Do’s and Don’ts of Medicare Compliance

Life as an agent before Medicare’s Annual Enrollment Period is a flurry of contracting and certifying. But there’s another C that’s even more important: Compliance.

It’s not just something to consider during the busy season. Compliance should be a year-long goal for every agent.

We’ll teach you how to stay compliant through all of your client interactions – from the point of first contact all the way through the enrollment process.

Permission to Contact

Every interaction with a potential client has a starting point. The Centers for Medicare and Medicaid Services (CMS), which oversees healthcare compliance, state that agents cannot make unsolicited direct contact with potential beneficiaries or approach potential enrollees in common areas. To begin the conversation with potential enrollees, you’ll need Permission to Contact, or PTC. You can use lead providers to send out business reply cards (BRCs) or flyers including an optional form to collect this permission. PTCs are event specific and not open-ended permission for future contact.

We’ve talked before about the importance of an online presence, but be forewarned, likes or shares on social media do not constitute PTC for sales purposes. Additionally, PTCs are not the same as a Scope of Appointment, or SOA. The PTC comes first, hopefully followed by an appointment. At that time, you’ll need to fill out the appropriate SOA form.

Permission to Contact is not the same as Scope of Appointment. Mostly, PTC comes first, then SOA next.

Scope of Appointment

Scope of Appointment means just what it says. It’s a form outlining exactly what you’ll be presenting to a client during a meeting. The SOA ensures that potential enrollees will not be pitched plans other than those they originally requested. The latest MMG removed the requirement for SOAs to be recorded 48 hours in advance. We interpret that to mean “same-day scopes” are compliant in any and all cases.

Every face-to-face meeting requires a Scope of Appointment. Additionally, SOAs must be filled out for one-on-one phone conversations. Per CMS, agents must keep SOA forms on file for at least 10 years, even if the appointment didn’t end in a sale.

What happens if your client requests Medicare information outside of the Scope during your meeting? You must fill out a second Scope covering the new information before continuing the meeting. If they’re interested in non-health related products, you must schedule a future appointment to discuss them.

Marketing Rules

CMS also regulates marketing and plan presentations including when you’re allowed to market, and how you market.

Agents must wait until October 1 to begin marketing next year’s plans to potential beneficiaries, and cannot enroll members until October 15.

When presenting plans, you’re not allowed to use statistics without documentation and prior CMS approval. Do not attempt to make your own marketing materials, but instead use carrier materials that have gone through the stringent CMS approval process.

During presentations, you should never attempt to mislead your clients, willingly or unwillingly. Stay away from using absolutes and superlatives to describe plans and benefits. Your job is to present information, not show favoritism between carriers or plans. Similarly, if a potential enrollee expresses interest in just one plan, you must inform them that other plans are also available to them.

Avoid using absolutes and superlatives to describe Medicare plans and benefits.

CMS puts a large focus on agent transparency. Similar to their rules on absolutes and superlatives, agents should not use the word “free” to describe $0 premiums. CMS also states that the term free should not be used “in conjunction with any reduction in premiums, deductibles or cost share, including Part B premium buy-down, low-income subsidy or dual eligibility.”

While one component of your client’s health care may come at low or no cost, costs could be incurred in other areas. For example, $0-premium plans typically have higher copays, while plans with higher premiums offer lower out-of-pocket cost. By calling a plan “free” you’re generalizing just one part of the plan’s full package.

When mentioning star ratings, you must include that the rating is out of five stars. Agents must also let potential enrollees know when a plan has been assigned an LPI or Low Performing Icon by CMS. You may not showcase the overall star rating and fail to disclose that the plan has previously suffered from performance issues.

New for 2018, star ratings may not be published until CMS releases them on the Medicare Plan Finder. Agents must also now clearly identify which contract year they reference. You may not “reference the star rating that was achieved based on prior contract year data, when the marketing materials are for the upcoming year.”

Events & Appointments

The types of presentations you host throughout the year typically fall under one of three categories; educational events, sales events, and individual appointments.

Educational events are meant to inform Medicare beneficiaries about the parts of Medicare in general. When holding an educational event:


  • Distribute educational materials free of plan-specific information
  • Distribute educational health-care materials
  • Provide business cards only if requested by the consumer
  • Hold the event in a public venue


  • Distribute plan-specific materials or enrollment packets
  • Attach business cards or plan information to educational materials
  • Conduct sales presentations, even after the main educational presentation
  • Distribute and collect PTCs or SOAs
  • Require attendees to sign in (sign-in sheets MUST be optional)

Sales events, on the other hand, are designed to steer, or attempt to steer potential enrollees towards a limited set of plans. During a sales event:


  • Follow the specific carriers filing and reporting procedures prior to the event
  • Follow the specific carrier’s cancellation procedures
  • Make sure to use only carrier-approved materials
  • Collect applications


  • Offer meals
  • Make absolute statements
  • Use pressure to sign someone up
  • Cross-sell or promote non-health-related products
  • Require attendees to sign in (sign-in sheets MUST be optional)

Individual appointments fall under the same category as sales events and the same CMS regulations apply. Don’t forget, whether you’re meeting face-to-face, or discussing plans one-on-one over the phone, you must have a Scope of Appointment.

Meeting face-to-face or discussing plans one-on-one over the phone requires a Scope of Appointment.

Secret Shoppers

Staying compliant should be a year-long objective for every agent. Annual Enrollment is the culmination of revised CMS marketing guidelines, new 2018 plans, and all kinds of potential enrollees, some of which could be secret shoppers.

CMS secret shoppers measure quality of service and compliance with Medicare regulations as a way to gather specific information about products and services. These secret shoppers will be looking to make sure you’re compliant, from what you say to how you present it.


CMS requires any agent marketing MAPD or PDP plans to consumers to submit all website content to HPMS for approval. This is typically accomplished through the carriers. You may refer to the specific carrier’s policy regarding website review. CMS has increasingly cracked down on websites in recent years, so it’s important to be sure your website is properly evaluated.

If you’re looking for a simple way to market a website with your own contact information, is a good place to start. It’s a free CMS-accepted website, exclusively developed by Ritter, with a quote engine, direct-enroll buttons, and electronic Scope of Appointment. And the best part of it all is Medicareful is filed and accepted for use by CMS. We did the hard work so you don’t have to!

As a certified agent, you’re responsible for following CMS guidelines. Compliance doesn’t have to be difficult, but it does require research and due diligence on your part. When in doubt, refer to Ritter for guidance!

● ● ●

Editor’s Note: This was originally published in September 2016. It has been updated to include information more relevant to the 2018 Annual Enrollment Period.

Tagged with: , , , , , , , , , , , , , , , ,

Leave a Reply

Your email address will not be published. Required fields are marked *