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Navigating Medicare Advantage Regulations: Ensuring Your Marketing Aligns with the Rules

Medicare advantage rules

Navigating the intricacies of Medicare plans can be challenging. With the rising competition in Medicare Advantage promotions and the onset of another bustling enrollment season, the last thing on your agenda should be a potential compliance error that could hinder your progress. This guide offers a holistic approach to understanding and adhering to the Medicare Advantage compliance rules, ensuring your marketing strategies are always in line with the regulations.

Understanding the CMS Medicare Promotion Protocols

The foundation of Medicare promotional regulations starts, but doesn't conclude, with the regulatory authority known as CMS. A robust Medicare Advantage compliance plan should commence with a deep dive into their detailed promotional protocols.

The Center for Medicare and Medicaid Service (CMS) is a national institution responsible for various roles, including the establishment and enforcement of the Medicare Communications and Marketing Guidelines (MCMG). These directives are mandatory, mandating Medicare Advantage and Part D sponsors to oversee and review any associated entity they collaborate with—this encompasses lead sources and creators. Key elements of the CMS directives include:

  • Restricted Actions: The CMS directives detail a variety of banned promotional actions, ranging from disseminating deceptive or inaccurate information to offering meals to those attending events.

  • Mandatory Disclosures: The rules specify a comprehensive set of disclosures that must be incorporated in all promotional content. Additionally, there are new, distinct disclosures that promotional, lead generation, and sales affiliates of Medicare must adhere to.

  • Vital Enrollment Timelines: The CMS also provides explicit timeframes for enrollment, which are detailed below.

As competition intensifies in Medicare Advantage sales, it's paramount to navigate the intricate landscape of Medicare compliance with precision.

Key Timelines for Medicare Promotions

The Medicare Annual Enrollment Period (AEP) spans from October 15 to December 7 annually. For those involved in Medicare promotions or sales, it's evident that this timeframe, allowing Medicare beneficiaries to assess and modify their plans, is of paramount importance—and quite intense. During AEP, beneficiaries have the liberty to:

  • Transition from a traditional Medicare plan (Part A and Part B) to a Medicare Advantage plan (Part C)

  • Migrate from one Medicare Advantage plan to a different one

  • Change from one Prescription Drug plan (Part D) to another or register for a Medicare Advantage Prescription Drug plan

  • Opt for a new Prescription Drug plan if they hadn't done so earlier

Post AEP, after a brief hiatus, the Medicare Advantage Open Enrollment Period (OEP) commences, lasting from January 1 to March 31. In this phase, only existing Medicare Advantage members can modify their plans for the forthcoming year.

While being aware of the annual enrollment dates is crucial, there's an additional significant date for Medicare promotional compliance: October 1. Post this date, Medicare entities can initiate the promotion of their plans for the next year, as per the guidelines set by CMS's Medicare promotional rules.

Consent to Engage

The Consent to Engage (CTE) principle is a pivotal element in Medicare promotion and adherence, ensuring that individuals' communication preferences are respected when presenting Medicare schemes. This system mandates that insurance representatives or Medicare plan providers secure clear consent from Medicare beneficiaries prior to initiating marketing dialogues.

As delineated by the CMS, the CTE guideline shields individuals from unwanted outreach and fosters a bond of trust and clarity between Medicare promoters and prospective customers. The consent acquisition process might involve individuals completing a form or verbally affirming their interest in Medicare plan details, granting them the power to decide who reaches out to them and in what manner.

When is CTE Essential?

While the CTE notion is straightforward, it's vital to discern precisely when it's applicable. Medicare representatives can dispatch unrequested emails to potential enrollees to promote their services (not the plans themselves), provided the email adheres to standards and offers an opt-out choice. To delve deeper and discuss specific plans, CTE is mandatory.

Without CTE, agents are permitted to:

  • Engage beneficiaries who have opted in through a digital contact form.

  • Engage beneficiaries who have sought a callback, like after an incoming call.

  • Dispatch business response cards.

However, the following outreach methods necessitate CTE:

  • SMS communications.

  • Direct doorstep interactions.

  • Direct messaging on social platforms.

Furthermore, beyond the CMS directives, it's crucial to recognize that Medicare interactions are still regulated by national compliance statutes such as the TCPA and the Telephone Sales Rule (TSR).

Appointment Parameters

Upon obtaining CTE from a potential enrollee, the next step is to gather what's termed an Appointment Parameters, or AP.

AP is another core Medicare adherence principle aimed at guaranteeing a transparent and mutual dialogue between Medicare beneficiaries and agents. As per CMS directives, prior to any personal sales discussion, the insurance representative must secure a documented consensus from the beneficiary, detailing the product categories to be addressed during the session.

This record establishes explicit limits and anticipations for the conversation, ensuring the topics remain confined to the mutually agreed subjects, which might encompass Medicare Advantage, Prescription Drug Plans, or other related insurance offerings.

Medicare Adherence Directives for TPOs

In 2022, with the announcement of regulations for the 2023 contract year, CMS introduced specific criteria for TPOs, or third-party outreach organizations. Within its promotional guidelines, CMS characterized TPOs as entities compensated for executing lead generation, marketing, sales, and enrollment-linked tasks as part of the enrollment process. Fundamentally, CMS perceives all insurance agents and brokers as TPOs, necessitating adherence to a stringent set of directives, which include:

  • Incorporating TPO disclaimers in all promotional content, websites, and dialogues, spanning print and TV advertisements, and even sales discussions.

  • Accurately revealing details to potential clients during lead generation endeavors. Lead generators must notify beneficiaries—whether via phone, written communication, or digital means—that their data will be shared with licensed insurance agents for subsequent engagement. Similarly, TPOs must notify beneficiaries of a transfer to a licensed insurance agent capable of enrolling them in a new scheme.

  • Establishing a mechanism and monthly reporting to plans regarding any disciplinary actions linked to beneficiary interactions and any breach of applicable requirements.

  • Documenting all interactions (including video calls) related to marketing, sales, and enrollment comprehensively. This encompasses retention marketing initiatives and any mention of offered benefits, including dental, vision, hearing, cost savings, and premium reduction.

With the evolving landscape of Medicare, staying updated with CMS directives is not just a necessity but a commitment to transparent and ethical marketing practices.

Updates to CMS Directives for the 2024 Contractual Year

Following its revisions from the previous year, the CMS has intensified its efforts to curb deceptive and aggressive promotional tactics in the Medicare domain. Consequently, the modifications to the MCMG for the 2024 contractual year encompass a variety of stipulations impacting Medicare promotional compliance. Regulations set to be implemented on September 30, 2023, encompass:

  • Banning:

    • Advertisements that either (1) omit a specific plan or (2) exploit the Medicare name or emblem deceptively.

    • Promoting advantages in a service region where such benefits aren't accessible.

    • Using superlatives (terms like “top” or “foremost”) in promotional content, unless the material substantiates the claim with current or previous year data.

  • Plans are mandated to annually inform members in writing about their right to decline telephonic communications concerning Medicare Advantage and Part D plan affairs.

  • Collection of SOA cards at informational sessions is prohibited.

  • A 48-hour gap is mandated between the completion of an SOA and a representative's interaction with a beneficiary.

  • A promotional event cannot be scheduled within 12 hours post an informational session at an identical venue.

  • Sales representatives are permitted to contact a potential member up to 12 months post their initial information request.

  • Medical advantages must be sequentially listed at the beginning of a plan’s Benefits Summary.

  • TPMOs are required to display or reference all the Medicare Advantage or Part D plan sponsors they represent in promotional materials.

  • Plans must mandate agents to elucidate the implications of a member’s enrollment choice on their existing coverage during enrollment decisions.

  • Plans should possess a supervisory strategy that scrutinizes agent/broker actions and communicates agent/broker non-adherence to CMS.

In the realm of Medicare marketing, the Permission to Contact (PTC) protocol stands as a beacon of trust and transparency between marketers and potential clients.

Beyond CMS: Upholding TCPA Adherence in Medicare Promotion

While adhering to CMS guidelines concerning PTC remains paramount, lead originators, purchasers, and promoters must also maintain TCPA compliance during peak enrollment phases.

In a seminar orchestrated by ActiveProspect, specialist lawyer Puja Amin elaborated on scenarios where written consent is mandated under the TCPA:

  • Automated or pre-recorded voice calls to mobile phones (inclusive of business cell phones) with promotional content.

  • Pre-recorded or synthetic voice calls to home landlines with promotional content.

  • Calls to home landlines on the DNC registry for promotional purposes, barring those with an existing business relationship or in response to a query.

  • Pre-recorded calls to home landlines surpassing the TRACED Act exemption thresholds, including informational calls. The TRACED Act restricts commercial, survey, and charitable calls to 3 monthly; healthcare-related calls are capped at 3 weekly.

Beyond the CMS guidelines, the essence of Medicare marketing lies in striking a balance between effective outreach and unwavering adherence to TCPA regulations.

Consent Documentation Methods

Securing consent is just the beginning; it's also essential to document and validate that consent. Here are diverse methods to register and retain evidence of consent, safeguarding your enterprise:

  • Digital forms are efficient but can pose challenges. Ensure forms adhere to optimal design standards and employ TrustedForm, the pinnacle of independent consent verification.

  • Contractual clauses can be employed to secure written consent in line with the TCPA. Ensure you're archiving evidence of these terms being accepted.

  • Mobile applications and online platforms.

  • Audio recordings. Utilize recordings to preserve consent records, but restrict their use to informational (non-promotional) calls to bolster TCPA adherence.

  • SMS communications. As businesses increasingly utilize outbound SMS to engage clients, ensure you're upholding SMS compliance standards and can document client consent within this medium.

Crafting a Comprehensive Enrollment Compliance Guide

Ensuring TCPA adherence for Medicare promoters goes beyond mere consent matters. Elevate your compliance assistance by employing these optimal strategies to formulate an exhaustive compliance guide.

  1. Pinpoint TCPA and Medicare Promotional Vulnerabilities: Conduct a thorough assessment of your establishment and associates. This includes examining consumer engagement methods, vendors, agents, and TPMOs to discern potential risk zones.

  2. Institute DNC Protocols and Consent Measures: Refine and bolster your internal DNC operations and guarantee that all representatives and collaborators are well-informed.

  3. Collaborate with Compliance-Centric Vendors: Opt for vendors that offer compliance solutions, such as and ActiveProspect. These can be seamlessly integrated with your calling software.

  4. Oversee Your Vendors Effectively: Given the recent CMS directives, it's pivotal to be discerning about your collaborations. The CMS is evidently amplifying its supervisory role in Medicare-associated sales and promotional endeavors.

  5. Reassess Contractual Agreements: Engage in dialogues with your associates to establish mutual standards, ensuring both parties comprehend and agree on liability responsibilities.

  6. Handle Litigations and Habitual Litigants: Employ litigation screening tools, like the one offered by Additionally, establish a systematic approach to address (often spurious) claims presented by litigants.

In the intricate world of Medicare promotions, crafting a comprehensive enrollment compliance guide is the cornerstone of ethical and effective marketing.

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