What Is EKRA? A Plain-English Guide for Rehabs

EKRA, the Eliminating Kickbacks in Recovery Act of 2018, is a federal criminal law at 18 U.S.C. § 220. It bans paying or taking anything of value to induce referrals to recovery homes, clinical treatment facilities and labs, when a public or private health plan covers the services. The penalty is up to $200,000 and 10 years in prison for each occurrence.

This guide sticks to the statute, court opinions and Department of Justice (DOJ) releases. Every rule links to its source. Where we give our own view, we say so. It explains the law. It is not legal advice, so have a health care attorney review any marketing contract.

What does EKRA stand for, and where did it come from?

EKRA stands for the "Eliminating Kickbacks in Recovery Act of 2018." It is Subtitle J of the SUPPORT for Patients and Communities Act, Public Law 115-271, which was approved on October 24, 2018 (Public Law 115-271). It added a new section, 18 U.S.C. § 220, titled "Illegal remunerations for referrals to recovery homes, clinical treatment facilities, and laboratories."

DOJ describes the reason plainly. EKRA was passed "to target the rise in body brokering and substance abuse facility profiteering" (DOJ). The Ninth Circuit added that Congress wanted a kickback ban like the one Medicare already had, "for patients with private insurance" (U.S. v. Schena).

Who does EKRA apply to?

Anyone. The law starts with "whoever," so it reaches facility owners, marketers, recruiters and labs alike (18 U.S.C. § 220). It covers referrals to three kinds of businesses, defined in the statute:

Clinical treatment facility: "a medical setting, other than a hospital, that provides detoxification, risk reduction, outpatient treatment and care, residential treatment, or rehabilitation for substance use, pursuant to licensure or certification under State law."
Recovery home: "a shared living environment that is, or purports to be, free from alcohol and illicit drug use and centered on peer support and connection to services that promote sustained recovery from substance use disorders."
Laboratory: as defined in the Public Health Service Act (42 U.S.C. 263a).

Note the words "for substance use." The definition is written around substance use treatment. We found no source on whether EKRA reaches a mental-health-only program, so we don't claim it either way.

What does EKRA prohibit?

Two things, when done "knowingly and willfully" (18 U.S.C. § 220(a)):

Taking money for referrals. Soliciting or receiving "any remuneration (including any kickback, bribe, or rebate)" in return for referring a patient to a recovery home, clinical treatment facility or lab.
Paying for referrals. Paying or offering any remuneration "to induce a referral of an individual" to one of those businesses, or "in exchange for an individual using the services" of one.

"Remuneration" covers payment "directly or indirectly, overtly or covertly, in cash or in kind." So indirect and in-kind payments count, not just cash.

What are the penalties under EKRA?

A person who breaks EKRA "shall be fined not more than $200,000, imprisoned not more than 10 years, or both, for each occurrence" (18 U.S.C. § 220(a)).

Does EKRA apply to private insurance?

Yes. EKRA covers "services covered by a health care benefit program." Federal law defines that term as "any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual" (18 U.S.C. § 24(b)). Commercial insurance counts, not only Medicare and Medicaid.

We found no source on cash-pay patients with no health plan involved, so we don't make a claim about them.

What are the exceptions to EKRA?

The statute lists exceptions in § 220(b). The two that matter most for marketing:

Employees and independent contractors. A payment from an employer to an employee or independent contractor is allowed only if it "is not determined by or does not vary by" (A) "the number of individuals referred," (B) "the number of tests or procedures performed," or (C) "the amount billed to or received from" the health plan (§ 220(b)(2)).
Personal services contracts. Payments under a contract that meets the federal safe harbor at 42 CFR 1001.952(d) "as in effect on the date of enactment" (§ 220(b)(4)). The 2018 version requires, among other things, a term of "not less than one year" and aggregate pay that "is set in advance, is consistent with fair market value" and doesn't take "into account the volume or value of any referrals" (42 CFR 1001.952(d), 2018 edition).

Other exceptions cover properly disclosed discounts, some copay waivers that are "not routinely provided" and made "in good faith," and alternative payment models. The statute lets the Attorney General write regulations that explain the exceptions (§ 220(c)). One law firm describes EKRA as having "limited regulations" so far (Robinson & Cole, National Law Review).

How is EKRA different from the Anti-Kickback Statute?

	EKRA (18 U.S.C. § 220)	Anti-Kickback Statute (42 U.S.C. § 1320a-7b)
Which payers	"any public or private plan or contract"	"a Federal health care program"
Maximum fine	$200,000 per occurrence	$100,000
Maximum prison	10 years	10 years
Staff pay exception	Employee or independent contractor, pay can't vary with referrals, tests or billing	Bona fide employee

Sources: 18 U.S.C. § 220, 18 U.S.C. § 24(b), 42 U.S.C. § 1320a-7b. EKRA "shall not apply to conduct that is prohibited under" the Anti-Kickback Statute, and it doesn't push aside state laws on the same subject (§ 220(d)).

Can a treatment center pay a marketer per admission or a percentage?

The sources don't all agree on this one.

The statute: the employee and contractor exception only protects pay that doesn't vary with the number of people referred, tests performed or amounts billed (§ 220(b)(2)). Pay outside that exception gets no protection from it.
The Ninth Circuit: in the first appeals ruling on EKRA, the court said "we do not think the mere fact of a percentage-based marketing arrangement, without more, would constitute a per se violation of EKRA." The government agreed at oral argument. But percentage payments to marketers "directed to mislead those making the referrals" do violate EKRA. The court suggested companies "consider whether it is preferable to structure their compensation arrangements in accordance with the statute's safe harbor" (U.S. v. Schena, July 11, 2025). The Supreme Court denied review on March 23, 2026 (docket 25-447).
Some health care lawyers read it more strictly: "per-head, per-admission, percentage-based, or success-fee compensation tied to resident referrals is the core conduct that EKRA targets" (Liles Parker, June 2026).

Our position: we charge a flat monthly fee for services and never price per admission, per patient, or with a census bonus. We think rehabs should pay every vendor that way, and have a health care attorney check any deal that changes with patient volume.

What do EKRA prosecutions look like?

Treatment facilities, Orange County, California. Casey Mahoney paid "nearly $2.9 million in illegal kickbacks to so-called 'body brokers'" from 2018 to 2020. His contracts claimed fixed payments. DOJ says: "In reality, Mahoney and the brokers negotiated payments based on the patients' insurance reimbursements and the number of days Mahoney was able to bill for treatment." DOJ says his conviction "arose out of violations of" EKRA. He was sentenced on March 21, 2025 to 41 months in prison and fined $240,000 (DOJ).
Laboratory, Northern California. Mark Schena "paid kickbacks to marketers in violation of the Eliminating Kickbacks in Recovery Act." He was sentenced on October 18, 2023 to eight years in prison and $24 million in restitution (DOJ). The Ninth Circuit found his marketers "were paid a percentage of the revenue that they were able to bring in" and upheld the EKRA counts (U.S. v. Schena).
Recovery homes, New Jersey. Facilities paid a marketing company "a fee of $5,000 to $10,000 per patient referral" for patients "who had robust private health insurance." A California doctor "pleaded guilty in September 2020 to conspiracy to violate" EKRA. Other people in the scheme were charged under different laws (DOJ, May 10, 2022).

How do state patient brokering laws fit in?

EKRA doesn't replace state law (§ 220(d)(2)), so state bans apply too. Florida is one example. Its statute makes it unlawful to "offer or pay a commission, benefit, bonus, rebate, kickback, or bribe, directly or indirectly, in cash or in kind, or engage in any split-fee arrangement, in any form whatsoever, to induce the referral of a patient or patronage to or from a health care provider or health care facility." It covers "any substance abuse service provider licensed under chapter 397." Fines run $50,000, $100,000 when 10 to 19 patients are involved, and $500,000 for 20 or more (Fla. Stat. § 817.505).

Other states have their own laws. Check the ones where you operate and where you advertise.

What should you check in your marketing contracts?

Based on the statute and the DOJ cases above, read every vendor deal for these:

Does the fee change with admissions, patients, census, VOBs or insurance payouts? The exception in § 220(b)(2) only covers pay that doesn't vary that way.
Does a "fixed fee" contract hide side deals tied to volume? That is what DOJ described in the Mahoney case.
Does anyone get paid per patient referral, or more for patients with richer insurance? That is the structure in the New Jersey case.
Is the fee set in advance, at fair market value, in a written contract? The 2018 safe harbor that EKRA points to requires that.

Frequently asked questions

What does EKRA mean?

EKRA stands for the Eliminating Kickbacks in Recovery Act of 2018. It is a federal criminal law, codified at 18 U.S.C. § 220, that bans paying or receiving anything of value for referrals to recovery homes, clinical treatment facilities and laboratories when a public or private health plan covers the services.

What law was enacted to address patient brokering?

At the federal level, EKRA. DOJ says it was passed in October 2018 “to target the rise in body brokering and substance abuse facility profiteering.” Many states also have their own patient brokering laws, such as Florida Statutes § 817.505.

Which activity is prohibited under patient brokering laws?

Paying or receiving anything of value to induce a patient referral. EKRA bans paying “to induce a referral of an individual” to a recovery home, clinical treatment facility or lab, and taking payment for such referrals. Florida's law also bans “any split-fee arrangement, in any form whatsoever” to induce a referral.

Can you give an example of a kickback in addiction treatment?

In a case DOJ tied to EKRA, a facility owner paid “body brokers” nearly $2.9 million. The contracts claimed fixed fees, but the real payments tracked the patients' insurance reimbursements and billed treatment days. He was sentenced in March 2025 to 41 months in prison and fined $240,000.

Does EKRA apply to Medicare and Medicaid patients?

EKRA covers public and private plans, but it “shall not apply to conduct that is prohibited under” the federal Anti-Kickback Statute, which covers federal health care programs. So conduct the Anti-Kickback Statute already prohibits falls under that law, not EKRA.

Does EKRA apply to marketing agencies?

Yes. The law applies to “whoever” pays or receives illegal remuneration. The Ninth Circuit held in 2025 that EKRA covers payments to marketing intermediaries, even ones who never deal with patients directly. It also said percentage pay alone is not automatically a violation, but percentage pay plus misleading referral sources is.

Is it legal to pay a rehab marketer per admission?

It is a serious legal risk. EKRA's exception for employees and contractors only covers pay that doesn't vary with referrals, and Florida bans bonuses and split fees paid to induce referrals. Courts and lawyers differ on the details. We never price per admission, and we suggest rehabs pay every vendor a flat fee.

Sources

All sources checked October 6, 2026.