The Agent's Guide to CMS-Compliant Medicare Enrollment Calls
A single missed disclosure or prohibited phrase can turn a successful enrollment into a compliance violation, a CTM complaint, and potentially a CMS audit. This guide walks through every phase of a compliant Medicare enrollment call—from the opening greeting to the final close—so you know exactly what to say, what to avoid, and where the compliance landmines are buried.
The 7 Phases of a Compliant Enrollment Call
Phase 1: Opening and Agent Identification
The first 30 seconds of a Medicare enrollment call set the compliance tone for everything that follows. CMS requires agents to clearly identify themselves and the purpose of the call before any plan discussion begins. This is not just best practice—it is a regulatory requirement outlined in the CMS Marketing Guidelines.
Compliant Opening Script Example
"Hello, this is [Agent Name], a licensed insurance agent with [Agency Name]. I am calling regarding Medicare plan options. This call may be recorded for quality assurance and compliance purposes. Before we continue, I want you to know that I represent [Carrier Name(s)] and I am not connected with the federal government or the Medicare program. Is it okay to proceed?"
Required Elements in the Opening
Phase 2: Recording Consent
After the opening identification, you must obtain explicit consent to record the call. In one-party consent states, notification may suffice, but in two-party consent states (California, Florida, Illinois, etc.), you need affirmative verbal consent. Best practice is to always obtain explicit consent regardless of state—it provides an extra layer of protection during audits. For detailed consent requirements, see our Medicare compliance guide.
Do Say
- "This call is being recorded for quality and compliance purposes. Do you consent to being recorded?"
- "May I have your permission to record this conversation?"
- "Before we continue, I need to let you know this call is being recorded. Is that okay with you?"
Don't Say
- "By staying on the line, you agree to be recorded." (passive consent—not acceptable in all states)
- "We always record calls." (does not ask for consent)
- "Don't worry about the recording." (dismissive, does not document consent)
Phase 3: Scope of Appointment (SOA)
The Telephonic Scope of Appointment is a CMS requirement that must be completed before any plan-specific discussion. The SOA documents what product types the beneficiary has agreed to discuss and protects both the agent and the beneficiary from unauthorized sales pressure.
48-Hour Rule
For outbound calls, the SOA must be obtained at least 48 hours before the sales appointment—except during certain enrollment periods when CMS allows same-day SOA capture. For inbound calls where the beneficiary initiates contact, the SOA can be captured during the call. Always verify which rule applies before proceeding.
T-SOA Script Example
"Before we discuss any specific plans, I need to document the types of products you would like to review today. This is called a Scope of Appointment. Would you like to discuss: Medicare Advantage plans, Medicare Supplement plans, Part D Prescription Drug plans, or a combination? Please note that the products we discuss today will be limited to what you authorize right now. You are under no obligation to enroll in anything."
Phase 4: Needs Assessment
A compliant needs assessment gathers information about the beneficiary's healthcare needs, current coverage, preferred providers, and prescription medications. This phase serves two purposes: it ensures you recommend appropriate plans, and it documents that your recommendation was based on the beneficiary's actual needs—not sales pressure.
Compliant Needs Assessment Questions
Phase 5: Plan Presentation and Required Disclosures
When presenting plan options, CMS requires specific disclosures and prohibits certain types of language. Every benefit claim must be accurate, and you must present limitations alongside benefits. Cherry-picking positive features while hiding drawbacks is a compliance violation that frequently triggers CTM complaints.
Prohibited Language During Plan Presentation
- "This is the best plan available" — Superlatives without qualification violate CMS rules
- "You need to switch plans" — Creates undue pressure on the beneficiary
- "Everyone in your area is switching to this plan" — Misleading and unverifiable claim
- "You will save money guaranteed" — Cannot guarantee savings without verifying individual circumstances
- "Your current plan is terrible" — Disparaging competitors or current coverage violates CMS guidelines
Mandatory Disclosures During Plan Presentation
You Must Disclose:
- Network restrictions — If the plan uses an HMO or PPO network, explain that the beneficiary may need to use in-network providers
- Prior authorization requirements — Disclose that some services may require pre-approval from the plan
- Formulary limitations — Explain that prescription drug coverage is subject to the plan's formulary and tier structure
- Out-of-pocket maximums — State the plan's maximum out-of-pocket costs for the year
- Service area limitations — Confirm the plan is available in the beneficiary's county and ZIP code
- Disenrollment rights — Inform the beneficiary of their right to disenroll during applicable enrollment periods
Phase 6: Enrollment Process
If the beneficiary decides to enroll, the enrollment process itself has strict compliance requirements. Every data point must be verified verbally, the beneficiary must confirm their understanding of the plan, and they must provide explicit consent to enroll—never assumed consent.
Compliant Enrollment Practices
- Read back all enrollment data for verbal verification
- Confirm the beneficiary understands plan costs and coverage
- Obtain explicit verbal consent: "Do you wish to enroll in [Plan Name]?"
- Provide the enrollment confirmation number and next steps
Non-Compliant Enrollment Practices
- Enrolling without the beneficiary's explicit verbal consent
- Rushing through terms and conditions
- Skipping the data read-back verification
- Failing to provide confirmation details or next steps
Enrollment Verification Checklist
Before submitting the enrollment, read back each field and ask the beneficiary to confirm accuracy. This step protects against data entry errors and provides documented proof that the beneficiary authorized the enrollment.
Pre-Submission Verification Points
Phase 7: Closing and Post-Enrollment Disclosures
The close of the call is not just a courtesy wrap-up—it contains required CMS disclosures that are frequently missed by agents in a hurry. These final disclosures ensure the beneficiary understands their rights, next steps, and how to get help if needed.
Required Closing Disclosures
- Disenrollment period — Inform the beneficiary they have the right to disenroll within the first few months of coverage
- 1-800-MEDICARE — Provide the Medicare helpline number for questions or complaints
- Enrollment materials — Confirm that written enrollment confirmation materials will be mailed
- Agent contact information — Provide your direct contact details for follow-up questions
- No further action required — Clarify that their enrollment is submitted and no additional steps are needed from them
Common Compliance Pitfalls Throughout the Call
Beyond the phase-specific requirements above, several compliance pitfalls can occur at any point during the call. These are the issues that most frequently result in CTM complaints and CMS enforcement actions.
Top Compliance Pitfalls
Scope Creep
Discussing products not authorized in the Scope of Appointment. If the beneficiary asks about a product type not in the SOA, you must obtain a new SOA before discussing it.
Cross-Selling Without Permission
Introducing ancillary products (dental, vision, life insurance) during a Medicare enrollment call without specific SOA authorization for those product types.
Benefit Misrepresentation
Overstating benefits, understating costs, or making comparisons that do not reflect actual plan details. Every claim must be verifiable against the Summary of Benefits.
Pressure Tactics
Creating false urgency ("This offer expires today"), using fear ("You will lose coverage"), or refusing to let the beneficiary end the call without enrolling.
Key Takeaways
- Every enrollment call has 7 distinct compliance phases—skipping any one of them can trigger a CMS violation
- Agent identification and carrier disclosure must happen in the first 30 seconds of every call
- Scope of Appointment must be captured and documented before any plan discussion begins
- Prohibited language includes superlatives, pressure tactics, and unverifiable benefit claims
- Closing disclosures about disenrollment rights and the 1-800-MEDICARE helpline are just as mandatory as the opening
Compliance is not about memorizing a script—it is about understanding the purpose behind each requirement and building those principles into every call interaction. When agents understand why each disclosure exists, compliance becomes natural rather than forced. Use this guide as a training foundation, practice with mock calls, and review real call recordings regularly to ensure every enrollment call meets the standard.
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Try AgentTech Dialer NowReferences & Authoritative Sources
The information on this page is supported by the following official and authoritative sources.
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Medicare.gov CMS