There are two separate compliance regimes in Medicare broker marketing, and most brokers apply only one of them to the wrong population. CMS Medicare Communications and Marketing Guidelines govern what brokers can do with enrolled Medicare beneficiaries. State insurance department regulations govern what brokers can do with individuals who are approaching 65 but have not yet enrolled. Confusing the two produces either unnecessary restriction (treating every T65 prospect like a CMS-protected beneficiary) or actual violations (treating an enrolled beneficiary like a prospect who can receive unsolicited calls).
Key Takeaways
- CMS MCMG marketing restrictions apply to Medicare beneficiaries, meaning individuals enrolled in Part A or Part B. A prospect who has not yet enrolled is not a Medicare beneficiary and is governed by state insurance producer outreach rules instead.
- The 7-month IEP runs 3 months before the birthday month, the birthday month itself, and 3 months after. Enrollment in the first 3 months produces Part B coverage starting the first of the birthday month. Late enrollment in the IEP delays Part B and triggers the permanent late enrollment penalty.
- Cold calls, door-to-door visits, and sending unsolicited marketing materials via email are prohibited once a client becomes a Medicare beneficiary under 42 CFR 422.2268. These restrictions cover Medicare Advantage plans specifically; Medigap carriers are regulated by state insurance codes, not CMS beneficiary marketing rules.
- The Scope of Appointment must be obtained at least 48 hours before an appointment to discuss Medicare Advantage or Part D plans. Walk-in appointments and beneficiary-initiated same-day contacts are the two exceptions. The SOA timing obligation starts when the client becomes a Medicare beneficiary.
- Brokers who use lead lists purchased from third-party vendors bear the compliance risk if those lists include current Medicare beneficiaries. Buying a list of individuals turning 65 in a given month mixes prospects and current beneficiaries, creating exposure.
Who the CMS marketing rules actually apply to
The CMS Medicare Communications and Marketing Guidelines are built around a specific legal definition: a Medicare beneficiary is an individual enrolled in Medicare Part A, Part B, or both. An individual who is 64 years and 11 months old and has not submitted an enrollment application to the Social Security Administration or CMS is not a Medicare beneficiary. That person is an insurance prospect governed by state law.
The transition from prospect to beneficiary happens on the effective date of Part A or Part B coverage, not on the 65th birthday. A client who enrolls in Part A and Part B during the first 3 months before their birthday month receives coverage effective the first of the birthday month. From that date forward, the CMS MCMG apply. A client who waits and enrolls in their birthday month or after has their Part B effective date pushed forward by one month, meaning the CMS rules apply a month later than the birthday.
For brokers building a T65 pipeline, this distinction matters practically. A broker can call, email, and mail prospects approaching age 65 under state producer regulations without triggering the cold-call prohibition in 42 CFR 422.2268. The moment the prospect enrolls and becomes a beneficiary, the call prohibition applies to any subsequent unsolicited outreach about Medicare Advantage or Part D plans.
| Timing | Prospect/beneficiary status | Rule applied | Allowed outreach |
|---|---|---|---|
| More than 3 months before birthday month | Prospect (not yet IEP-eligible) | State insurance dept. rules | Direct mail, email (with consent), educational seminars |
| 3 months before birthday month | IEP opens — still a prospect | State insurance dept. rules | Same as above; begin Medigap plan comparisons |
| Birthday month | IEP — may enroll in Part A/B this month | Transition point | SOA required once enrollment is confirmed; Medigap OEP opens |
| After Part A/B effective date | Medicare beneficiary | CMS MCMG — 42 CFR 422.2268 | No cold calls; SOA required before MA/PDP appointments |
State rules vary. Verify state-specific solicitation restrictions with the state insurance department before designing a T65 outreach program. Medigap is regulated under state insurance codes regardless of beneficiary status.
What the IEP timing means for the outreach calendar
The Medicare Initial Enrollment Period is a 7-month window: 3 months before the birthday month, the birthday month itself, and 3 months after. The optimal outreach window for a T65 prospect is the 3 months before the IEP opens, which means contacting a client who turns 65 in March as early as the prior October.
Brokers who wait until the IEP opens are already two steps behind. By the time the IEP opens, the prospect has received mail from carriers, has probably been through a Social Security Administration enrollment prompt, and may have already been contacted by other brokers. The T65 pipeline advantage goes to brokers who make contact 6 months or more before the birthday month, when the prospect is still entirely in prospect status and no CMS restrictions apply.
Quotit's Medicare quoting interface does not distinguish between beneficiary and prospect status in its marketing compliance prompts. Brokers using that platform should track each client's enrollment status independently and apply the appropriate contact rules outside the quoting tool.
The SOA obligation and when it starts
The Scope of Appointment requirement under 42 CFR 422.2264 applies to appointments to discuss Medicare Advantage or Part D plans with Medicare beneficiaries. It does not apply to conversations with prospects who have not yet enrolled in Medicare.
A broker who begins a relationship with a T65 prospect in October before a March birthday can discuss Medigap options, compare plan designs, and build a full recommendation without collecting an SOA. The moment the prospect enrolls in Part A or Part B and the CMS-effective date arrives, the broker needs an SOA before the next appointment covers Medicare Advantage or Part D options.
The 48-hour advance SOA rule has two exceptions: walk-in appointments and beneficiary-initiated same-day calls. A T65 client who calls the broker on their birthday wanting to discuss Medicare Advantage plans that day satisfies the beneficiary-initiated exception. The SOA still needs to be collected and retained for 10 years, but the 48-hour advance requirement is waived for that specific call.
The Medigap OEP and its interaction with the T65 window
The Medigap open enrollment period is a 6-month window that begins when a beneficiary is simultaneously age 65 or older and enrolled in Medicare Part B. During this window, Medigap insurers cannot deny coverage or apply health-based surcharges. Outside the window, most states allow full medical underwriting.
A broker who contacts a T65 prospect 4 months before the birthday can educate the prospect about all available Medigap plan designs, compare monthly premiums across carriers, and prepare the application. The Medigap application itself cannot be submitted until Part B is effective, but the broker can have the client ready to apply on day one of Part B coverage to preserve the full 6-month OEP window.
Medigap is not covered by the CMS MCMG prohibition on cold calls and unsolicited contact. Medigap is regulated under state insurance codes. A broker can mail a Medigap comparison letter to a newly enrolled Medicare beneficiary without triggering the CMS unsolicited contact prohibition. However, adding a Medicare Advantage plan comparison to that same letter changes the nature of the communication and brings it under CMS MCMG review.
Vendor lead lists and the mixed-population problem
Most T65 lead list vendors sell lists of individuals whose 65th birthday falls within a defined window, such as the next 90 days. These lists combine individuals who are still in prospect status with individuals who have already enrolled in Part A or Part B and are current Medicare beneficiaries. Using the same outreach campaign for both populations creates compliance exposure on the beneficiary portion.
The practical fix is to filter the list. A broker can contact the SSA or use a Medicare enrollment verification service to identify which individuals on the list are already enrolled. The enrolled individuals require SOA-based contact and cannot receive unsolicited outreach. The unenrolled individuals can receive standard prospect marketing.
Example: A purchased list of 200 individuals turning 65 in a given county in the next 90 days contains an unknown mix of beneficiaries and prospects. Sending 200 unsolicited Medicare Advantage plan mailers treats all 200 as prospects. If 80 of them are already enrolled Medicare beneficiaries, those 80 mailings are potential CMS violations. The carrier whose plan appears on those mailers bears the exposure under 42 CFR 422.2268, and the broker bears the consequence through the carrier agency agreement.
Illustrative example. Actual list composition, enrollment rates, and carrier enforcement practices vary.
Medicare T65 marketing rules: common questions
What brokers need to know about prospect outreach, the beneficiary transition, and SOA timing.
Can a broker send a mailer to a prospect who is 64 and approaching Medicare eligibility?
Yes, in most cases. Direct mail to individuals who are not yet enrolled in Medicare is governed by state insurance regulations for solicitation, not by CMS MCMG rules. Most states permit direct mail to prospects for insurance products without restriction. Some state insurance codes have rules about solicitation timing relative to life events, but those rules vary widely. A broker with a T65 mailing list of individuals who have not yet enrolled in Part A or Part B is operating under state insurance department oversight, not CMS oversight. The practical safeguard is to confirm that the mailing list contains only non-enrolled individuals before treating it as a CMS-compliant list.
When exactly does a prospect become a Medicare beneficiary for CMS compliance purposes?
A person becomes a Medicare beneficiary on the effective date of their Part A or Part B enrollment. This can happen at different times depending on when they enrolled in the IEP. A prospect who enrolled in Part A and Part B during the three months before their birthday month has their coverage effective the first day of the birthday month. A prospect who enrolls in their birthday month or in the first or second month after has their Part B coverage effective the first of the following month. The CMS marketing rules apply from the effective date of enrollment, not from the birthday and not from the date of the enrollment application.
Does the SOA requirement apply when the first conversation with a prospect is about Medigap?
No. The Scope of Appointment requirement under 42 CFR 422.2264 applies to Medicare Advantage and Part D plan appointments, not to Medigap or Medicare supplement conversations. Medigap is regulated under state insurance codes and does not carry the federal SOA requirement. Brokers who discuss both Medigap and Medicare Advantage in the same appointment are technically operating under two different compliance regimes for the same conversation. The standard practice is to obtain an SOA for the MA portion of the discussion even when the primary purpose of the appointment is a Medigap comparison. The SOA documentation covers the broker for any MA plan reference that arises during the meeting.
Can a broker use a T65 data list purchased from a vendor for Medicare Advantage outreach?
Only for individuals who are not yet enrolled in Medicare. A purchased T65 list typically includes individuals turning 65 within a certain window, which means it will contain a mix of people who have already enrolled in Part A or Part B and those who have not. Anyone already enrolled in Medicare is a beneficiary subject to CMS cold-call and unsolicited contact prohibitions. Before using a vendor list for Medicare Advantage outreach, the broker must either verify non-enrollment status for each record or restrict outreach to individuals who have expressly requested contact, which constitutes a solicited response that survives the prohibition.
What is the penalty for violating CMS T65 marketing rules?
CMS does not directly fine individual brokers for marketing violations. Enforcement runs through plan sponsors and carriers. A carrier found to have committed or permitted marketing violations can face civil monetary penalties under 42 CFR 422.760, plan suspension, or contract termination. Individual brokers who are agents of a carrier that has a compliance program bear consequences under that carrier's agency agreement. Most carrier contracts include a provision that the broker is responsible for marketing compliance and that violations can result in de-authorization, termination of appointed status, and chargeback of commissions on affected enrollments. Beyond carrier enforcement, state insurance departments can take license disciplinary action for producer solicitation violations under state law.
