What CMS Requires Medicare Agents to Discuss Prior to Enrollments

Starting September 30, 2023, agents who sell Medicare Advantage and Part D will need to ensure they discuss specific CMS-required topics with beneficiaries prior to enrollment. We list those requirements here, so you can more easily stay compliant!

Before enrolling a client in a Medicare Advantage or prescription drug plan, agents will need to discuss CMS-required questions and information on the following topics:

Medicare eligibility
Primary care providers and specialists
Prescription drug coverage and costs
Specific health care needs & costs
Premiums and cost-sharing
Plan benefits
Effect of a coverage change
Administrative items

Below, we’ll summarize these discussion topics and requirements. For a full list of questions and topics that must be discussed, please review CMS’ 2024 Agent and Broker Training and Testing Guidelines. For all of CMS’ requirements for the 2024 plan year, check out our summary on the upcoming changes for Medicare, the CMS 2024 Final Rule fact sheet, and the full 2024 MA & Part D Final Rule on the Federal Register. You can also download our more comprehensive MA & PDP Compliant Sales Checklist!

Medicare Eligibility

Near the start of your conversation, you should check if your client has a basic understanding of their Medicare options, including Original Medicare and Medicare Advantage. Explain that, to enroll in a Medicare Advantage plan, the client must be entitled to Medicare Part A, be enrolled in Medicare Part B, and continue to pay the Part B premium. Double-check that they’re eligible for Medicare Advantage and if they qualify for a special needs plan (e.g., D-SNP or C-SNP).

Ensure your client understands when they can enroll in, disenroll from, and change Medicare plans at specific times of the year (e.g., special enrollment period when they move out of their plan’s service area, when they qualify for Medicaid or Extra Help, or when they move into an institution like a nursing home). Once they decide they want to enroll in a plan, go over the effective date of their coverage with them.

If applicable, also discuss:

• The income-related monthly adjustment amount (IRMAA) for Part B and Part D, if applicable
• The Part B and Part D late enrollment penalty, if applicable
• The public assistance program, if applicable
• Medicare Medical Saving Account (MSA) plan rules (e.g., high deductible, MSA, no drug coverage, eligibility, enrollment period, cancellation)
• Private Fee-for-Service (PFFS) plan rules (e.g., “Your doctor or hospital can continue to treat you if it agrees to accept our terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies.“)
• Special Needs Plans’ (SNPs) special eligibility requirements including the disenrollment rules for members who no longer meet the requirements.

Primary Care Providers & Specialists

On the topic of providers, at minimum, you should ask the client which primary care providers and specialists they typically see or would like to see in the future, then let the client know if those individuals, practices, or facilities are in the plan’s network.

It’s also important to ensure the client understands what in network and out of network means and their coverage and costs. (For example, stating something like, “You must use plan providers, except in emergencies, urgent care situations, or when ‘out-of-area.’ If you obtain routine care from out-of-network providers, neither Medicare nor the plan will be responsible for the costs.“) If the client is interested in a preferred provider organization (PPO) plan, review both the in-network and out-of-network costs. Additionally, explain or show the beneficiary how to look up network providers.

Prescription Drug Coverage & Costs

Many Medicare beneficiaries take prescription drugs. While discussing a potential plan with a client, you must review their prescription drug needs and ensure they understand how the plan impacts both their medical and prescription drug needs, including whether their current prescriptions will be covered. Explain the different Part D coverage stages (i.e., deductible, initial, coverage gap, and catastrophic), copays/coinsurance for their selected pharmacy, and the use of preferred pharmacists.

You should also make sure they understand how to use the pharmacy directory, step therapy, prior authorization, and quantity limitation. To prepare them for any future prescription needs, show clients how to find out if and how their prescription drugs will be covered via the formulary.

While discussing a potential plan with a client, you must review their prescription drug needs and ensure they understand how the plan impacts both their medical and prescription drug needs.

Specific Health Care Needs & Costs

The cost of health care services keeps increasing, while many Medicare beneficiaries are on a fixed budget. It’s important to ask your client what health care services they regularly use or may use in the future. Do they go to the gym? Do they visit a chiropractor? Visit urgent care when sick instead of a family doctor? Review how much their health care services would cost if they enrolled in a plan and how those costs may affect their budget. Make sure your client understands preventive care, emergency room visits, and urgently needed services.

Do they have any specific health conditions they haven’t already mentioned? Do they use or expect to use alternative medicine or any durable medical equipment? If they answer “yes” to any of these questions, that could affect whether a plan will work the best for them.

Don’t forget: Your client may not know or understand how their deductible, maximum out-of-pocket limit, or copays and coinsurance work. KFF found that only four percent of the public answered 10 questions about basic health insurance terms and concepts correctly. To understand the costs of health care services, it’s vital your client understands these parts of coverage. For copays, be sure to touch on how they differ for in-network versus out-of-network providers, in-patient versus out-patient hospital stays, and specialists versus primary care providers.

Premiums & Cost-Sharing

Are your clients aware that, even though they’re enrolling in a Medicare Advantage plan, they’ll still be responsible for paying their Medicare Part A (if they don’t receive premium-free Part A) and Part B premiums in addition to any premiums their Medicare Advantage and Part D (if applicable) have? Do they know what a premium is? (Hopefully, but you don’t know unless you ask!)

Health care costs can be unpredictable from one month to the next, but your client should never really be surprised by their monthly Medicare premiums or any cost-sharing, especially upon a new enrollment. They are expenses they can budget for. Make sure to cover what premiums and cost-sharing they’ll be responsible for paying, including the specific dollar amounts or percentages. If their plan includes a Part B premium reduction or giveback, make sure they understand what that is and what they can expect back!

Health care costs can be unpredictable from one month to the next, but your client should never really be surprised by their monthly Medicare premiums or any cost-sharing.

Plan Benefits

Medicare Advantage plan benefits can differ from one plan to the next. Your client should understand that they may not have the same benefits as their neighbor Suzy or brother Bill, just because they have a Medicare Advantage or Part D plan. Review the plan’s benefits with your client and ensure that they understand how these benefits, and the costs associated with said benefits, would impact them. Don’t forget to go over any potential limitations of their plan, such as their dental, vision, and hearing coverage.

Effect of a Coverage Change

Explain the potential effect that enrolling in this plan will have on other, current coverage. In some cases, electing new coverage may mean that the individual is disenrolled from other, current coverage (e.g., another MA plan, a Medicare Supplement, etc.). Make sure the beneficiary understands if this will happen and the effects of losing that coverage.

It’s also important to cover the effective date of the new plan and when the beneficiary can expect their other, current coverage to no longer be in effect.

Administrative Items

There are a few additional, more “administrative” items you must always discuss with beneficiaries that aren’t necessarily discussion topics as listed above. For instance, if you’re holding the appointment remotely, you must disclose call recording and state the third-party-marketing organization disclaimer within the first minute. In person or remote, ensure the beneficiary understands that you are not a representative of Medicare or the government.

Ensure the beneficiary understands that you are not a representative of Medicare or the government.

Additionally, it’s good practice to identify the products to be discussed at the start of any appointment. Remember, you can only discuss products documented in the Scope of Appointment. If the beneficiary requests to discuss additional products, you must obtain a new SOA or schedule a new appointment, depending on the additional products they’re interested in.

Other items you should discuss during appointments include the overall star ratings for the plans discussed and where the beneficiary can find them as well as how to file a complaint with Medicare and/or the applicable health plan. You will also need to cover the Evidence of Coverage (EOC) and Pre-Enrollment Checklist (PECL), a standardized piece that aims to help enrollees understand important plan benefits and rules. You may find the PCEL incorporated with the Summary of Benefits as part of the carrier’s enrollment kit.

While CMS requirements can be intimidating, we want to assure you that the requirement to discuss these topics should be a relatively easy one to meet, if you’re the trustworthy and ethical agent we know you are. Each of topics involve factors that will allow you to make the best plan recommendation possible. As long as you’re truly selling with your clients’ best interests at heart, these requirements are just best sales practices put to paper!