Humana’s External Agent Escalation Program

Humana has announced new compliance standards designed to strengthen oversight and improve member experience across all distribution channels. These changes affect both current Humana agents and those looking to transfer from one ToH (Transfer of Hierarchy) to another.

If you contract with Humana, or are considering transferring, it’s important to understand exactly how this program works and what it means for your business.

What Is the External Agent Escalation Program?

The External Agent Escalation Program is Humana’s new compliance initiative, created to support CMS requirements around Third Party Marketing Organization (TPMO) oversight, while also reducing Complaint Tracking Module (CTM) issues and improving Star Ratings.

This program applies to all external sales agents — including call center agents and those aligned with FMOs — who are contracted to sell Humana Medicare products.

Key Standards and Implications

1. Current Agents

• Humana is reviewing compliance and quality metrics across its field force.

• Agents who do not meet these standards will be terminated prior to this AEP.

• Terminated agents will be ineligible to recontract for 12 months. After that period, they may appeal for reconsideration.

• For example, across the many thousands of Humana agents under YPC, only 21 agents are expected to be terminated this AEP cycle.

👉 Action Step: Review your HARP reports regularly to confirm you are meeting Humana’s compliance standards.

2. Agents Requesting Transfers (ToH Changes)

• Any agent requesting a transfer from one ToH to another will first be terminated under their current ToH.

• Before being allowed to recontract, the agent will undergo Humana’s External Agent Escalation Program review process.

• Approval to recontract is not automatic — it depends on the agent’s compliance record and performance metrics.

3. Compliance Metrics That Trigger Escalation

Effective immediately, any agent meeting the following criteria will be flagged for review and possible termination:

• A CTM rate of 5.0 or higher

• An accretion rate of 68% or less

• More than 10 CTMs within a rolling 12-month period

Agents who meet these thresholds will be submitted to Humana’s Agent Review Board for termination.

Humana will conduct quarterly reviews to identify agents who meet the escalation criteria.

Why This Matters

Humana’s initiative reflects a broader industry trend: tightened compliance oversight and accountability for TPMOs and agents.

For agents, the message is clear: compliance is not optional. Tracking your metrics, avoiding CTMs, and providing high-quality, client-focused service will not only keep you in good standing but also strengthen your business in the long run.

Best Practices for Agents

• Monitor your HARP reports consistently — know where you stand.

• Prioritize compliance in every interaction: SOAs, call recordings, marketing materials, and disclosures all matter.

• Keep client satisfaction front and center: Many CTMs stem from misunderstandings or unmet expectations.

• Ask for guidance: Work with your FMO’s compliance team (like PSM Brokerage) to review practices and ensure you’re staying audit-ready.

Final Thoughts

The Humana External Agent Escalation Program is now in effect. For most agents, this won’t result in immediate changes — but it’s a reminder that compliance and quality matter more than ever.

Stay informed, stay compliant, and lean on your support partners for help. By doing so, you’ll be well-positioned to thrive this AEP and beyond.

👉 Have questions about staying compliant or reviewing your HARP reports? Connect with the PSM Brokerage compliance team for guidance.