a private insurance company through the Company, “consumer” means a person who may purchase a product; “member” means someone who has purchased such a product and “agent” means any downline agent contracted through American Exchange with a private insurance carrier.

  1. I shall conduct myself in an ethical manner with courtesy and dignity and with respect for the rights and reasonable requests of consumers and members at all ti
  1. I will not make statements or engage in activities that could mislead or confuse consumers, members and/or agents or misrepresent the Company, insurance carrier products or the Centers for Medicare & Medicaid Services (CMS).
  1. I will use no form of coercion, deception, sympathy appeal or other high-pressure tactics to entice agents to enroll consumers in a I will always give clear and accurate information regarding my relationship with the Company and avoid the use of false, contextually misleading or exaggerated statements.
  1. I will protect the privacy of consumers, members and agents and preserve the confidentiality of their records in accordance with the Company’s Policies and I will handle the enrollment application and any other consumer or member health information in my possession in a professional and confidential manner. I will maintain only such consumer or member information required to conduct business and will do so in a secure and compliant manner and in accordance with the Company’s Privacy Policies and Procedures.
  1. I shall observe the Company’s Policy of Nondiscrimination by reason of race, creed, color, sex, age, national origin or economic Enrollments in any product shall not be predicated on age or medical condition, except as provided by federal rules of access to Medicare. I understand that discrimination based on health status or disability is prohibited.
  1. I am aware that marketing activities in connection with the sales of products to consumers are strictly regulated by both state and federal law and rules and regulations promulgated by the Centers for Medicare & Medicaid Services (CMS) and I agree to comply with these
  1. I understand that agents must use sales and marketing materials that have been approved by the required entities (CMS, Departments of Insurance and the Company, as applicable) in all sales and marketing to consum
  1. I understand that I cannot use the Company’s logos or carrier logos (including but not limited to: letterhead, business cards, websites, shirts or other use) without prior written permission from the Company or the
  1. I understand it is my responsibility to comply with all applicable federal and state regulations including but not limited to HIPPA.
  1. I have reviewed and understand the Company’s Policies and Procedures and agree to abide by them.
  1. I understand that any breach of the above pledge could result in the immediate unilateral termination of my employment with the Company.

 

Agent Code of Conduct

For Medicare Advantage and Medicare Part D Sales

American Exchange (referred to herein as the Company) is committed to excellence in its compliance efforts as well as integrity while conducting its business affairs.  Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us.  Each Company employee, licensed agent or broker representing a carrier through us and all third parties subscribes to our Code of Conduct as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” refers to the plans or services available through the carriers the Company represents; “consumer” refers to a person who may purchase a product; “member” refers to someone who has purchased such a product.

  1. I shall conduct myself in an ethical manner with courtesy and integrity, and with respect for the rights and reasonable requests of consumers and members at all time
  1. I will not make statements or engage in activities that could mislead, confuse or influence consumers and/or members or misrepresent the carrier or its products, Medicare or the Centers for Medicare and Medicaid Services (CMS).
  1. I will not disparage competitors or Original Medicare in an effort to influence an enrollment of a consumer into a represented produc
  1. I will never make offers of gifts or payments or share commission as an inducement for consumers to enroll in a product
  1. I will use no form of coercion, deception, sympathy appeal or other high-pressured sales tactics to enroll consumers in a produc I will always give clear and accurate information regarding my relationship with the carrier or Medicare and will avoid the use of false, contextually misleading or exaggerated statements.
  1. I will make sure that all information on the application is filled in by the Medicare consumer, their legal representative or by me, the age I will not ask a consumer to sign an incomplete enrollment application. I will not hold enrollment applications on behalf of the consumer but instead will submit enrollment applications upon receipt to the carrier or the Company per the guidelines of each specific carrier.
  1. I will use only the identification or writing number assigned to me by the carrier on enrollment applica I will not use the identification number of another agent on an enrollment application solicited by me, nor will I place my identification number or signature on an application that I did not complete or sell.
  1. I will protect the privacy of consumers and members and preserve the confidentiality of their records in accordance with all federal and state rules and regulations and carrier guideline I will handle the enrollment application and any other consumer or member health information in my possession in a professional, compliant and confidential manner. I will maintain only such consumer or member information as required to conduct business and will do so in a secure and compliant manner and in accordance with all carrier guidelines and state and federal regulations.
  1. I am aware that marketing activities in connection with the sales of products to consumers are strictly regulated by both state and federal laws and rules and regulations promulgated by CMS and I agree to comply with these requireme
  1. I understand that I must use sales and marketing materials that have been approved by the required entities (CMS, Departments of Insurance, carriers) in all sales and marketing to consumer
  1. I understand that in order to market Medicare Advantage and/or Medicare Part D plans I must annually complete and pass the training and certification requirements set forth by each carrier and CMS, and that I am required to keep current my insurance license and all carrier appointme
  1. I understand that it is my responsibility to comply with all federal and state regulations for sales and marketing activitie I pledge that I shall at all times conduct myself and my sales activities in compliance with CMS rules and guidelines and other applicable rules and regulations.
  1. I understand that any unsolicited direct contact, including but not limited to door-to-door solicitation, cold calling, leave-behinds at or on the consumer’s personal property and e- mail solicitation is strictly prohibite
  1. I agree to comply with all federal and state rules and regulations including HIPAA, MIPPA and CMS guidelines, as well as any carrier specific policies that are not outlined above.
  1. I understand that any breach of the above pledge could result in the immediate unilateral termination of my appointment and my agreement.

Telesales Code of Conduct

American Exchange, here after used interchangeably with the Company, is committed to excellence in providing insurance coverage options to licensed telesales agents and in conducting its business affairs. Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us. Each telesales agent subscribes to this Code of Conduct as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” means the plans or services available from a private insurance company through the Company, “consumer” means a person who may purchase a product; “member” means someone who has purchased such a product and “agent” means any downline agent contracted through American Exchange with a private insurance carrier.

  1. I will record and upload all calls to Hightail, the Company’s secure FTP site for call scoring and monitoring. I will upload all calls for the previous week no later than close of business the following Monday.
  1. I understand that if my downline agents fail greater than 5% of calls scored, I will be required to complete internal score two (2) calls per agent per week and submit the results to the Company upon reque I agree to conduct retraining and enforce disciplinary action as need as a result of these scores.
  1. I agree to follow all CMS rules regarding lead genera I will review all lead sources for appropriate permission-to-call (PTC) verbiage.  If my lead company does not use CMS required permission to call verbiage for MA/PD, then I will NOT call regarding MA/PD.  I will submit lead sources to the carrier and my up line as requested.
  1. I will not cold call in regards to MA/PD. I will provide proper oversight to my downline telesales agents to ensure they will not cold call in regards to MA/PD as wel
  1. I will follow all applicable telemarketing regulatio
  1. I will ensure that my downline is trained on each carrier’s enrollment proce
  1. I will ensure that my downline is using the correct scripting and that only materials that have been approved by either CMS or the carrier are being utilize
  1. I or a designated member of my management team will retrain any agent that scores less than 100% on their weekly call audits on the items that are considered to be below an acceptable thre I will complete an Agent Counseling Report (ACR) for each retraining instances and submit to my up line.
  1. I will make my agent payment compensation and/or bonus schedule available for review by the carriers and my up line to ensure CMS compliance regarding agent compensa
  1. I will submit all marketing plans and lead pieces for review and approval prior to use.

I have read this Telesales Code of Conduct and Ethics, and agree to the Terms and Conditions as outlined on these forms.

 

Telesales Agent Code of Conduct

American Exchange (referred to herein as the Company or American Exchange) is committed to excellence in its compliance efforts as well as integrity while conducting its business affairs.  Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us.  Each Company licensed telesales agent or broker representing a carrier through us and all third parties subscribes to our Telesales Agent Code of Conduct as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” refers to the plans or services available through the carriers the Company represents; “consumer” refers to a person who may purchase a product; “member” refers to someone who has purchased such a product.

  1. I will record all calls and make them available for review and scoring by my upline when requested no more than 48 hours after the request is made.
  1. I understand that I may not engage in telesales activities with any carrier until my agency and I are approved to conduct telesales and have completed all licensing, certification, training and any other requirements specific to the telesales channe I understand that this training may be above and beyond what is required for face-to-face sales.
  1. I will only use the carrier provided, approved enrollment scripts while conducting telesales activitie I agree to read the enrollment script verbatim and in its entirety on every call.
  1. I will only use pre-enrollment sales script(s) that have be submitted and approved for use.

I will not deviate from the approved script(s).

  1. I understand that I may only take enrollment applications on inbound ca No enrollment shall be completed on an outbound call.
  1. I will follow all CMS and carrier rules regarding lead genera I will review all lead sources for appropriate permission-to-call (PTC) verbiage prior to conducting a call for MA/PD.  If my lead company does not use CMS required PTC verbiage for MA/PD then I will NOT call the member regarding MA/PD.

 

 

Appendixes

Insider Trading and Fair Discloser Policy

American Exchange employees shall not use or share inside information that is otherwise not available to the general public, for personal gain, or the gain of others.

No employee may trade in securities while in possession of material inside information or disclose material inside information to third parties (“tipping”). Material inside information is any information that has not reached the general marketplace and is likely to be considered important by investors deciding whether to trade (e.g., earnings estimates, significant business investments, mergers, acquisitions, dispositions and other developments, expansion or curtailment of operations, and other activity of significance). Using material inside information for trading, or tipping others to trade, is both unethical and illegal.

Accordingly, no employee may:

  • “Trade securities of the Company or any other Company while in possession of material inside information with respect to that Company.
  • “Recommend or suggest that anyone else buy, sell, or hold securities of any Company while the employee is in possession of material inside information with respect to that Company (this includes formal or informal advice given to family, household members and friends); and
  • “Disclose material inside information to anyone, other than those persons who need to know such information in order for UIC to properly and effectively carry out its business (e.g., to lawyers, advisers and other Company employees working on the matter).

Where material inside information is permitted to be disclosed, the recipient should be advised of its non-public nature and the limitations on its use. Any questions as to whether information is material or non-public should be directed to the General Counsel or another Company attorney.

Additionally, all employees, officers and directors must provide full, fair and accurate disclosure in all government filings and public communications.

Policy on Maintaining a Safe, Healthy and Affirmative Workplace

The Company is committed to a workplace where people are treated with dignity, fairness and respect. You have the right to work in an environment that provides equal employment opportunities and one that is free of discrimination and illegal harassment. The Company bases its recruitment, employment, development and promotion decisions solely on a person’s ability and potential in relation to the needs of the job, and the Company complies with local, state and federal employment laws.

The Company does not discriminate on the basis of:

  • Sex
  • Race
  • Color
  • Religion
  • Sexual orientation
  • Age
  • National origin
  • Citizenship status
  • Disability

The Company makes reasonable, job-related accommodations for any qualified employee or officer with a disability when notified by the employee that he/she needs an accommodation.

The Company will not tolerate any:

  • Sexual, racial or other unlawful harassment
  • Threats or acts of violence or physical intimidation
  • Abusive, harassing or other offensive conduct, whether verbal, physical or Visual

If you believe that you have been harassed, or threatened with or subjected to physical violence in or related to the workplace, you should report the incident to an appropriate supervisor, who will arrange for it to be investigated. It is the policy of the Company to protect those who communicate bona fide concerns from any retaliation for such reporting. No retaliation against any individual who reports violations of this Code in good faith will be permitted. All efforts will be made to handle the investigation confidentially.

In addition, the Company will not tolerate on Company property:

  • Possession, use or distribution of pornographic, racist, sexist or otherwise offensive materials
  • Use of Company personal computers or other equipment to obtain or view such Materials

All employees and officers must promptly contact an appropriate supervisor or about the existence of offensive materials on the Company’s systems or premises.

Alcohol and Substance Abuse

The Company is committed to providing a drug-free work environment. The illegal possession, distribution or use of any controlled substances on Company premises or at Company functions is strictly prohibited. Similarly, reporting to work under the influence of any illegal drug or alcohol, and the abuse of alcohol or medication in the workplace is not in the Company’s best interest and violates this Code.

Fostering a Safe Workplace

The Company places the safety of its employees at the top of its priority list. If you come across or are concerned about unsafe equipment, practices, conditions or other potential hazards, you should immediately report it to an appropriate supervisor. If  you witness or are involved in any accidents while at work, or you are injured in any way, you should immediately contact your supervisor.

Corporate Contribution Policy

In jurisdictions that permit corporations to make contribution to campaigns of candidates or party committees, American Exchange uses the same criteria and framework to evaluate such contributions.

Under this policy American Exchange, may contribute corporate funds where allowed by law.  Under the policy, all corporate political contributions are subject to approval by the President and/or CEO of American Exchange

Foreign Corrupt Practices Act (FCPA) Policy

The Foreign Corrupt Practices Act (FCPA) is a federal law (15 U.S.C. § 78-dd-21 et seq.) that exists to prevent corrupt practices in international transactions. The Act prohibits bribery of foreign officials and employees who work for foreign governments. The FCPA prohibits the corrupt payment (or offer, promise or authorization of payment) of anything of value to any foreign official or employee, directly or indirectly, for the purpose of obtaining or retaining business, directing business to any person or entity, or securing any improper advantage.

The FCPA’s prohibitions are applicable to United States organizations, public or private, and any person, including a foreign person or firm, if they commit a prohibited act in the United States. Further, a United States entity may be held liable under the FCPA for the improper activities of its foreign subsidiaries if the United States entity authorized or participated in the conduct. This Policy ensures the American Exchange community is aware of, monitors, and complies with this statute.

Statement of Policy

It is the policy of American Exchange that each of our employees comply with the anti-bribery laws of the United States and of the foreign countries where American Exchange does business. Bribery of any kind in the United States and abroad, regardless of foreign custom or practice, is strictly prohibited. No American Exchange employee shall make any payment or provide anything of value, to any person, in order to improperly influence that person to secure any advantage for American Exchange, including obtaining or retaining business, or directing business to any person or entity.

Public Relations/Media Inquiries Policy

American Exchange will generally provide a response to media inquiries within 48 hours of receipt.  Individuals designated to speak on the organization’s behalf are the President and CEO. No one other than these individuals (with the exceptions noted below) should represent the company’s position to the media.

Acknowledgement of Receipt

I have read and am familiar with the policies and procedures found within this manual. I understand that I am to abide by all of the policies found within and apply those to my call center and/or downstream agents. Should I fail to do so, I understand that American Exchange reserves the right to enforce disciplinary action as needed and/or terminate our relationship if deemed necessary. No aspect of this manual should be interpreted as a contract of employment.

Policies and Procedures Manual

Version 1

Table of Contents

1.    Commitment to Compliance

  • Compliance Charter

2.    Organization Chart

  1. Policy on Policies
    • Policy Statement
    • Policy Purpose (Scope)
    • Policy Provisions and Exhibits (Procedure)
      • Development and Review
      • Approval and Communication
      • Restriction on Distribution of Policies and Procedures

4.    Company Compliance and Regulatory Affairs

  • State License
  • Carrier Appointments
  • Carrier Certification
  • Disaster Recovery
    • Temporary Displacement
    • Permanent Displacement or Restructuring

5.    Internal Employees

  • New Hires
  • Employee Files
  • The Violent Crime Control and Law Enforcement Act
  • Office of Inspector General Exclusions
  • System for Award Management (SAM) Exclusion List
  • Code of Conduct
  • Corrective and Disciplinary Action
  • Reporting of Disciplinary Action
  • Employee Separation 5.10.In-House Licensed Agents

5.11.Distribution of Carrier Documents

6.    Internal Employee Training

  • Telesales Agents
  • Administrative Staff
  • Enrollment Staff
  • In-House Licensed Agents

Table of Contents

  1. Agent Compensation
    • Payment Guidelines and Compliance for External Agents
    • Payment Guidelines and Compliance for Internal Agents
    • Chargeback Process
    • Rapid Disenrollments
    • Agent Files
      • Agent Contracting
      • Required Tax Forms

8.    HIPAA Compliance

  • Personal Health Information (PHI) and Personally Identifiable Information (PII)
    • Member Files
    • Agent Files
    • Employee Files
  • Email
  • Passwords
  • Secure Areas
  • Logical Access

9.    Privacy and Security

  • Personal Health Information (PHI) and Personally Identifiable Information (PII)
    • Access to Personal Health Information or Personally Identifiable Information
    • Personal Health Information or Personally Identifiable Information Policies and Procedures
  • Collection of Personal Health Information or Personally Identifiable Information
    • Sensitive Personal Health Information or Personally Identifiable Information
  • Use and Retention of Personal Health Information or Personally Identifiable Information
  • Disclosure and Cross-Border Transfers
    • Disclosures of Personal Health Information or Personally Identifiable Information
    • Transfer of Personal Health Information or Personally Identifiable Information
  • Security of Personal Health Information or Personally Identifiable Information
  • Data Quality
  • Monitoring and Enforcement
    • Reporting
    • Review
    • Disciplinary Actions

Table of Contents

  1. MIPPA Compliance
    • External Agent Contracting
    • External Agent Certification and Training
    • Sales and Marketing Events
    • Scope of Appointment Forms
    • Agent Code of Conduct
    • MIPPA Rules and Regulations
    • Prohibited Practices

11. Agent Oversight

  • Agent Licensing and Contracting 11.1.1.Agent Contracting

11.1.2.Records Retention and Maintenance 11.2.Reporting of Terminated Agents 11.3.CMS Approved Material

11.4.Downline Oversight

12. Agent Violations

  • Carrier Originated Complaint Process 12.2.Agent Violations Uncovered Internally 2.1.Documentation of Violation(s)

12.2.2.Agent Re-Training

12.2.3.Reporting of Violation to Carriers

12.2.4.Corrective and Disciplinary Actions

12.2.5.Termination of Agents

12.3.Agent Violations Uncovered by FMO (External Source) 12.4.Agent Reporting of Violations

13. Telesales

  • Telesales Code of Conduct and Ethics
  • Telesales Contracting and Appointment Process
  • Telesales Certification and Training Process
  • Call Recordings
  • Call Scoring and Retraining
  • CMS Approved Materials
  • Telesales Agent Code of Conduct and Ethics

Addendums

PP – 5.1a “Code of Conduct”

PP – 10.5a “Agent Code of Conduct”

PP – 12.2.1a “Agent Violation Report”

PP – 12.2.1a “Agent Counseling Report”

Table of Contents

PP – 13.1a “Telesales Code of Conduct and Ethics”

PP – 13.7a “Telesales Agent Code of Conduct and Ethics”

Appendixes

PPA – 1 “Insider Trading and Fair Disclosure Policy”

PPA – 2 “Policy on Maintaining a Safe, Healthy and Affirmative Workplace” PPA – 3 “Corporate Contribution Policy”

PPA – 4 “Foreign Corrupt Practices Act (FCPA) Policy” PPA – 5 “Public Relations/Media Inquiries Policy”

Forms:

Acknowledgment of Receipt

Our Commitment to Compliance

American Exchange’s Policies and Procedures Manual forms the basis of our Compliance Program. The purpose of this program is to ensure the highest standards of morals and compliance by all employees, Downstream Call Centers and Subcontracted Agents, and to provide guidance on conducting business in an ethical manner.

Our policies and procedures apply to all employees, Downstream Call Centers and Subcontracted Agents. They do not create any contractual agreement between the Company and its employees or the aforementioned entities, nor does it guarantee any promise of employment.

This manual and the code found within may be changed or amended by American Exchange at any time.

Compliance Charter

American Exchange Adopted <Date>

Introduction

The principle purpose of the Company’s Compliance Program is to promote and facilitate corporate governance of operations and services rendered in accordance with established laws, regulatory requirements, and the Policies and Procedures of the Company.  The Compliance Program ensures the business operations, of every individual who conducts business for or on behalf of the Company, reflect the values, integrity and commitment to compliance that the Company strives to meet.

Responsibilities and Obligations

The Company’s Compliance Program is guided by the principles contained within the Company’s corporate responsibilities.  It includes the 7 key elements of an effective compliance program (see below) which will foster a culture that promotes prevention and detection of conduct that does not conform to the laws, regulations and company policies associated with government-funded healthcare programs. These 7 key elements include:

  1. Written Policies and Procedures – The policies and procedures of the Company should serve as guide for its employees, contracted agents and business partners in regards to compliance standards and the procedures and practices relating to compliance
  1. Compliance Officer and Committee – An effective compliance program must have a compliance officer to oversee the entire program. The compliance officer’s responsibilities include developing, operating and monitoring the compliance program; along with reporting to management on a periodic and as needed basis. The compliance officer will also be responsible for coordinating and participating in the training of all employees, independently investigating compliance matters and ensuring that any necessary corrective action is taken.
  1. Effective training and education – A necessary component of an effective compliance program is the proper and periodic education and training of all Company personnel and contracted agents at all levels. The Company’s compliance organizations must administer training specific to requirements to ensure understanding of applicable laws, regulations and policies.  This training should be in addition to mandatory annual certification training/testing requirements. All employees will be trained to ensure they’ve gained the necessary knowledge of all laws, regulations, and best practices of a successful Compliance Program.

4.    Effective lines of communication (including anonymous reporting function)

– The compliance officer must effectively create and maintain effective lines of communication.  It is crucial to the success of the program that all employees and staff have an effective way to ask questions and report concerns or violations when the need arises.  This may include a process, such as a hotline or other reporting system, to encourage questions and complaints and procedures to protect the confidentiality or reports and anonymity of the complainants and to protect employees against retaliation.

  1. Internal monitoring and auditing – There will be ongoing evaluation and monitoring of the compliance program to ensure its effectiveness. The Company will utilize multiple avenues for internal monitoring and auditing purposes. The information gathered from monitoring efforts may result in the correction and/or modification of our internal processes; re-coaching and re-training efforts of employees and/or contractors or; disciplinary action taken by the Company. The Company’s compliance organizations must immediately notify the appropriate carrier(s) of any egregious compliance failure
  1. Disciplinary enforcement – Depending on the severity of violations, re-training and disciplinary actions up to and including termination may be taken if the monitoring and auditing process uncovers any egregious compliance.
  1. Mechanisms for responding to and reporting detected problems – All reports and/or indications of suspected noncompliance will result in an immediate investigation to determine whether there has been a violation of law or other requirements; and, if so, make sure all affected parties are notified of the breach, and do everything possible to correct/minimize the severity of the violation. All suspected incidents or breaches will be reported to the appropriate carrier(s) Privacy Department, Legal Department or Compliance Department upon

Structure and Membership of The Company’s Compliance Organizations

The Chief Administrative Officer (CAO) will be the head of the Compliance Program. They will be responsible for everything regarding compliance. It is their responsibility to  keep  the  lines  of  communication  open  and  fluid,  not  only  with

employees, but with senior management as well. The CAO is also responsible for training and educating all employees regarding compliance. However, the success of any compliance program depends on the diligence of everyone involved to be aware of all rules and regulations and adhere to them, as well as help monitor for possible breaches and violations, and if any are found report them immediately.

Knowledge of Regulations and The Company’s Policy

The Company’s Compliance Program will establish and maintain an inventory of applicable policies and procedures, regulations and guidance documents applicable to the day-to-day duties of the Company’s employees and contracted agents. Additionally, broader, more general compliance requirements pertaining to, but not limited to, Information Security, Records Management, and Privacy and Security Awareness will be addressed in these policies and procedures. These will include, but are not limited to, Health Insurance Portability and Accountability Act (HIPAA) regulations; the Center for Medicare and Medicaid Services (CMS) guidelines; and federal, state, and/or local laws and regulations.

Oversight of the Company Compliance Program

To help ensure the success of the Compliance Program, the Company will conduct periodic reviews and audits of compliance operations and performance. The goal of this internal monitoring is to uncover any non-compliance issues, so they can be addressed internally, and remediated before any actual breach of compliance occurs. This internal checks and balances system will help ensure the success of the         Compliance Program. The Company’s Compliance organizations will immediately notify each affected carrier of any egregious compliance failure by reporting such incidents or breaches to the carrier(s) Compliance Department or Legal Office.

American Exchange

Code of Compliance and Ethics

American Exchange, here after used interchangeably with the Company, is committed to excellence in providing insurance coverage options to licensed agents and in conducting its business affairs. Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us. Each American Exchange employee subscribes to this Code of Compliance and Ethics as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” means the plans or services available from a private insurance company through the Company, “consumer” means a person who may purchase a product; “member” means someone who has purchased such a product and “agent” means any downline agent contracted through American Exchange with a private insurance carrier.

  1. I shall conduct myself in an ethical manner with courtesy and dignity and with respect for the rights and reasonable requests of consumers and members at all ti
  1. I will not make statements or engage in activities that could mislead or confuse consumers, members and/or agents or misrepresent the Company, insurance carrier products or the Centers for Medicare & Medicaid Services (CMS).
  1. I will use no form of coercion, deception, sympathy appeal or other high-pressure tactics to entice agents to enroll consumers in a I will always give clear and accurate information regarding my relationship with the Company and avoid the use of false, contextually misleading or exaggerated statements.
  1. I will protect the privacy of consumers, members and agents and preserve the confidentiality of their records in accordance with the Company’s Policies and I will handle the enrollment application and any other consumer or member health information in my possession in a professional and confidential manner. I will maintain only such consumer or member information required to conduct business and will do so in a secure and compliant manner and in accordance with the Company’s Privacy Policies and Procedures.
  1. I shall observe the Company’s Policy of Nondiscrimination by reason of race, creed, color, sex, age, national origin or economic Enrollments in any product shall not be predicated on age or medical condition, except as provided by federal rules of access to Medicare. I understand that discrimination based on health status or disability is prohibited.
  1. I am aware that marketing activities in connection with the sales of products to consumers are strictly regulated by both state and federal law and rules and regulations promulgated by the Centers for Medicare & Medicaid Services (CMS) and I agree to comply with these
  1. I understand that agents must use sales and marketing materials that have been approved by the required entities (CMS, Departments of Insurance and the Company, as applicable) in all sales and marketing to consum
  1. I understand that I cannot use the Company’s logos or carrier logos (including but not limited to: letterhead, business cards, websites, shirts or other use) without prior written permission from the Company or the
  1. I understand it is my responsibility to comply with all applicable federal and state regulations including but not limited to HIPPA.
  1. I have reviewed and understand the Company’s Policies and Procedures and agree to abide by them.
  1. I understand that any breach of the above pledge could result in the immediate unilateral termination of my employment with the Company.

I have read this Code of Compliance and Ethics and Ethics, and agree to the Terms and Conditions as outlined on these forms.

 

 

PP – 2.0 Organizational Chart

American Exchange (“Company”) will have an Organizational Chart available upon request. It is the responsibility of the Human Resources Director to update the Company’s Organizational Chart by the 15th of each month.

3.1  Policy on Policies

American Exchange has established a Compliance Committee to create, review and implement the policies and procedures of the organization.  It is the policy of the Company that all employees and downline agents and agencies adhere to the policies and procedures found within this manual, and are subject to review and disciplinary action by the Compliance and Oversight Board of upline MGAs, FMOs, or Carriers should any deficiencies be found.

3.2  Policy Statement

It is American Exchange’s policy to develop and maintain policies and procedures that provide guidance and demonstrate the Company’s commitment to compliance.

3.3  Policy Purpose (Scope)

This document outlines the process of development, review, approval and communication of sales operations, policies and procedures.

3.4  Policy Provisions and Exhibits (Procedure)

Policies and procedures are developed and maintained to provide guidance to ensure compliant and ethical conduct, professionalism and knowledge of required business processes and responsibilities.

3.4.1  Development and Review

All policies and procedures are developed and reviewed by the Compliance Committee of American Exchange The Compliance Committee is notified of potential policy issues as they arise by other individuals within the Company.  The Compliance Committee then meets to assess the issue and develop a process addressing the issue. American Exchange will conduct quarterly and annual audits to ensure proper implementation and address any deficiencies. The audits will assess the following areas: Internal Employee Training, HIPAA and MIPPA Compliance, Agent Oversight and Agent Violations.

3.4.2  Approval and Communication

All policies and procedures are approved by the President of American Exchange Once approved, the new or amended policy is distributed to all employees in memo form. The new or amended policy should also be distributed to any carrier, vendor or other entity as needed.

3.4.3  Restriction on Distribution of Policies and Procedures

American Exchange’s Policies and Procedures are for “Internal Use Only”.

All policies and procedures are kept in electronic format on a secure server that can only be accessed by American Exchange’s employees.

 

American Exchange has developed set policies on how to manage and maintain its state licenses and appointments with each carrier as well its Day-to-Day operations. Additionally, all downstream entities are required to apply the following policies to their internal regulatory processes.

PP – 4.1 State Licenses

The Company agrees to hold all appropriate resident and non-resident licenses in each state, and with each carrier, in which a particular product is being represented.  The Company will also pay all necessary licensing fees and complete any required CE to maintain state appointments.

It is the responsibility of the Chief Administrative Officer to update each and all licenses and fees with all carriers, as needed.

PP – 4.2 Carrier Appointments

It is the responsibility of the Chief Administrative Officer of American Exchange

to ensure that they are appropriately licensed and appointed with each carrier in all states where plans are represented.

PP – 4.3 Carrier Certification

American Exchange and its representatives agree to annually comply with each carrier’s individual certification guidelines as well as any additional CMS requirements.

Only the President will be responsible for completing certification on behalf of the agency.

PP – 4.4 Disaster Recovery

The Company will have set policies in place to govern the steps taken to ensure day-to- day operations can continue in the fullest capacity possible in any instance where the normal business processes may be interrupted.

PP – 4.4.1 Temporary Displacement

If, for any reason, natural disaster or otherwise, employees and executive staff are unable to enter the building, or are required to leave the premises for a length of time deemed to be “temporary”, business operations will resume in a minimal capacity as considered necessary by the President. This may include accessing email from a secure, backup, email server or forwarding phone calls and voicemails to employee cell phones.  Access to the main server will not be available in these circumstances.

PP – 4.4.2 Permanent Displacement or Restructuring

In the event of a natural disaster or other event which results in permanent abandonment of the building, the Company will have a Business Continuity Plan (BCP) which outlines the procedures necessary to resume the organization’s normal operations. The BCP includes issues such as permanent loss of the main IT server and relocation of the office. The BCP will also address issues not resulting in displacement but instead restructuring of the organization such as loss of a key employee.

Addendums                                                                                              None

PP – 5.0 Internal Employees

American Exchange views internal employees as any person holding a permanent full-time or part-time position with the Company.  American Exchange does not view its independent, telesales and/or captive downline agents as employees and are therefore not addressed within this section.  The policies found within this section will also apply to any internal employees of the Company.

PP – 5.1 New Hires

All new hires will complete compliance orientation and agree to all compliance rules and regulations. This includes HIPAA, the Policies and Procedures Manual and Employee Handbook. All new hires must sign American Exchange s Code of Conduct (Please refer to document PP – 5.1a).

PP – 5.2 Employee Files

All personnel files will be managed and maintained in accordance with HIPAA and the guidelines outlined in the Employee Handbook.

PP – 5.3 The Violent Crime Control and Law Enforcement Act (18

  • 1033 et seq)

The Violent Crime Control and Law Enforcement Act (18 U.S.C. 1033 et seq.) makes it a crime for individuals convicted of certain felonies to willfully engage in the business of insurance.  The Company will comply by terminating employment with any individual who falls under this category.

PP- 5.4 Office of Inspector General Exclusions

Sections 1128 and 1156 of the Social Security Act prohibit certain individuals and entities from participating in federally funded healthcare programs, including Medicare, Medicare Advantage and Medicare Part D plans.  The Office of the Inspector General (OIG) maintains a list of excluded individuals and entities.  The list is available on the internet at:

http://oig.hhs.gov/fraud/exclusions.asp

American Exchange will comply by screening all new employees against the OIG exclusion list prior to hire and all current employees against the OIG exclusion list on a monthly basis.  A screenshot of the result from the check will be saved in PDF format and available upon request.  Employees will be immediately removed from all activity related to Medicare products if found to be on the OIG listing.

Should a potential employee appear on the OIG exclusion list, employment will be denied.  In the event an existing employee is added to the OIG exclusion list, their employment with American Exchange will be terminated citing the sections of the Social Security Act listed above.

PP – 5.5 System for Award Management (SAM) Exclusion List

It is the policy of American Exchange that all new employees are screened against the SAM exclusion list prior to hire and all current employees against the SAM exclusion list on a monthly basis. A screenshot of the result from the check will be saved in PDF format and available upon request.  Agents will be immediately removed from all activity related to Medicare products if found to be on the SAM listing.  This list is available on the internet at:

www.sam.gov

Should a potential employee appear on the SAM exclusion list, employment will be denied. In the event an existing employee is added to the SAM exclusion list, their employment with American Exchange will be terminated.

PP- 5.6 Code of Conduct

All employees of American Exchange must sign and agree to maintain the Company’s Code of Conduct.  (Please refer to document PP – 5.1a)

PP- 5.7 Corrective and Disciplinary Actions

CMS maintains regulations governing the sale of all insurance products.  It is the Company’s policy that all employees abide by these regulations without exception. Failure to do so will lead to disciplinary action up to and including termination.

PP 5.8 Reporting of Disciplinary Action

Employees that face disciplinary action as a result of non-compliance or fraud, waste or abuse will be reported up to the carriers and/or the Compliance and Oversight Board of American Exchange or any of our partners as required. The report will include the following information:

  • The steps taken by the Company in response to the violation
  • The information uncovered during the investigation process
  • The completed report on the findings of the investigation
  • Copies of any disciplinary warnings (if issued)
  • A list of all violations and consequences uncovered

PP 5.9 Employee Separation

In the event of employee separation, American Exchange will ensure all HIPAA and sensitive information remains secure.  Upon separation, all company passwords the separated employee had access to will be changed immediately. Passwords that were assigned specifically to the terminated agent will be deactivated immediately upon termination. The separated employee’s manager will be responsible for ensuring that the employee does not have access to his/her work space, computer or E-mail.  The manager will be responsible for escorting the said employee off the property.

PP 5.10 In-House Licensed Agents

All agents that are in a captive relationship with the Company will be held to the same monitoring and disciplinary standards as other internal employees.  This includes monthly verification against the OIG and SAM Exclusion Lists, annual background checks, training and corrective action.  In addition, all licensed agents are also expected to comply with individual carrier guidelines in regard to licensing, certification and oversight.  All in-house agents are trained on Fraud, Waste and Abuse and general compliance upon initial contract with the Company.

PP – 5.11 Distribution of Carrier Documents

The Company will comply with all carrier specific guidelines in regard to the distribution of documents pertaining to that individual carrier.  These documents may include Codes of Conduct, carrier generated Fraud, Waste and Abuse training materials, Conflict of Interest policies, etc.  The Company will distribute these within 90 days of hire and periodically thereafter to all employees and vendors who conduct business on behalf of that carrier.

 

PP – 6.0 Internal Employee Training

American Exchange has established and is committed to maintaining on-going compliance training for all staff. This includes, but is not limited to, General Compliance, HIPAA, MIPPA, Policies and Procedures and Fraud, Waste and Abuse Training.  All aforementioned training must occur within 30-days of initial hire, and annually thereafter, for all employees dealing with Medicare Advantage, Medicare Prescription Drug Plans, under 65 Health Plans, and Life Policies. Internal Employees of Downstream Call Centers must also follow the same training schedule in addition to any training offered by individual carriers specific to the call center structure.

All employees and agents of the Company will complete a compilation of the following trainings based on their job function with the Company:

  • MIPPA regulations including prohibited marketing practices
  • PHI and PII data
  • Sales presentations and outlines; call scripts and guidelines
  • Comparison of Medicare Advantage plans to Original Medicare
  • Plan rules and member responsibility
  • Election periods
  • Enrollment and disenrollment processes
  • Benefits (Out-of-Network coverage, emergency services, etc.)
  • Eligibility and LIS eligibility

PP – 6.1 Telesales Agents

All Telesales Agents will be responsible for ensuring marketing and sales compliance through on-going training.  This includes maintaining current knowledge of the CMS Marketing Guidelines. Telesales Agents are responsible for completing annual certification when applicable as well as Fraud, Waste and Abuse Training and other carrier specific training as required.  Telesales agents must complete all licensing, certification, training and any other requirements specific to the telesales channel prior to writing business.

PP – 6.2 Administrative Staff

Administrative Staff will be required to participate in on-going training on compliance rules and regulations.  This includes HIPPA, Fraud, Waste and Abuse Training, Policies and Procedures and all applicable federal and state guidelines.

PP – 6.3 Enrollment Staff

Any individual handling enrollment applications will participate in on-going training on compliance rules and regulations.  This includes HIPPA, Policies and Procedures and all applicable federal and state guidelines.  In addition, they will also be trained on carrier and CMS guidelines regarding submission timelines and guidelines, document retention and proper handling of PHI/PII.

PP – 6.4 In-House Licensed Agents

In-House, captive agents will be required to participate in on-going training on compliance rules and regulations.  This includes HIPPA, Fraud, Waste and Abuse Training, Policies and Procedures and all applicable federal and state guidelines.

In addition, they will be required to complete all training specific to each individual carrier they are licensed and appointed with

PP – 7.0 Agent Compensation

In instances where American Exchange pays agent compensation out of its internal accounting office, policies are enforced to ensure compliant and accurate payments to agents.

PP – 7.1 Payment Guidelines and Compliance for External Agents

It is American Exchange’s policy to have commissions paid directly to brokers whenever possible.  In the event American Exchange is requested by an insurance carrier to pay broker commissions, American Exchange will pay according to insurance carrier commission schedules.  The Company will comply with all CMS rules and regulations regarding the amount of commissions that can be paid to a given individual or agency.

PP – 7.2 Payment Guidelines and Compliance for Internal Agents

Internal agents such as telesales and captive agents may receive a different compensation schedule than agents that are contracted directly with the carrier(s).                             It is the Company’s policy that all agent payment compensation and/or bonus schedules are available for review by the carriers and my up line upon request to ensure CMS compliance regarding agent compensation.

PP – 7.3 Chargeback Process

It is American Exchange’s policy to charge back commissions according to each insurance carrier’s policy and CMS guidelines. The Company will comply with all carrier guidelines regarding chargebacks.

PP – 7.4 – Rapid Disenrollments

It is the Company’s policy to track rapid disenrollment trends in downline and captive agents when made available to the Company by the insurance carrier. The Company will charge back all rapid disenrollments when applicable.

PP – 7.5 – Agent Files

Agents licensed under the Company are required to be licensed, appointed, certified and have the correct tax forms on file with American Exchange

PP – 7.5.1 Agent Contracting

Agents must complete the carrier specific contracting, certification and be appointed prior to soliciting business and/or receiving commission.

PP – 7.5.2 Required Tax Forms

Agents must have a W-9 on file with the American Exchange

PP – 8.0 – HIPAA Compliance

It is American Exchange’s commitment to the protection and integrity of all personal and health information. It is American Exchange’ policy to comply with the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) as well as other laws aimed at safeguarding privacy.  The

Company is required to maintain, at a minimum, the following policies and procedures regarding HIPAA.

PP – 8.1 – Personal Health Information (PHI) and Personally Identifiable Information (PII)

All written PHI/PII shall be placed in an appropriately secured file.  Paper files (members, agents and employee) containing such information shall be kept in a secure place at all times within the resources available other than when being updated or used by authorized personnel as a necessary function of their work.  All applicable physical and electronic documents will be retained for a minimum period of ten years.

PP – 8.1.1 – Member Files

Privacy regulations protect the confidentiality of the member’s individual medical information with respect to others. These privacy regulations apply to all forms of PHI/PII, including but not limited to, paper, verbal and electronic.  Members’ files will be kept in a secure place at all times.

PP – 8.1.2 – Agent Files

American Exchange’s HIPAA Policies and Procedures ensure that all identifiable health information encountered by our staff as a result of processing is protected from unauthorized access and/or release as defined in the privacy regulations.  The Company is to take necessary measures to ensure all agent files are in compliance with HIPAA standards.

PP – 8.1.3 – Employee Files

The Company will protect all health-related records and make sure they are secure in a separate area from employment files and available only to those with the proper authority to see them. Employee files will be managed and maintained in accordance to HIPAA guidelines.

PP- 8.2- E-mail

The Company will ensure all emails containing PHI/PII are transmitted in a secure manner and in accordance with HIPAA guidelines.

PP- 8.3- Passwords

Each Company employee will have a set of unique passwords to access computers, e- mail, networks and client and agent management software.  These passwords are assigned on a need to access basis and are to remain confidential and should not be shared with anyone.  In the event of employee separation, pertinent passwords will be changed.

PP- 8.4- Secure Areas

All areas that may contain PHI/PII will be deemed secure areas. Secure areas must maintain a strict level of compliance.

PP- 8.5- Logical Access

The Company grants logical access to employees on a Need-to-Access basis.  All forms of PHI and PII, both physical and electronic, are housed in secure areas and assessable only to those employees who utilize the information to conduct normal and necessary business practices.  Access is granted by the employee’s manager and all high-levels approved by the President of the Company.  Should an employee be found in violation of any of the policies found within this section or should a breach occur, access to all forms of information is immediately suspended for all employees involved in said violation.

PP – 9.0 Privacy and Security

American Exchange relies on information for their success. Managing personal information responsibly and legally serves our business objectives and helps build trust with stakeholders, partners and brokers. The policies outlined below operate in conjunction with other privacy policies laid out by either American Exchange or its affiliates.

PP – 9.1 Personal Health Information (PHI) or Personally Identifiable Information (PII)

All individuals who conduct business for, or on behalf of, American Exchange are responsible for understanding and complying with applicable laws and regulations that protect the privacy and security of Personal Health Information (PHI) or Personally Identifiable Information (PII) pertaining to members, customers, employees and business partners.  American Exchange employees must collect, maintain, use and disclose PHI and PII in a manner consistent with all applicable laws in the all areas in which American Exchange conducts business.

All managers at the executive and administrative levels are responsible for monitoring and ensuring compliance in regards to any privacy laws and/or policies set forth within this manual.

PP – 9.1.1 Access to Personal Health Information or Personally Identifiable Information

Access to PHI and PII is granted on a need-to-access basis determined by the individual’s direct manager.  All written PHI and PII will be kept in a secure file accessible only to those employees deemed necessary.  Paper files (members, agents and employee) containing such information shall be kept in a secure place at all times within the resources available other than when being updated or used by authorized personnel as a necessary function of their work.  Electronic PHI and PII will be stored on a secure server and password protected.

PP – 9.1.2 Personal Health Information or Personally Identifiable Information Policies and Procedures

American Exchange is responsible for identifying the applicable laws and regulations relating to PHI and PII and relaying that information to its employees, brokers and any other individual conducting business on their behalf. The Compliance Committee will review all pertinent rules and regulations and develop and enforce policies and procedures for meeting the requirements of state and federal laws.

PP – 9.2 Collection of Personal Health Information or Personally Identifiable Information Policies and Procedures

American Exchange will collect PHI and PII lawfully and will require the same of third party entities collecting information on their behalf. The collection of PHI and PII should be limited to that which is relevant and appropriate for purposes of providing a service, employment or that which is required by law.

PP – 9.2.1 Sensitive Personal Health Information or Personally Identifiable Information

The definition of Sensitive PHI or PII varies across jurisdictions and can included information regarding race, ethnic origin, political opinions, religious beliefs, trade union membership, physical or mental health, sex, commission or alleged commission of offenses, court proceedings, financial information, government-issued identification numbers (i.e. Social Security numbers), etc.  American Exchange will limit the collection of sensitive PHI and PII to that related to a legitimate business purpose. Where required by law, American Exchange will collect Sensitive PHI and PII only with the consent of the individual.

PP – 9.3 Use and Retention of Personal Health Information or Personally Identifiable Information

American Exchange will use and retain PHI and PII only for legitimate business purposes consistent with the policies and procedures outlined in this manual, documented legal requirements and/or any applicable privacy notices provided to the individual. American Exchange will retain all PHI and PII in accordance with federal and state guidelines and only that which is required by law or necessary to satisfy operational needs. All written PHI and PII will be kept in a secure file accessible only to those employees deemed necessary.  Paper files (members, agents and employee) containing such information shall be kept in a secure place at all times within the resources available other than when being updated or used by authorized personnel as a necessary function of their work. Electronic PHI and PII will be stored on a secure server and password protected.

PP – 9.4 Disclosure and Cross-Border Transfers

Disclosures of PHI and PII to vendors, contractors, service providers and other third party affiliates must be consistent with applicable privacy notices, contracts, agreements and laws.  It is the policy of American Exchange that such disclosures will be limited to the minimum amount of PHI and PII necessary for the intended purpose. American Exchange is also responsible for identifying their legal obligations and for determining those obligations are met in regards to the handling, protection and transfer of PHI and PII to recipients outside the borders of the United States.

PP – 9.4.1 Disclosure of Personal Health Information or Personally Identifiable Information

Prior to disclosing PHI or PII, American Exchange will ensure the following procedures are adhered to: the transfer of all forms of PHI is completed in a secure manner, through a secure outlet; the employee, system or entity that is receiving the PHI and PII is clearly identified; and, when required by law, the third party is contractually committed to protecting the PHI and PII and limiting is usage and disclosure.

PP – 9.4.2 Transfer of Personal Health Information or Personally Identifiable Information

American Exchange will allow the transfer of PHI or PII to, or allow access by, entities in foreign countries for the sole purpose of conducting legitimate business transactions and only when assured the information will be lawfully processed and protected.

PP – 9.5 Security of Personal Health Information or Personally Identifiable Information

It is the policy of American Exchange to establish, implement and monitor administrative, physical and technological security and safeguards to protect all forms of PHI or PII from unauthorized access, unintended disclosure, corruption or loss.

PP – 9.6 Data Quality

It is American Exchange’s policy to maintain accurate and complete PHI and PII in all instances when required to do so either by state and/or federal regulations or carrier guidelines.

PP – 9.7 Monitoring and Enforcement

American Exchange requires all employees to comply with the privacy laws set forth in this manual as well as all other state and federal regulations, and has set procedures in place to monitor and enforce these policies.

PP – 9.7.1 Reporting

Any possible breach of PHI or PII privacy must be reported to the Compliance Committee immediately and reported to each carrier affected by the breach.  In addition, the Compliance Committee has the responsibility for investigating each individual situation and reporting those findings to any additional entities that are deemed necessary.

PP – 9.7.2 Review

It is the policy of American Exchange to review and audit all policies related to privacy and security on a quarterly basis to ensure proper implementation. The Compliance Committee is responsible for conducting the quarterly audits as well as addressing any privacy complaint that may arise.

PP – 9.7.3 Disciplinary Actions

If the Compliance Committee of American Exchange determines that an employee or third party entity has, either knowingly or unknowingly, violated any policy related to privacy and/or security, disciplinary action will be taken up to, and including, verbal and written warnings, suspension with or without pay, or termination. Several factors will be taken into consideration when assessing the disciplinary measures taken including, but not limited to, severity of the violation; nature of the violation (accidental, inadvertent or purposeful misconduct); potential risk created by the disclosure to the individual; whether the employee in violation self-reported and was cooperative with the investigation and if the employee in question is a repeat offender.  All violations will be reviewed on a case-by-case basis and disciplinary measures issued accordingly.

PP – 10.0 MIPPA Compliance

It is the policy of American Exchange to comply with all guidelines set forth by the Medicare Improvements for Patients and Providers Act (MIPPA). The President, CEO and Vice President of Senior Services along with the Director of Operations oversee each portion of this policy.

PP – 10.1 External Agent Contracting

American Exchange follows all state and federal guidelines, as well as any carrier specific requirements, regarding agent licensing and appointments.  All agents must be fully appointed, when applicable, prior to marketing Medicare Advantage and/or Medicare Prescription Drug Plans for which they will be representing.  Any agent acting on behalf of a Downline Call Center must also hold all applicable licenses and appointments prior to submitting business. Telesales agents must also adhere to specific contracting requirements as covered in PP – 13.0 of this manual.

PP – 10.2 External Agent Certification and Training

It is the policy of American Exchange that all downline agents certify annually for each carrier they represent for Medicare Advantage and/or Medicare Part D plans. Each agent must complete and pass all certification, general compliance and Fraud, Waste and Abuse training required by each carrier prior to engaging in any sales activities with said carrier. This training can include, but is not limited to, certifications administered by America’s Health Insurance Plans (AHIP), Gorman and CMS. Employees of American Exchange will not assist agents in any way, shape or form with answers to certification test(s).  Telesales agents must also adhere to specific certification and training requirements as covered in PP – 13.1 of this manual.

PP – 10.3 Sales and Marketing Events

American Exchange adheres to all MIPPA guidelines related to sales and educational events. American Exchange requires all independent downline agents to report all sales events to the carrier and CMS per each carrier’s specific guidelines as well as notify them of any changes made once the event is filed.  It is also the policy of American Exchange and its downline agents to comply to with all CMS and MIPPA rules regarding the prohibiting of methods of coercion during sales and marketing events, including, but not limited to, gifts valued more than $15, foods other than light snack and monetary rewards of any kind.

PP – 10.4 Scope of Appointment Forms

It is the policy of American Exchange that its Downstream Call Center agents comply with all carrier requirements pertaining to the obtaining, submission and storage of Scope of Appointment Forms. In addition, all Downstream Call Centers must adhere to any and all CMS specific rules and regulations regarding these documents.

PP – 10.5 Agent Code of Conduct

Downstream agents will be requested to sign the Agent Code of Conduct for Medicare Advantage and Medicare Part D Sales upon contracting stating that they agree to abide by all rules set forth by CMS and the MIPPA document prior to entering into a relationship with the Company.  The Agent Code of Conduct also states that independent agents are responsible for monitoring the Medicare and CMS websites, reviewing all agent updates distributed by the company and completing all required certification and training annually. (Please refer to document PP – 10.5a)

PP – 10.6 MIPPA Rules and Regulations

In addition to the policies referenced above, the Company also requires all agents selling on their behalf to:

  • Provide written mandatory compensation language to each Medicare beneficiary to whom a health plan is presented
  • Present all information in a fair and accurate manner so that each beneficiary is fully informed to make a decision
  • Provide each enrollee with written information of the complete benefit package and confirm that the individual understands the program, the grievance and appeal procedure and their disenrollment rights
  • Ensure that all potential enrollees receive a clear explanation of the plan’s networks’ provisions which include proper utilization of the urgent care and emergency benefits
  • Utilize only marketing materials that have been approved by CMS and/or American Exchange
  • Enroll only qualified Medicare beneficiaries that reside in approved service areas; using only approved enrollment applications and enrollment methods as set forth by CMS, the carrier and/or the Company
  • Provide the enrollee with a copy of the signed enrollment form including the proposed effective date

PP – 10.7 Prohibited Practices

Agents are expected to refrain from performing prohibited sales and marketing practices in accordance with Chapter 3 of the Medicare Marketing Guidelines.  These activities include but are not limited to:

  • Conducting activities that may cause potential enrollees to feel pressured, compelled or coerced in any way
  • Conducting activities that mislead or misrepresent potential enrollees
  • Claiming that the Company or the agent is recommended, endorsed, affiliated with or employed by CMS, the state Department of Insurance or Medicare
  • Making statements or claims that contradict or conflict with information found in CMS approved materials
  • Using definitive statements that cannot be supported by facts and data
  • Inducing providers or provider groups to:
    • Distribute printed information comparing benefits to different health plans unless the materials have received prior CMS approval
    • Accept enrollment applications
    • Persuade individuals to enroll into specific health plans
    • Offer anything of value to induce plan enrollees to select them as aprovider
  • Conducting presentations, distributing or accepting enrollment applications or soliciting potential enrollees in health care settings with the exception of designated common areas permitted under CMS guidelines
  • Conducting plan sponsored specific presentations or distributing and accepting enrollment applications at designated educational events
  • Presenting or selling non-health related products during MA, MAPD or PDP appointments
  • Presenting or selling products beyond the scope agreed upon by the beneficiary prior to the appointment
  • Offering gifts, payments or remuneration of any kind to induce enrollm This includes cash gifts, charitable donations or contributions made on behalf of the individual, gift certificates or gift cards that can readily be converted into cash or offering meals (regardless of value) at sales events.
  • Practicing discriminating activities which may deny eligible beneficiaries of their right to enroll
  • Requiring an in-home appointment
  • Falsifying or participating in false signatures
  • Ignoring or delaying an enrollee’s request for cancellation or disenrollment
  • Overstating plan benefits
  • Implying permanent coverage
  • Using any form of unsolicited contact including but not limited to:
    • Sending e-mails to beneficiaries that have not given their permission
    • Making outbound marketing calls without written permission by the individual or calling disenrolled members with the purpose of re-enrolling
  • Soliciting door-to-door or leaving information on doors, cars, etc.
  • Bait-and-switch practices
  • Any other sales or marketing practice prohibited by CMS or the carrier

Addendums

PP – 10.5a “Agent Code of Conduct for Medicare Advantage and Medicare Part D Sales”

PP – 11.0 Agent Oversight

American Exchange utilizes several methods in an attempt to prevent, detect and correct fraud, waste and abuse as well as other compliance issues.  Using these tools, American Exchange can take a proactive approach to compliance and help ensure a high standard of business ethics.

PP – 11.1 Agent Licensing and Contracting

American Exchange will monitor all subagent’s state license status on a monthly basis including but not limited to continued professional education and state exam results. American Exchange will monitor all agent certification results that are made available by the carrier.

PP – 11.1.1 Agent Contracting

Once received, all agent contracts are reviewed for accuracy and missing information prior to being submitted to the company for approval.  All agent information is documented in the Company’s database system including name, phone number, address, social security, and date of birth. The contract is then submitted to the upline per each individual guideline.

PP – 11.1.2 Records Retention and Maintenance

All agent records are scanned into our secure server and are retained for no less than a minimum of ten (10) years.  All agent information is also documented in the Company’s database system, updated as needed and retained indefinitely. Designated employees will be able to view and maintain records as needed.

PP – 11.2 Reporting of Terminated Agents

In the event a downline agent is terminated with cause by a Medicare Advantage and/or Medicare Part D Plan, the terminated agent will be reported to the internal Compliance Committee.

PP – 11.3 CMS Approved Material

It is American Exchange’s policy to provide agents with supplies for Medicare Advantage and Medicare Part D plans that are current and approved by CMS.  American Exchange ensures agent use of updated materials during “Ride-A-Longs” and Secret Shopper audits.  Telesales agents must utilize CMS approved scripts on all sales calls.

PP – 11.4 Downline Oversight

It is the Company’s policy that all independent agents within its downline adhere to the same compliance and ethics guidelines as its internal employees and agents.  American Exchange does the following to ensure all agents within our organization receive, understand and follow the compliance guidelines set forth by this manual, the carriers and CMS.  The Vice President of Senior Services and Assistant Director of Senior Services are responsible for the oversight of the Company’s agents.

Some examples of agent oversight we provide are:

  • Weekly Meetings with Agents
  • Ride-a-Longs with new and existing Agents
  • Web Conferences

PP – 12.0 Agent Violations

American Exchange takes all agent violations extremely serious and has detailed policies and procedures in place to handle such instances.  These policies and procedures apply to all downline agents regardless of their appointment level as well as Downstream Call Centers and any agent appointed under them.

PP – 12.1 Carrier Originated Complaint Process

In the event that American Exchange receives a complaint directly from a carrier, immediate action is taken to ensure a response is received in the designated time frame. The Company will assist the carrier in obtaining the agent’s response to the complaint within the designated time frame.

PP – 12.2 Agent Violations Uncovered Internally

American Exchange takes any violation of MIPPA, HIPAA, carrier policies and procedures and all other federal and state rules and regulations very seriously and has policies in place should an internal employee or downline agent uncover a breach of any of the above.

PP – 12.2.1 Documentation of Violation(s)

All violations will be reported to the Company’s Chief Administrative Officer who will then submit a summary of the violation to the Compliance Committee and to the Chief Administrative Officer at American Exchange. These summary reports may be submitted in any of the following manners:

Email:

Phone:

Anonymous reporting can be done through the carrier or CMS.

An Agent Violation Report (AVR) will be completed for each violation and kept in the agent’s personal file. (Please refer to document PP – 12.2.1a)

PP – 12.2.2 Agent Re-training

It is the policy of American Exchange to re-educate downline agents in all areas where policies and/or rules and regulations were misinterpreted or misunderstood.  Retraining can include, but is not limited to: webinars, one-on-one coaching with Company employees, carrier sponsored training, ride-a-longs and recertification.  An Agent Counseling Report will be completed after any retraining occurs.  (Please refer to document PP – 12.2.2a)

PP – 12.2.3 Reporting of Violation to Carrier

It is American Exchange’s policy to report all violations to the appropriate carrier in accordance with their individual guidelines.

PP – 12.2.4 Corrective and Disciplinary Actions

American Exchange and/or American Exchange reserves the right to enact corrective actions whenever a violation occurs up to and including termination of contract through American Exchange  Disciplinary actions may include but are not limited to retraining and/or recertification, carrier mandated compliance training, reporting of the violation to carrier(s) and/or CMS and termination of agent contract.  All corrective and disciplinary actions are document using the ACR and AVR and added to the agents’ personal file.

PP – 12.2.5 Termination of Agents

For agents that are deemed repeat offenders or are found to be acting maliciously and with intent, American Exchange and/or American Exchange reserves the right to terminate agents from any or all appointments, and may opt to deny agent future appointments with American Exchange. Actions that may result in agent termination include, but are not limited to, three failed “Ride-A- Longs”, three (3) failed Secret Shopper Reports or two (2) or more sales allegations within a calendar year.  In the event either party terminates an agent’s contract(s), the applicable carrier(s) will be notified within five business days.

PP – 12.3 Agent Violations Uncovered by FMO (External Source)

In the event a member grievance against an agent or a sales allegation is received directly by American Exchange, the applicable carrier will be notified within 24 business hours of receipt. American Exchange follows all carrier rules and regulations regarding the handling of any and all sales allegations and will comply with individual requirements. The Agent Violation Report will be filled out by the employee working with the agent in question and will be submitted to the Compliance Committee for review.

PP – 12.4 Agent Reporting of Violations

The Company has in place several methods for agents to report any compliance violations they uncover as well as seeking answers to compliance questions they may have. Agents may utilize any of the following methods to reach the Compliance Committee:

Email:

Phone:

Anonymous reporting can be done through the carrier or CMS.

Addendums

PP – 12.2.1a “Agent Violation Report”

PP – 12.2.2a “Agent Counseling Report”

PP – 13.0 Telesales

American Exchange understands that the guidelines surrounding call centers and telesales agents may be different than those for agents that conduct business in a face-to-face scenario. The policies outlined in this section are specific to telesales channels and agents only and supersedes all other policies within this manual.

PP – 13.1 Telesales Code of Conduct and Ethics

The principal of this Company’s call center has reviewed and agreed to American Exchange’s Telesales Code of Conduct and Ethics. (Please refer to document PP – 13.1a)

PP – 13.2 Telesales Contracting and Appointment Process

It is the policy of American Exchange that no sales will be conducted via the telesales channel until the agency has been licensed and appointed as an official call center by each carrier they represent.  All downline telesales agents must also be appointed and designated as a telesales agent (as required by carrier) prior to submitting business in this manner.

PP – 13.3 Telesales Certification and Training Process

The Company’s policy is that all telesales specific training and certification be completed prior to the agency or downline agents engaging in marketing or selling via the call center channel. This training may be in addition to the annual, CMS required certification. The Company is responsible for ensuring all downline telesales agents are trained on each carrier’s enrollment process as well.

PP – 13.4 Call Recordings

It is the policy of the Company that all calls are recorded and made available for review upon request.  All requests for call recordings will be submitted to the requesting entity within 48 hours unless otherwise noted. The Company agrees to submit call recordings to their upline based on carrier guidelines.

PP – 13.5 Call Scoring and Retraining

Telesales calls will be scored in accordance with carrier guidelines by the upline and/or the carrier(s).  It is the policy of American Exchange that two (2) calls per agent per week are scored internally as well.  The results of the scoring may result in retraining or disciplinary action as deemed necessary.  Retraining will be documented in the agent’s file and logged for trending patterns.

PP – 13.6 CMS Approved Materials

It is the policy of the Company that only CMS and/or carrier approved materials and scripts are used by telesales agents.

PP – 13.7 Telesales Agent Code of Conduct and Ethics

In addition to the Agent Code of Conduct, it is the policy of the Company that all telesales agents also review and sign the Telesales Agent Code of Conduct and Ethics prior to engaging in telesales activities.  (Please refer to document PP – 13.7a)

Addendums

PP – 13.1a “Telesales Code of Conduct and Ethics”

PP – 13.7a “Telesales Agent Code of Conduct and Ethics”

Addendums

American Exchange

Code of Compliance and Ethics

American Exchange, here after used interchangeably with the Company, is committed to excellence in providing insurance coverage options to licensed agents and in conducting its business affairs. Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us. Each American Exchange employee subscribes to this Code of Compliance and Ethics as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” means the plans or services available from a private insurance company through the Company, “consumer” means a person who may purchase a product; “member” means someone who has purchased such a product and “agent” means any downline agent contracted through American Exchange with a private insurance carrier.

  1. I shall conduct myself in an ethical manner with courtesy and dignity and with respect for the rights and reasonable requests of consumers and members at all ti
  1. I will not make statements or engage in activities that could mislead or confuse consumers, members and/or agents or misrepresent the Company, insurance carrier products or the Centers for Medicare & Medicaid Services (CMS).
  1. I will use no form of coercion, deception, sympathy appeal or other high-pressure tactics to entice agents to enroll consumers in a I will always give clear and accurate information regarding my relationship with the Company and avoid the use of false, contextually misleading or exaggerated statements.
  1. I will protect the privacy of consumers, members and agents and preserve the confidentiality of their records in accordance with the Company’s Policies and I will handle the enrollment application and any other consumer or member health information in my possession in a professional and confidential manner. I will maintain only such consumer or member information required to conduct business and will do so in a secure and compliant manner and in accordance with the Company’s Privacy Policies and Procedures.
  1. I shall observe the Company’s Policy of Nondiscrimination by reason of race, creed, color, sex, age, national origin or economic Enrollments in any product shall not be predicated on age or medical condition, except as provided by federal rules of access to Medicare. I understand that discrimination based on health status or disability is prohibited.
  1. I am aware that marketing activities in connection with the sales of products to consumers are strictly regulated by both state and federal law and rules and regulations promulgated by the Centers for Medicare & Medicaid Services (CMS) and I agree to comply with these
  1. I understand that agents must use sales and marketing materials that have been approved by the required entities (CMS, Departments of Insurance and the Company, as applicable) in all sales and marketing to consum
  1. I understand that I cannot use the Company’s logos or carrier logos (including but not limited to: letterhead, business cards, websites, shirts or other use) without prior written permission from the Company or the
  1. I understand it is my responsibility to comply with all applicable federal and state regulations including but not limited to HIPPA.
  1. I have reviewed and understand the Company’s Policies and Procedures and agree to abide by them.
  1. I understand that any breach of the above pledge could result in the immediate unilateral termination of my employment with the Company.

 

For Medicare Advantage and Medicare Part D Sales

By signing this Code, you are attesting that you are personally agreeing to all of the information found below.  Failure to comply with the conditions of the Code will have consequences as outlined in the Code.

American Exchange (referred to herein as the Company) is committed to excellence in its compliance efforts as well as integrity while conducting its business affairs.  Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us.  Each Company employee, licensed agent or broker representing a carrier through us and all third parties subscribes to our Code of Conduct as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” refers to the plans or services available through the carriers the Company represents; “consumer” refers to a person who may purchase a product; “member” refers to someone who has purchased such a product.

  1. I shall conduct myself in an ethical manner with courtesy and integrity, and with respect for the rights and reasonable requests of consumers and members at all time
  1. I will not make statements or engage in activities that could mislead, confuse or influence consumers and/or members or misrepresent the carrier or its products, Medicare or the Centers for Medicare and Medicaid Services (CMS).
  1. I will not disparage competitors or Original Medicare in an effort to influence an enrollment of a consumer into a represented produc
  1. I will never make offers of gifts or payments or share commission as an inducement for consumers to enroll in a product
  1. I will use no form of coercion, deception, sympathy appeal or other high-pressured sales tactics to enroll consumers in a produc I will always give clear and accurate information regarding my relationship with the carrier or Medicare and will avoid the use of false, contextually misleading or exaggerated statements.
  1. I will make sure that all information on the application is filled in by the Medicare consumer, their legal representative or by me, the age I will not ask a consumer to sign an incomplete enrollment application. I will not hold enrollment applications on behalf of the consumer but instead will submit enrollment applications upon receipt to the carrier or the Company per the guidelines of each specific carrier.
  1. I will use only the identification or writing number assigned to me by the carrier on enrollment applica I will not use the identification number of another agent on an enrollment application solicited by me, nor will I place my identification number or signature on an application that I did not complete or sell.
  1. I will protect the privacy of consumers and members and preserve the confidentiality of their records in accordance with all federal and state rules and regulations and carrier guideline I will handle the enrollment application and any other consumer or member health information in my possession in a professional, compliant and confidential manner. I will maintain only such consumer or member information as required to conduct business and will do so in a secure and compliant manner and in accordance with all carrier guidelines and state and federal regulations.
  1. I am aware that marketing activities in connection with the sales of products to consumers are strictly regulated by both state and federal laws and rules and regulations promulgated by CMS and I agree to comply with these requireme
  1. I understand that I must use sales and marketing materials that have been approved by the required entities (CMS, Departments of Insurance, carriers) in all sales and marketing to consumers.
  1. I understand that in order to market Medicare Advantage and/or Medicare Part D plans I must annually complete and pass the training and certification requirements set forth by each carrier and CMS, and that I am required to keep current my insurance license and all carrier appointments
  1. I understand that it is my responsibility to comply with all federal and state regulations for sales and marketing activitie I pledge that I shall at all times conduct myself and my sales activities in compliance with CMS rules and guidelines and other applicable rules and regulations.
  1. I understand that any unsolicited direct contact, including but not limited to door-to-door solicitation, cold calling, leave-behinds at or on the consumer’s personal property and e- mail solicitation is strictly prohibited.
  1. I agree to comply with all federal and state rules and regulations including HIPAA, MIPPA and CMS guidelines, as well as any carrier specific policies that are not outlined above.
  1. I understand that any breach of the above pledge could result in the immediate unilateral termination of my appointment and my agreement.

 

 

American Exchange

Telesales Code of Conduct

American Exchange, here after used interchangeably with the Company, is committed to excellence in providing insurance coverage options to licensed telesales agents and in conducting its business affairs. Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us. Each telesales agent subscribes to this Code of Conduct as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” means the plans or services available from a private insurance company through the Company, “consumer” means a person who may purchase a product; “member” means someone who has purchased such a product and “agent” means any downline agent contracted through American Exchange with a private insurance carrier.

  1. I will record and upload all calls to Hightail, the Company’s secure FTP site for call scoring and monitoring. I will upload all calls for the previous week no later than close of business the following Monday.
  1. I understand that if my downline agents fail greater than 5% of calls scored, I will be required to complete internal score two (2) calls per agent per week and submit the results to the Company upon reque I agree to conduct retraining and enforce disciplinary action as need as a result of these scores.
  1. I agree to follow all CMS rules regarding lead genera I will review all lead sources for appropriate permission-to-call (PTC) verbiage.  If my lead company does not use CMS required permission to call verbiage for MA/PD, then I will NOT call regarding MA/PD.  I will submit lead sources to the carrier and my up line as requested.
  1. I will not cold call in regards to MA/PD. I will provide proper oversight to my downline telesales agents to ensure they will not cold call in regards to MA/PD as well.

 

  1. I will follow all applicable telemarketing regulations.
  1. I will ensure that my downline is trained on each carrier’s enrollment processes.

 

  1. I will ensure that my downline is using the correct scripting and that only materials that have been approved by either CMS or the carrier are being utilized.
  1. I or a designated member of my management team will retrain any agent that scores less than 100% on their weekly call audits on the items that are considered to be below an acceptable thre I will complete an Agent Counseling Report (ACR) for each retraining instances and submit to my up line.
  1. I will make my agent payment compensation and/or bonus schedule available for review by the carriers and my up line to ensure CMS compliance regarding agent compensation.
  1. I will submit all marketing plans and lead pieces for review and approval prior to use.

 

Telesales Agent Code of Conduct

By signing this Code, you are attesting that you are personally agreeing to all of the information found below.  Failure to comply with the conditions of the Code will have consequences as outlined in the Code.

American Exchange (referred to herein as the Company or American Exchange) is committed to excellence in its compliance efforts as well as integrity while conducting its business affairs.  Our company’s continued growth and leadership depend upon the integrity of all the men and women who represent us.  Each Company licensed telesales agent or broker representing a carrier through us and all third parties subscribes to our Telesales Agent Code of Conduct as an expression of personal commitment to ethical and compliant marketing practices.

In this document, “product” refers to the plans or services available through the carriers the Company represents; “consumer” refers to a person who may purchase a product; “member” refers to someone who has purchased such a product.

  1. I will record all calls and make them available for review and scoring by my upline when requested no more than 48 hours after the request is made.
  1. I understand that I may not engage in telesales activities with any carrier until my agency and I are approved to conduct telesales and have completed all licensing, certification, training and any other requirements specific to the telesales channe I understand that this training may be above and beyond what is required for face-to-face sales.
  1. I will only use the carrier provided, approved enrollment scripts while conducting telesales activitie I agree to read the enrollment script verbatim and in its entirety on every call.
  1. I will only use pre-enrollment sales script(s) that have be submitted and approved for use.

I will not deviate from the approved script(s).

  1. I understand that I may only take enrollment applications on inbound ca No enrollment shall be completed on an outbound call.
  1. I will follow all CMS and carrier rules regarding lead genera I will review all lead sources for appropriate permission-to-call (PTC) verbiage prior to conducting a call for MA/PD.  If my lead company does not use CMS required PTC verbiage for MA/PD then I will NOT call the member regarding MA/PD.

 

 

Appendixes

Insider Trading and Fair Discloser Policy

American Exchange employees shall not use or share inside information that is otherwise not available to the general public, for personal gain, or the gain of others.

No employee may trade in securities while in possession of material inside information or disclose material inside information to third parties (“tipping”). Material inside information is any information that has not reached the general marketplace and is likely to be considered important by investors deciding whether to trade (e.g., earnings estimates, significant business investments, mergers, acquisitions, dispositions and other developments, expansion or curtailment of operations, and other activity of significance). Using material inside information for trading, or tipping others to trade, is both unethical and illegal.

Accordingly, no employee may:

  • “Trade securities of the Company or any other Company while in possession of material inside information with respect to that Company.
  • “Recommend or suggest that anyone else buy, sell, or hold securities of any Company while the employee is in possession of material inside information with respect to that Company (this includes formal or informal advice given to family, household members and friends); and
  • “Disclose material inside information to anyone, other than those persons who need to know such information in order for UIC to properly and effectively carry out its business (e.g., to lawyers, advisers and other Company employees working on the matter).

Where material inside information is permitted to be disclosed, the recipient should be advised of its non-public nature and the limitations on its use. Any questions as to whether information is material or non-public should be directed to the General Counsel or another Company attorney.

Additionally, all employees, officers and directors must provide full, fair and accurate disclosure in all government filings and public communications.

Policy on Maintaining a Safe, Healthy and Affirmative Workplace

The Company is committed to a workplace where people are treated with dignity, fairness and respect. You have the right to work in an environment that provides equal employment opportunities and one that is free of discrimination and illegal harassment. The Company bases its recruitment, employment, development and promotion decisions solely on a person’s ability and potential in relation to the needs of the job, and the Company complies with local, state and federal employment laws.

The Company does not discriminate on the basis of:

  • Sex
  • Race
  • Color
  • Religion
  • Sexual orientation
  • Age
  • National origin
  • Citizenship status
  • Disability

The Company makes reasonable, job-related accommodations for any qualified employee or officer with a disability when notified by the employee that he/she needs an accommodation.

The Company will not tolerate any:

  • Sexual, racial or other unlawful harassment
  • Threats or acts of violence or physical intimidation
  • Abusive, harassing or other offensive conduct, whether verbal, physical or Visual

If you believe that you have been harassed, or threatened with or subjected to physical violence in or related to the workplace, you should report the incident to an appropriate supervisor, who will arrange for it to be investigated. It is the policy of the Company to protect those who communicate bona fide concerns from any retaliation for such reporting. No retaliation against any individual who reports violations of this Code in good faith will be permitted. All efforts will be made to handle the investigation confidentially.

In addition, the Company will not tolerate on Company property:

  • Possession, use or distribution of pornographic, racist, sexist or otherwise offensive materials
  • Use of Company personal computers or other equipment to obtain or view such Materials

All employees and officers must promptly contact an appropriate supervisor or about the existence of offensive materials on the Company’s systems or premises.

Alcohol and Substance Abuse

The Company is committed to providing a drug-free work environment. The illegal possession, distribution or use of any controlled substances on Company premises or at Company functions is strictly prohibited. Similarly, reporting to work under the influence of any illegal drug or alcohol, and the abuse of alcohol or medication in the workplace is not in the Company’s best interest and violates this Code.

Fostering a Safe Workplace

The Company places the safety of its employees at the top of its priority list. If you come across or are concerned about unsafe equipment, practices, conditions or other potential hazards, you should immediately report it to an appropriate supervisor. If  you witness or are involved in any accidents while at work, or you are injured in any way, you should immediately contact your supervisor.

Corporate Contribution Policy

In jurisdictions that permit corporations to make contribution to campaigns of candidates or party committees, American Exchange uses the same criteria and framework to evaluate such contributions.

Under this policy American Exchange, may contribute corporate funds where allowed by law.  Under the policy, all corporate political contributions are subject to approval by the President and/or CEO of American Exchange

Foreign Corrupt Practices Act (FCPA) Policy

The Foreign Corrupt Practices Act (FCPA) is a federal law (15 U.S.C. § 78-dd-21 et seq.) that exists to prevent corrupt practices in international transactions. The Act prohibits bribery of foreign officials and employees who work for foreign governments. The FCPA prohibits the corrupt payment (or offer, promise or authorization of payment) of anything of value to any foreign official or employee, directly or indirectly, for the purpose of obtaining or retaining business, directing business to any person or entity, or securing any improper advantage.

The FCPA’s prohibitions are applicable to United States organizations, public or private, and any person, including a foreign person or firm, if they commit a prohibited act in the United States. Further, a United States entity may be held liable under the FCPA for the improper activities of its foreign subsidiaries if the United States entity authorized or participated in the conduct. This Policy ensures the American Exchange community is aware of, monitors, and complies with this statute.

Statement of Policy

It is the policy of American Exchange that each of our employees comply with the anti-bribery laws of the United States and of the foreign countries where American Exchange does business. Bribery of any kind in the United States and abroad, regardless of foreign custom or practice, is strictly prohibited. No American Exchange employee shall make any payment or provide anything of value, to any person, in order to improperly influence that person to secure any advantage for American Exchange, including obtaining or retaining business, or directing business to any person or entity.

Public Relations/Media Inquiries Policy

American Exchange will generally provide a response to media inquiries within 48 hours of receipt.  Individuals designated to speak on the organization’s behalf are the President and CEO. No one other than these individuals (with the exceptions noted below) should represent the company’s position to the media.

Acknowledgement of Receipt

I have read and am familiar with the policies and procedures found within this manual. I understand that I am to abide by all of the policies found within and apply those to my call center and/or downstream agents. Should I fail to do so, I understand that American Exchange reserves the right to enforce disciplinary action as needed and/or terminate our relationship if deemed necessary. No aspect of this manual should be interpreted as a contract of employment.