[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.104]



[Page 223]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                Subpart C_Enrollee Rights and Protections

 

Sec.  438.104  Marketing activities.



    (a) Terminology. As used in this section, the following terms have 

the indicated meanings:

    Cold-call marketing means any unsolicited personal contact by the 

MCO, PIHP, PAHP, or PCCM with a potential enrollee for the purpose of 

marketing as defined in this paragraph.

    Marketing means any communication, from an MCO, PIHP, PAHP, or PCCM 

to a Medicaid recipient who is not enrolled in that entity, that can 

reasonably be interpreted as intended to influence the recipient to 

enroll in that particular MCO's, PIHP's, PAHP's, or PCCM's Medicaid 

product, or either to not enroll in, or to disenroll from, another 

MCO's, PIHP's, PAHP's, or PCCM's Medicaid product.

    Marketing materials means materials that--

    (1) Are produced in any medium, by or on behalf of an MCO, PIHP, 

PAHP, or PCCM; and

    (2) Can reasonably be interpreted as intended to market to potential 

enrollees.

    MCO, PIHP, PAHP, or PCCM include any of the entity's employees, 

affiliated providers, agents, or contractors.

    (b) Contract requirements. Each contract with an MCO, PIHP, PAHP, or 

PCCM must comply with the following requirements:

    (1) Provide that the entity--

    (i) Does not distribute any marketing materials without first 

obtaining State approval;

    (ii) Distributes the materials to its entire service area as 

indicated in the contract;

    (iii) Complies with the information requirements of Sec.  438.10 to 

ensure that, before enrolling, the recipient receives, from the entity 

or the State, the accurate oral and written information he or she needs 

to make an informed decision on whether to enroll;

    (iv) Does not seek to influence enrollment in conjunction with the 

sale or offering of any private insurance; and

    (v) Does not, directly or indirectly, engage in door-to-door, 

telephone, or other cold-call marketing activities.

    (2) Specify the methods by which the entity assures the State agency 

that marketing, including plans and materials, is accurate and does not 

mislead, confuse, or defraud the recipients or the State agency. 

Statements that will be considered inaccurate, false, or misleading 

include, but are not limited to, any assertion or statement (whether 

written or oral) that--

    (i) The recipient must enroll in the MCO, PIHP, PAHP, or PCCM in 

order to obtain benefits or in order to not lose benefits; or

    (ii) The MCO, PIHP, PAHP, or PCCM is endorsed by CMS, the Federal or 

State government, or similar entity.

    (c) State agency review. In reviewing the marketing materials 

submitted by the entity, the State must consult with the Medical Care 

Advisory Committee established under Sec.  431.12 of this chapter or an 

advisory committee with similar membership.