As AEP gets into full swing you are preparing to assist an influx of clients and new prospects who are trying to understand their plan changes for 2025. No matter how busy you are, you must take the time to stay compliant with all of CMS’s rules and regulations, including the pre-enrollment checklist (PECL).
The checklist covers a list of topics that you are required to discuss before enrolling a customer into a Medicare Advantage or Part D plan. You may find the PECL in the carrier’s enrollment platform or as part of the plan Summary of Benefits. Using the checklist benefits you and can also help optimize your customers experience.
How you benefit:
- You make certain that you have asked all the necessary questions and provided all of the required information.
- It gives you a roadmap to follow for finding the best plan for that individual based on their needs.
- The checklist allows you to stay focused and be more efficient.
- You stay compliant with CMS regulations.
How your customers benefit:
- Medicare can be confusing and the PECL simplifies the process and creates a sense of order that makes it easier for your clients to understand the information you are giving them.
- They are being educated on their options and feel involved in the process.
- It provides a thorough review of benefits and costs and confirms their understanding so they will have no surprises when it comes to their Medicare coverage.
In preparation for your discussion, ask your clients to bring their Medicare red, white, and blue card, a list of their doctors, specialists, and preferred hospitals, as well as a list of medications and dosages. This will help expedite your information gathering and help determine the best plan to fit their needs.
The PECL should cover the following topics:
Confirm Medicare Eligibility
Confirm Medicare Part A and B eligibility and the effective dates.
Review Premiums and Cost Sharing
Before doing an in depth benefit and cost review, make sure your client understands what premiums, deductibles, copays, and coinsurance are. They should understand that they will pay a monthly premium for their Medicare Advantage plan, as well as their monthly Part B premium.
Review Doctors, Specialist and Hospitals
You must check to see that all of their healthcare providers are in the plan’s network. You must explain out of network coverage and whether the plan they are considering offers that. If so, you must clarify how the out of pocket costs vary.
If the plan includes dental, hearing or vision coverage, you must confirm if there is a special network for these benefits and determine if your client’s providers are in these networks.
Review Medications
Check your client’s medications to make sure they are on the plan’s formulary. Provide any deductible, copay or coinsurance based on the drug’s tier. Explain any special requirements such as prior authorizations, step edits, quantity limits or mail order. Check to see that their preferred pharmacy is in the plan’s network. Be sure to cover the 2025 $2,000 out of pocket maximum and the availability of the Prescription Payment Plan.
Verify Specific Healthcare Needs and Costs
Ask your client if there are any chronic health conditions they are being treated for or any healthcare services they receive on a regular basis. Ask if there will be any new treatments, medications or surgeries planned for the coming year. Cover in detail what these services will cost based on the plan’s benefits.
Plan Benefits
Do a thorough review of all benefits and costs including emergency room, urgent care, preventive services and any wellness and ancillary benefits. Include any plan limitations or anything that is not covered. Make sure your client understands how this may differ from the plan they currently have.
Effect of a Coverage Change
You must let your client know the effective date of their new coverage and what will happen to their current coverage. In most cases they will be automatically disenrolled from their current plan, but if they have a Medigap plan they may need to cancel it. Make sure they understand that they may not be able to get that policy, or any Medigap policy back.
Follow Up and Administrative Tasks
Confirm all topics on the PECL have been covered. Make sure you have answered all your client’s questions. Let them know when to expect their new ID card and carrier welcome kit.
As a last step before wrapping up, remind your customers that you are here to help them year round with any questions or concerns that may arise. Confirm all enrollment tasks have been completed including the application. Document everything in your CRM tool.
Using the PECL may seem like extra work, but in reality, it can help keep you organized and on track this AEP. If you have questions the team at PTT Financial is here to support, you every step of the way. Contact us today.
