Compliance The Pinnacle Team will help you navigate all your compliance needs, protecting your business

Stay Compliant with Pinnacle At Pinnacle, we don’t just keep up - we lead the way. We provide our agent partners with the insurance marketing strategies they need to succeed. Empowering agents to connect with qualified, high-value leads is a cornerstone of our marketing philosophy. Our approach goes beyond aesthetics; we focus on insurance agent marketing strategies that bring in real prospects.

Proposed Rule from CMS

Build Your Compliance Program Pinnacle also will assist its agents and agency partners in developing their own Compliance program

Carrier Codes of Conduct At Pinnacle we provide the training and guidance on which we require all of our agent and agency partners to adhere

Pinnacle's Code of Business Conduct Pinnacle’s hold its and it’s agent partner to a high standard of integrity and honesty.

Medicare SEP: Medicaid / LIS Eligibility Change (MCD)
Overview: The Medicaid / Low-Income Subsidy (LIS) Eligibility Change SEP (MCD) allows

beneficiaries to make changes to their Medicare Advantage or Part D plans when their Medicaid or LIS eligibility changes. This SEP helps ensure coverage remains aligned with financial and medical needs following eligibility updates under the Title XIX (Medicaid) program or LIS provisions.

Regulatory Basis

42 CFR §§ 422.62(b)(14) and 423.38(c)(19)

Medicare Managed Care Manual, Chapter 2 – Sections 30.4.4 and 30.6.8 provide official CMS guidance for this SEP.

Who Qualifies

A beneficiary qualifies for this SEP if they experience any of the following:

Gain Medicaid or LIS eligibility (full or partial dual status).

Lose Medicaid or LIS eligibility.

Experience a change in the level of assistance (e.g., transition from partial to full Medicaid, or cost-sharing change).

What Can Be Done

Eligible individuals may enroll in, disenroll from, or switch Medicare Advantage (MA) or Part D prescription drug plans. Those newly dual-eligible may join a Dual Eligible Special Needs Plan (DSNP) tailored to their Medicaid benefits.

Timing and Frequency

The SEP may be used within three months of the change or notification of the change, whichever occurs later. Use of this SEP does not count toward the quarterly SEP for subsidy-eligible individuals (§30.6.7).

CMS Manual Guidance (Section 30.6.8)

According to CMS, this SEP allows a “full-benefit dual-eligible individual” or “other LIS-eligible individual” to enroll in or disenroll from a Part D plan one time if they gain, lose, or have a change in Medicaid or LIS eligibility. This includes individuals who:

Become eligible for assistance under Title XIX (Medicaid) or qualify for LIS without Medicaid benefits.

Lose eligibility for any type of Medicaid or LIS assistance.

Experience a change in the level of assistance (e.g., losing Medicaid but keeping LIS, a cost-sharing change, or gaining new Medicaid benefits).

For example, a beneficiary may newly qualify for nursing home level of care (becoming eligible for Medicaid long-term services) or move from Medicaid premium assistance to full Medicaid coverage.

Agent Compliance Guidance

Verify Medicaid or LIS changes using state systems or CMS databases.

Use SEP Code MCD in MARx and OEC for all applicable enrollments.

Retain proof of eligibility changes (state notice, LIS letter, or attestation) for 10 years.

Apply the most specific SEP; do not substitute with Disaster (DST) SEPs.

Educate clients on how Medicaid or LIS changes affect their coverage and costs.

Compliance Disclaimer: This document is for informational and training purposes only and

does not replace official CMS guidance. Information may change without notice. Agents must confirm current CMS publications before use or distribution.
Marketing Compliance Checklist
CMS Requirements
Please send me a Complimentary Guide on CMS Requirements

Our goal is to assist our distribution by providing a “Blueprint” for a Complete Compliance Program.

SCOPE OF APPOINTMENT RULES

It is important that you use and store this document compliantly. Please contact a Pinnacle representative for a full explanation.

GENERIC MARKETING MATERIALS

You do not have to file generic pieces however, you still need to use a compliant document. Please contact a Pinnacle representative for guidelines, and a free review of any piece you want to use.

BACKGROUNDING

If even one person is working on your Medicare business, you’ll need to be “backgrounding”. Please contact a Pinnacle representative for a simplified explanation of how to complete the process.

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Scope of Appointment Rules
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Security - All Products
Please Send Me Information About Security and Privacy

Our goal is to assist our distribution by providing a “Blueprint” to a Complete Compliance Program.

PRIVACY AND SECURITY POLICY

Every individual who conducts business should be responsible for understanding and complying with applicable laws and regulations that protect the privacy and security of personal information.

DATA ENCRYPTION

It is important to employ encryption solutions to preserve the confidentiality and integrity of, and control access to, customer data that is processed and stored or transmitted.

Pinnacle will help you build all the components needed for an effective compliance program. Help Pinnacle protects you by taking advantage of these tools:

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Developing A Compliance Program
Please Send Me a Complimentary “Blueprint”

Our goal is to assist our distribution by providing a “Blueprint” to a Complete Compliance Program.

ELECT A COMPLIANCE OFFICER

You need to appoint someone to act as your Compliance Officer. They will develop, implement, and monitor the compliance program.

DEVELOP A COMPLIANCE PROGRAM

You have to have a document that outlines your policies and establishes procedures.

IMPLEMENTATION OF THE PROGRAM

Framework for all employees and agents for actions, and conduct within the organization.

Pinnacle will help you build all the components needed for an effective compliance program. For your customized program, please complete the form and submit:

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Limra Anti-Money Laundering Certification
LIMRA AML Login Information

Video Instructions

Please Send Me Information about How I can Complete my Certification

Our goal is to assist our distribution by providing a “Blueprint” to a Complete Compliance Program.

Contact a Pinnacle Financial Services representative today for a list of what products require AML Certification.

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The Pinnacle Compliance Program Required Compliance Form & Instructions

This form must be completed, annually, or after any changes to regulations by CMS.

Required Compliance Form

Compliance Form Instructions

Pinnacle Financial Services strives to promote excellence and quality in the products and services we provide to our partner agents and agencies.

As a FMO in the Medicare world we have contracts with insurers that offer Medicare Advantage and prescription drug plans. Compliance in this industry cannot be overlooked and our compliance team is on top of all the regulations on products, sales and marketing in the Medicare space.

Our Code of Conduct provides agents with fundamental information on Medicare sales practices.

Pinnacle also will assist its agents and agency partners in developing their own Compliance program. Whether you are a sole proprietor or have a large agency our focus is making sure you are up to date and compliant with all of the changing rules and regulations.

AEP Compliance Guidelines

AEP Compliance Guidance
This overview for the 2026 AEP details essential guidelines and best practices to ensure a smooth enrollment process. It will equip you with the knowledge and resources needed to navigate the enrollment process confidently and compliantly. Let’s start with a brief overview of AEP.

What is the AEP?

A designated window for Medicare beneficiaries to adjust their coverage

Runs October 15 to December 7, 2025

Allows enrollment, switching, or disenrollment in Medicare Advantage or Part D plans

Includes switching from Original Medicare to Medicare Advantage (or vice versa)

Changes effective January 1, 2026

Why it Matters

High-volume period for client outreach

Enhances client satisfaction through tailored, suitable plan options

Demands strict regulatory compliance
Importance of Compliance
Compliance is the foundation of AEP success. It is a fundamental requirement that upholds our ethical standards, safeguards our clients, strengthens our organization, and preserves your professional integrity within a highly regulated environment.

Compliance

Protects clients from misinformation

Prevents CMS sanctions, fines, or license loss

Builds trust and avoids complaints down the road

Consequences of Non-Compliance

Financial penalties or disciplinary actions

Loss of client confidence and business
Core Compliance Guidelines

Adhering to CMS regulations during AEP is essential for maintaining ethical, transparent, and client-centered interactions. Non-compliance may lead to significant consequences, such as fines, suspension of marketing privileges, or loss of contracts. The following rules and best practices establish a framework for compliant engagement with beneficiaries.
CMS Contact and Consent Rules
Unsolicited Contact

Strictly prohibited are:

cold calls,

door-to-door visits (door-knocking),

unsolicited emails, texts, or direct messages on social media.

CMS mandates that all contact must originate from a beneficiary-initiated request or express written permission to contact. This rule prevents coercive or intrusive marketing practices, ensuring beneficiaries are not pressured. Violations may lead to CMS sanctions, fines, or suspension of marketing privileges.

Scope of Appointment (SOA) Requirement

A signed Scope of Appointment (SOA) form is required at least 48 hours prior to discussing Medicare Advantage or Part D plans, unless it’s a walk-in appointment, a beneficiary-initiated event contact, or during the last four days of a valid enrollment period, in which case the SOA must still be completed before any discussions.

The SOA must specify the plans to be discussed, ensuring transparency and protecting beneficiary choice. Records must be retained for 10 years per CMS regulations. An agent must be able to produce a valid SOA upon request by a carrier or the compliance department.

An SOA is valid for 12 months, unless the customer wishes to discuss different products. If that is the case, a new SOA is required. A best practice is to use a generic SOA rather than a carrier specific SOA. This allows discussion of various carriers’ plans rather than one specific carrier.

A valid SOA is only valid for the existing agent. If a new agent is speaking to the consumer, then the new agent must collect a new SOA.

*Agents using SunFire must ensure their profile includes an updated valid signature, as blank or invalid signatures invalidate the SOA.

CMS 1:1 Consent Requirement

The CMS 1:1 consent requirement requires TPMOs to obtain prior express written consent from a Medicare beneficiary before sharing their personal data with another TPMO for marketing or enrollment purposes. This ensures transparency and protects consumer privacy.

*Please note, these AEP Guidelines are not intended to cover all aspects of the CMS 1:1 consent requirement. For full details, refer to CMS’s Medicare Communications and Marketing Guidelines.
Marketing and Communication Rules

Use of CMS-Approved Materials Only

All marketing materials, including scripts, brochures, and advertisements, must be submitted to CMS via the Health Plan Management System (HPMS) for approval before use.

Materials must include required disclaimers, such as “This is an advertisement for insurance.” Using unapproved content risks CMS sanctions and undermines beneficiary trust in accurate plan information.

Prohibited Language in Marketing

Avoid terms like “free,” “best plan,” or phrases that imply urgency (e.g., “enroll now or lose coverage”) that could mislead beneficiaries about plan benefits, costs, or provider networks. All claims must be verifiable and align with CMS-approved plan documents to maintain transparency and prevent deceptive marketing practices.

No Cross-Selling Non-Health Products

During AEP discussions, agents must not bundle or promote non-health related products, such as life insurance or annuities, with Medicare plans. This ensures the focus remains on Medicare Advantage or Part D plans, preventing confusion and maintaining compliance with CMS marketing restrictions. Remember that you can only talk about plans that the beneficiary has agreed to discuss as disclosed on the SOA.

Event Reporting and Conduct Standards

Educational or marketing events must be reported to CMS via HPMS at least 10 days in advance and need to be clearly identified as educational (no sales activities) or marketing (sales permitted), as appropriate. Sales activities are prohibited at educational events, and meals cannot be provided at marketing events. These standards ensure beneficiaries receive accurate information without undue pressure.

As an agent, you are responsible for filing events with CMS through the carriers. You must follow the carriers process to get the events filed.

PTC and BRC Submissions

Carrier partners are requesting review of Permission to Contact forms (PTC) and Business Reply Cards (BRC) prior to use, even if they are only classified as communications. Agents are responsible for submitting all PTC/BRC to carriers where required.

Carrier-Approved Scripts

If agents are conducting sales/enrollment calls, they must use a CMS and carrier approved script. YPC has provided an approved script on the Sunfire platform. This is NOT exclusive to call center agents.

Agent and Broker Training

Agents and brokers must complete annual CMS-approved training and pass certification exams before marketing Medicare plans. Training covers CMS regulations, plan specifics, and ethical marketing practices. Agents must maintain proof of certification to ensure only qualified individuals interact with beneficiaries.

Client Protections

Data Security

Beneficiary data must be safeguarded with secure storage and encryption to comply with the Health Insurance Portability and Accountability Act (HIPAA). This includes protecting personal health information during collection, storage, and transmission. Data breaches can lead to legal consequences and loss of client trust.

Non-Discrimination in Client Interactions

Agents must provide equitable treatment to all beneficiaries, regardless of health status, age, socioeconomic background, or other factors. Discrimination violates CMS regulations and undermines the integrity of the AEP process, potentially leading to sanctions.

Language Assistance for Accessibility

For beneficiaries with limited English proficiency, agents must provide language support or refer clients to multilingual resources, such as CMS-approved translators or materials. This ensures all beneficiaries can fully understand plan options and make informed decisions.
Accountability and Documentation
SunFire Call Recording

Agents must properly configure their SunFire Profile to enable call recording, ensuring adherence to all relevant call recording regulations. Follow these steps in SunFire to comply with these requirements:

From your dashboard, go to your profile

Scroll down and select “Add dialer phone for recording”

Enter the area code of your choosing

Click “Add dialer phone”

The system will generate a virtual phone number for you in that area code

Once you see the full number appear, you’re ready to make and receive calls!

SunFire Signatures

Agents must ensure their Sunfire profile includes a valid signature, as blank or invalid signatures invalidate SOAs. This requirement supports the integrity of the SOA and application process and prevents delays or penalties during CMS audits.

*This information applies to the YPC Sunfire platform and may be different if you are using a separate platform for enrollments.

Consequences of Non-Compliance

Failure to adhere to these rules can result in monetary consequences. For example, in 2024, an agent was fined $10,000 for missing SOA documentation, highlighting the importance of meticulous record-keeping and adherence to CMS regulations.
AEP Preparation
Preparation is the key to a seamless AEP season.

Training and Certification

Complete CMS and carrier trainings before the start of AEP (October 15)

Review 2026 plan changes, including the Part D $2,100 out-of-pocket cap

Be certified and ready-to-sell in every state where you are licensed to sell

Tools and Resources

Utilize CRM systems to effectively manage client information

Ensure proficiency with enrollment platforms to submit accurate data

Only use up-to-date, approved marketing materials

Planning

Schedule client appointments starting early October

Review Annual Notice of Change (ANOC) for plan updates
Practical Tips and Avoiding Mistakes
AEP’s fast pace demands sharp communication and organization skills. These tips will help you excel while steering clear of compliance pitfalls.

Effective Client Communication

Conduct a NEADs analysis (Needs, Eligibility, Affordability, Decision) to tailor plan options

Explain plans simply, ensuring clients understand signing an application means enrollment

Clarify the new Part D payment plan and $2,100 out-of-pocket cap

Documentation

Prioritize high-need clients using scheduling tools

Document SOAs and interactions with beneficiaries meticulously; submit to Home Office

Verify applications are complete and accurate (check numbers, spellings)

Recall that the last application submitted is the one that will be processed

Avoiding Pitfalls

Never use unapproved marketing materials or misrepresent plan benefits

Avoid high-pressure sales tactics; schedule follow-ups if more time is needed

Confirm plan details post-enrollment to prevent misunderstandings
Carrier Specific Guidelines
Carriers have unique rules that complement CMS regulations. Ensure you fully understand these carrier requirements.

Carrier-Specific Rules

Review carrier AEP policies and 2026 plan details

Understand benefits, limitations, and formularies

Follow carrier-specific enrollment processes

Submit applications within 24-48 hours per carrier guidelines

Verify plan availability by region

Report issues to carrier support immediately

Pinnacle's Code of Business Conduct Pinnacle’s hold its and it’s agent partner to a high standard of integrity and honesty. Pinnacle’s Code of Business Conduct is our guiding principle. To be ethical and compliant at all times in our day to day interactions.

Pinnacle's Code of Conduct

Maintain Integrity & Honesty Pinnacle also will assist its agents and agency partners in developing their own Compliance program

Ethical & Compliant At Pinnacle we provide the training and guidance on which we require all of our agent and agency partners to adhere

Deliver Quality & Excellence Pinnacle’s hold its and it’s agent partner to a high standard of integrity and honesty.

Medicare Compliance & FWA Training

Effective January 1, 2019: CMS no longer requires Plan Sponsors to ensure that their First Tier, Downstream, and Related Entities (FDRs) complete the CMS-publishes training modules. However, FDRs are still required to comply with all statues, regulations, and CMS guidelines.

It is advisable that Pinnacle’s downline agencies continue to educate and document their efforts to ensure that their non-agent employees, (non-licensed staff or licensed staff who are not appointed by any Medicare Advantage insurance companies), management, temporary workers, and-or subcontractors, are aware of these guidelines.

Agents and agencies may develop their own training material, or utilize carrier’s Codes of Conduct or training materials. They may also utilize the Pinnacle Code of Conduct, and training materials published on our website. Such training must be provided within 90 days of hiring, and repeated annually thereafter.

Medicare Communications & Marketing Guidelines

View CMS’ 2022 Medicare Communications and Marketing Guidelines (MCMG).

OIG & GSA Screening Websites

As a First Tier Entity, Pinnacle Financial Services must review the Department of Health and Human Services Officer of Inspector General (OIG) List of Excluded Individuals and Entities and the General Services Administration (GSA) Excluded Parties List System, to ensure our employees, management, temporary workers, or subcontractors, (if applicable,) are not listed on these exclusion lists. These databases must be checked prior to hiring the aforementioned types of personnel, and at least once a month, so long as they remain with Pinnacle Financial Services.

Pinnacle’s downline agencies are also required to review this information to adhere to the guidelines. The highest standard of employee must always be maintained and verified on a monthly basis.

Contact Compliance Officer

Kevin Shields, Jr.
Compliance Officer
x3033 | kjshields@pfsinsurance.com

Restricted Do Not Call Dates

Fevruary 2026

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