Medicare and Medicaid marketing: 50 matched rules, 13 that block approval

• Regulatory status22
• Offers and pricing15
• State law10
• Research recruitment2
• Superiority1

Federal and general rules first, blocking before warning, citations checked against stored text before the rest. Rules with their own page link there.

1. CG-MED-009 · Blocks approval · Citation checked against stored text

   Medicare marketing that offers free gifts for a Medicare number, claims a plan covers everything, urges action in hours, or switches a plan without consent violates CMS marketing and telemarketing rules.

   Source: 42 CFR 422.2263 (Medicare Advantage marketing); 42 CFR 422.2264 (permitted contact); Telemarketing Sales Rule, 16 CFR Part 310

   Safer wording: Do not use urgency, free-gift offers or coverage absolutes. Never take a Medicare number to enroll or switch without a documented request, and use the CMS required disclaimers.

   42 CFR 422.2263, 42 CFR 422.2264, 16 CFR Part 310 · Needs counsel review

2. CG-OIG-002 · Blocks approval · Citation checked against stored text

   Routinely waiving copays, paying premiums, billing one service as another, or offering free items to people on federal health programs can violate the anti-kickback statute and the False Claims Act.

   Source: federal anti-kickback statute, 42 U.S.C. 1320a-7b; OIG Special Fraud Alert on telemedicine arrangements; 42 CFR 422.2263

   Safer wording: Do not advertise copay waivers, premium payments or free items for Medicare and Medicaid patients, and bill every service accurately.

   42 CFR 422.2263, 42 U.S.C. 1320a-7b · Needs counsel review

3. CG-OIG-101 · Blocks approval · Citation checked against stored text

   OIG warns that a Medicare Advantage plan paying doctors or their office staff, in gift cards or in kind, to refer or recommend patients for enrollment can violate the federal anti-kickback statute and steer people into plans that do not fit them. CMS also bars a provider acting for a plan from accepting compensation for marketing or enrollment. Applies to plan sponsors, agents and providers.

   Source: OIG Special Fraud Alert (December 2024) on suspect payments in marketing arrangements related to Medicare Advantage and providers, part II; 42 CFR 422.2266(d)(1)(ix); 42 U.S.C. 1320a-7b

   Safer wording: Do not pay or reward providers or their staff for recommending a plan or for enrollments. Describe plans on their merits and tell people they can compare plans at medicare.gov.

   42 CFR 422.2266, 42 CFR 422.2266(d)(1)(ix), 42 U.S.C. 1320a-7b · Needs counsel review

4. CG-OIG-102 · Blocks approval · Citation checked against stored text

   OIG warns about payments from health care professionals to agents and brokers to recommend or refer Medicare Advantage enrollees to the professional, for example to be named an enrollee's primary care provider. Enrollees often do not know about the payment. DOJ settled with Oak Street Health for $60 million over allegations it paid agents about $200 per referred beneficiary. Applies to providers, agents and brokers.

   Source: OIG Special Fraud Alert (December 2024) on suspect payments in marketing arrangements related to Medicare Advantage and providers, part III; 42 U.S.C. 1320a-7b(b); DOJ Oak Street Health settlement (September 18, 2024)

   Safer wording: Do not pay agents or brokers per referral, per enrollee or per patient steered to your practice. If you use an agent, pay only compensation that CMS rules and counsel have cleared, and never tie it to which provider the enrollee picks.

   Oak Street Health settlement, 42 U.S.C. 1320a-7b · Needs counsel review

5. CG-RES-010 · Blocks approval · Citation checked against stored text

   Research ads must not promise access to better treatment or use urgency and heroism to push enrollment, because that overstates benefit and pressures participants.

   Source: FDA information sheet "Recruiting Study Subjects"; 21 CFR 50.20 (no undue influence); 21 CFR 312.7(a)

   Safer wording: Say it is a research study, what it tests, who may take part, and that benefit is not guaranteed. Remove urgency and heroism.

   21 CFR 50.20, 21 CFR 312.7(a) · Needs counsel review

6. CG-TRB-002 · Blocks approval · Citation checked against stored text

   Waiving Medicare cost sharing, promising free equipment or benefits to Medicare beneficiaries, guaranteeing coverage, and soliciting Medicare numbers by phone or mail are fraud markers and prohibited marketing practices.

   Source: Federal Anti-Kickback Statute, 42 USC 1320a-7b(b); Beneficiary Inducement CMP, 42 USC 1320a-7a(a)(5); CMS Medicare Communications and Marketing Guidelines, 42 CFR 422.2260 et seq.; Telephone Consumer Protection Act

   Safer wording: Do not waive copays, promise free items or total coverage, or ask for Medicare numbers in an ad. State covered services only as they appear in Medicare coverage rules.

   42 CFR 422.2260, Medicare Communications and Marketing Guidelines · Needs counsel review

7. CG-TRF-003 · Blocks approval · Citation checked against stored text

   Offering gift cards, cash or rich benefits to Medicare beneficiaries, asking for their Medicare number by text, unsolicited home visits by agents, and names implying a government plan are prohibited Medicare marketing practices.

   Source: CMS Medicare Communications and Marketing Guidelines, 42 CFR 422.2263 and 423.2263 (prohibited marketing activities); Federal Anti-Kickback Statute, 42 USC 1320a-7b(b)

   Safer wording: Do not offer cash or gift cards, do not collect Medicare numbers by text, do not make unsolicited visits, and never imply a plan is run by Medicare or Social Security.

   42 CFR 422.2263, Medicare Communications and Marketing Guidelines · Needs counsel review

8. CG-TRK-008 · Blocks approval · Citation checked against stored text

   Presenting a trial as lifesaving, inducing enrollment with testimonials and gifts, or recruiting without ethics review misleads prospective participants and bypasses human-subject protections.

   Source: FDA information sheet on recruiting study subjects; 21 CFR 50.20 and 21 CFR 56.109; 45 CFR 46.116; FTC Act section 5

   Safer wording: Describe the trial neutrally, state that benefit is unproven, and submit all recruitment material for IRB approval before use.

   21 CFR 50.20, 21 CFR 56.109, 45 CFR 46.116 · Needs counsel review

9. CG-TRF-002 · Blocks approval

   Routinely waiving or promising to absorb insurance copays and deductibles induces federal program patients and is an inducement issue under the federal anti-kickback and beneficiary inducement laws, and often misstates coverage.

   Source: Federal Anti-Kickback Statute, 42 USC 1320a-7b(b); Beneficiary Inducement CMP, 42 USC 1320a-7a(a)(5); OIG Special Fraud Alert on routine waiver of copayments

   Safer wording: Do not advertise blanket copay waivers. Say what the plan covers and that cost sharing may apply, and offer a financial hardship policy applied case by case.

   See source text · Needs counsel review

10. CG-TRJ-001 · Blocks approval

    Paying or rewarding people for sending patients, or charging for patient referrals, offers remuneration to induce referrals and can violate the federal Anti-Kickback Statute and state fee-splitting laws.

    Source: Federal Anti-Kickback Statute, 42 USC 1320a-7b(b); Beneficiary Inducement CMP, 42 USC 1320a-7a(a)(5); state patient brokering and fee-splitting laws

    Safer wording: Do not pay for referrals or per-patient leads. Use flat-rate advertising and have counsel review any referral or ambassador program.

    See source text · Needs counsel review

Sample wording we wrote to test these rules, run through the real engine at build time. The rule ids, reasons, sources and safer wording are the rule-set's own.

No state or platform has 3 or more rules of its own for this industry, so none is generated. The rules above are the whole set we can tie to it.