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Medicare Communications and Marketing Guidelines

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

The Centers for Medicare & Medicaid Services (CMS) Medicare Communications and Marketing Guidelines (MCMG), supplemented by the CMS Marketing Guidance for California Medicare-Medicaid Plans, has specific regulations regarding marketing communications by health plans and their participating providers to Medicare-eligible and Cal MediConnect Plan (Medicare-Medicaid)-eligible members as outlined below. Participating providers are required to comply with applicable Medicare laws and regulations and plan policies and procedures.

The MCMG states that CMS is concerned with provider marketing for the following reasons:

  • Providers are usually not fully aware of all Medicare health plan benefits and costs
  • A provider may confuse the beneficiary if the provider is perceived as acting as an agent of the Medicare health plan, versus acting as the beneficiary's provider. Providers may face conflicting incentives when acting as a Medicare health plan representative, since they know their patients' health status. Desires to either reduce out-of-pocket costs for their sickest patients, or to financially gain by enrolling their healthy patients may result in recommendations that do not address all of the concerns or needs of a potential Medicare health plan enrollee

The MCMG also prohibits participating providers from providing advice to potential enrollees who inquire regarding the selection of one health plan over another. Participating providers should direct members to call the Medicare Sales or Health Net Member Services Department or Cal MediConnect Member Services Department for benefit information and health plan comparisons. This practice protects participating providers from violating CMS regulations regarding provider marketing and allows beneficiaries to get the facts necessary for making the best possible decision regarding their health plan choices.

While providers may assist patients in an objective assessment of their needs and potential options to meet those needs, providers must remain neutral when assisting with enrollment decisions. Additionally, if providers advertise non-health-related items or services, the advertisement must make it clear that the items and services are not covered by the health plan with which the provider is contracting.

Refer to the Approval of Medicare Communications and Marketing Guidelines for additional information on this topic.

Last Updated: 04/20/2020