Agent violations in Medicare are actions by a licensed agent or broker that break the marketing, sales, enrollment, or post-enrollment rules set by the Centers for Medicare & Medicaid Services (CMS). They range from misleading advertising and unauthorized enrollment to failing to record a sales call or keep a required form. Depending on the conduct, the consequences can reach fines, loss of the ability to sell Medicare plans, state license discipline, and exclusion from federal healthcare programs.
What Counts as a Violation
CMS regulates almost every step of how an agent finds, contacts, advises, and enrolls a Medicare beneficiary. A violation is any deviation from those rules, whether the agent intended harm or not.
Marketing and Sales Conduct
Agents may use only CMS-approved and carrier-approved marketing materials, and any deviation from that approved content is a violation.1Medicare. Marketing Rules for Health Plans Common prohibited practices include:
- Misleading advertising, such as using terms like “free Medicare” or implying government endorsement. Agents cannot claim CMS or Medicare recommends a particular plan.
- Misrepresenting plan details by overstating benefits, understating costs, or describing a service area inaccurately.
- High-pressure tactics: insisting on immediate enrollment, claiming a limited-time offer, or manufacturing urgency.
- Improper gifts. Cash and cash equivalents are always prohibited, and non-cash gifts cannot exceed $15 per item or $75 per beneficiary per year.
- Superlatives and absolutes like “the best,” “the only choice,” or “guaranteed savings.”
CMS also draws a hard line between educational events and sales events. An agent can educate at a sales event, but cannot sell at an event advertised as educational. Discussing plan-specific premiums or benefits, handing out enrollment applications, or scheduling individual sales appointments at an educational event are all violations.2Centers for Medicare & Medicaid Services. Medicare Marketing Guidelines
Unsolicited Contact
Agents may send unsolicited conventional mail, print advertisements, and emails, and every email must include a working opt-out option.3eCFR. 42 CFR 422.2264 – Beneficiary Contact Other forms of unsolicited outreach are prohibited:
- Door-to-door visits, unless the beneficiary previously scheduled an appointment at that specific address and time. Leaving materials on a doorstep without a scheduled appointment counts as a violation.
- Cold calls without a prior request from the beneficiary.
- Robocalls, text messages, and voicemails.
Before contacting a potential enrollee through any non-mail channel, an agent needs documented Permission to Contact. Social media likes, comments, and shares do not count as permission.
Scope of Appointment
A Scope of Appointment (SOA) form documents which products and topics the beneficiary has agreed to discuss. Agents must obtain a completed SOA at least 48 hours before any in-person or telephone sales appointment, with limited exceptions for walk-ins and genuinely urgent situations.4Centers for Medicare & Medicaid Services. Medicare Managed Care Manual Discussing products or plan types not listed on the SOA is a violation, even if the agent believes the beneficiary would benefit from hearing about them. The SOA must be kept whether or not a sale results.
Enrollment Conduct
The enrollment process carries some of the most closely watched rules, because these violations directly affect a beneficiary’s coverage. Prohibited practices include:
- Enrolling anyone without their clear, documented consent. Unauthorized enrollment can trigger intermediate sanctions against the plan itself.5eCFR. 42 CFR 422.752 – Basis for Imposing Intermediate Sanctions and Civil Money Penalties
- Falsifying application information, including a beneficiary’s health conditions or eligibility status.
- Enrolling ineligible individuals, such as someone outside the plan’s service area.
- Demanding a Medicare Beneficiary Identifier, Social Security number, or other sensitive information just to show a beneficiary what plans exist. At that stage, an agent may ask only for a ZIP code.
TPMO Disclaimer and Call Recording
CMS classifies all agents and brokers who sell Medicare products as Third-Party Marketing Organizations (TPMOs). Every agent acting as a TPMO must include a disclaimer stating how many organizations they represent and how many products they sell, so beneficiaries can judge the advice accordingly.6Centers for Medicare & Medicaid Services. CY2026 Agent and Broker Training and Testing Guidelines
Every marketing, sales, and enrollment call must be recorded in its entirety, including the audio portion of web-based calls. Failing to record any sales-related call is specifically listed as a prohibited marketing activity.
Post-Enrollment Conduct
An agent’s obligations continue after the application is submitted. Violations at this stage include:
- Withholding required materials like the Evidence of Coverage and Pre-Enrollment Checklist.
- Ignoring a beneficiary’s complaint or failing to refer it to the plan’s grievance process.
- Churning, meaning switching a beneficiary from one plan to another without their prior consent or solely to earn a new commission. CMS regulations name this as grounds for intermediate sanctions.5eCFR. 42 CFR 422.752 – Basis for Imposing Intermediate Sanctions and Civil Money Penalties
- Any practice that would deny or discourage enrollment based on health status, medical history, or anticipated need for care.
Licensing and Record-Keeping
Selling Medicare products without a current state license, a valid appointment from the plan, or a completed annual certification is itself a violation. Agents whose licenses lapse or who face state disciplinary action must report those changes to the plans they represent.
CMS also requires agents and their organizations to keep complete records of all marketing, enrollment, and sales interactions for at least 10 years, including SOA forms (sale or no sale), recorded calls, and marketing materials used. Anyone who encounters suspected fraud, waste, or abuse in the Medicare program has an obligation to report it; staying silent is itself a violation.
Consequences for the Agent
An agent who commits violations risks decertification by the plan, which ends their ability to sell that plan’s products and typically means forfeiting commissions on improperly sold policies. State insurance departments can suspend or revoke a license based on the same conduct.
In serious cases involving fraud or other criminal conduct, the HHS Office of Inspector General can place an agent on the List of Excluded Individuals/Entities, barring them from any federally funded healthcare program. Exclusion is mandatory for convictions involving Medicare or Medicaid fraud, patient abuse, and felony healthcare-related financial misconduct. The OIG can also exclude individuals at its discretion for a broader range of conduct, including misdemeanor healthcare fraud, license surrender under professional misconduct, and involvement in kickback arrangements.7U.S. Department of Health and Human Services, Office of Inspector General. Background Information – Exclusions
Consequences for the Plan
When an organization’s agents break CMS rules, the plan itself faces consequences. CMS can impose intermediate sanctions that suspend the plan’s ability to enroll new members and halt all marketing. These sanctions are available for enrolling beneficiaries without consent, unauthorized plan transfers, and failures to comply with communication and marketing requirements.5eCFR. 42 CFR 422.752 – Basis for Imposing Intermediate Sanctions and Civil Money Penalties
CMS can also impose civil monetary penalties and, for sustained or severe violations, terminate the organization’s Medicare contract. Immediate termination is available when continued operation would pose an imminent and serious risk to enrollees’ health.8eCFR. 42 CFR 422.510 – Termination of Contract by CMS Organizations that keep agents who engage in prohibited conduct can face sanctions for that relationship alone.
How to Report an Agent Violation
Beneficiaries who experience a violation have several options. The most direct is calling 1-800-MEDICARE (1-800-633-4227), which is staffed 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048. Complaints can also be filed online through the Medicare Complaint Form on Medicare.gov and can be submitted anonymously.9Medicare.gov. Filing a Complaint
For suspected fraud involving a Medicare Advantage or Part D plan, call the Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379).10Medicare. Reporting Medicare Fraud and Abuse Contacting the plan directly using the phone number on the membership card is another option, especially for grievances about how an agent handled an interaction rather than outright fraud.