Medicare open enrollment period: 10-steps for guiding your clients

The Medicare annual enrollment period – also called AEP or the fall Medicare open enrollment period – can be a time of optimism and opportunity, as beneficiaries are presented with the chance to make improvements to their benefits. Medicare open enrollment lasts from October 15 to December 7 each year.

But this 54-day period every fall can also cause a great deal of confusion, as many older adults find themselves lost in a sea of options, applications and deadlines.

As an advisor, it’s your job to guide your client through the Medicare maze. I liken it to running a race alongside your client versus simply pointing them in the direction of the finish line.

Here’s my 10-step process for guiding clients through potential confusion around the Medicare AEP. You might put your own personal touch on it, but these core principles serve as a general guide most agents can follow.

1. Ask about their current coverage and what’s missing.

Advisors can be too quick to start talking about the latest and greatest plans without first getting an idea of their client’s current benefits and the things they’re looking to improve upon. I begin every initial conversation with a new client by asking about their current plan along with their likes and dislikes.

How does their current plan fit into their budget/? Are there benefit areas where they wish they had stronger coverage? Are they able to see their favorite doctors at the most convenient locations?

These are just some of the questions to ask before launching into the plan options for the upcoming year.

2. Determine which type of plan is best suited to their needs.

There are three basic types of private Medicare insurance, and it’s important to give a fundamental breakdown of each one and the role it plays. Clients often don’t have a firm grasp of the difference between Medicare Advantage, Medicare Part D and Medicare Supplement insurance, so it’s your job to educate and help them determine which coverage combination best addresses their needs.

This is also a good time to confirm your client’s eligibility. Medicare has a lot of eligibility rules for its various plans, and just because someone is a Medicare beneficiary doesn’t guarantee they will be eligible for a particular Medicare Advantage, Medicare Part D or Medigap plan.

It’s not enough to simply ask your client if they’re eligible and take their word for it, because there’s a good chance they don’t know. Go over each eligibility criteria for the type of plan they are interested in and make sure every box is checked.

3.  Gather the options.

Once you know the types of Medicare plans that may suit your client’s needs, it’s finally time to gather the options.

In 2021, the average Medicare beneficiary had access to 33 different Medicare Advantage plans, which is the highest number of options per beneficiary in at least a decade. But collecting all your client’s plan options is just the beginning. In steps four through nine, you’ll gradually whittle those down to just a select few.

4. HMO or PPO?

If a Medicare Advantage plan is the right choice for your client, you’ll want to help them carefully consider the type of plan structure that will work for them. Most 2022 Medicare Advantage plans are HMO or PPO plans.

An HMO plan member can benefit from a managed care approach, and they’ll typically need to see an in-network doctor, provider or facility for any services to be covered. PPO plan members, however, may have the flexibility to visit out-of-network providers for care, though they may pay higher out-of-pocket costs than they would if they saw an in-network provider.

If network restrictions are a concern for your client, they may want to consider a Medicare Supplement (Medigap) plan, as Medicare Supplement plans don’t have network restrictions and are accepted by any doctor, hospital, facility or provider who accepts Medicare.

5. Do they prefer lower premiums or lower copays and deductibles?

Some plans offer a higher monthly premium in exchange for a lower or $0 deductible, copayments or coinsurance. These plans allow members to better predict their annual health care spending and can make for easier budgeting.

Other plans offer a lower monthly premium combined with higher deductibles, copays or coinsurance amounts. These plans allow a member to limit their upfront costs and can equate to a great deal of annual savings when health care isn’t heavily utilized. However, this type of approach can lead to higher and less predictable out-of-pocket spending when costly care is needed.

Don’t forget to consider annual out-of-pocket spending limits. All Medicare Advantage plans come with an annual out-of-pocket spending limit, while most Medicare Supplement plans do not (Medigap Plan K and Plan L are the two Medigap plans with out-of-pocket spending limits).

It all comes down to personal preference, and you should be able to help your client eliminate several plans based on the above criteria.

6. What’s their provider preference?

Some people have great rapport with their primary care doctor and wish to continue seeing them. Others may have a specialist they really like. And many people have at least one convenient pharmacy or clinic near where they live.

Ask your client about their favorite health care providers and locations, and find out how important it is that those options are part of a plan network of preferred or accepted providers. A sizeable chunk of plans may be eliminated simply because they aren’t accepted by the client’s favorite providers.

7. Do they have any specific conditions?

Some Medicare Advantage plans offer better coverage in certain areas than others. And some Medicare Advantage plans (called special needs plans) are even tailored specifically to a particular health condition like diabetes or kidney disease.

While you may be somewhat limited in the questions you’re allowed to ask your client, mentioning that some plans focus their benefits on certain conditions may open a few doors. If they have a specific health condition that impacts the level of health care they need through the year, there may be a plan designed to better fit their needs than a general HMO or PPO plan.

8. Don’t forget prescription drug coverage.

It’s not uncommon for clients to skip on prescription drug coverage because they aren’t currently taking any medications. But I always remind them that just because they may not be taking any prescriptions today doesn’t mean they won’t be tomorrow.

If they enroll in a Medicare prescription drug plan during AEP, your client may run the risk of paying out-of-pocket for any medications they end up needing over the course of a full year. Given the high cost of prescription drugs without insurance, that’s likely not a risk they want to take.

This is also a good time to remind your client of the Part D late enrollment penalty. One recent survey found that 80% of Medicare beneficiaries were unaware of this permanent financial penalty. If your client goes 63 or more days in a row without Medicare drug coverage (and if they don’t have other “creditable” drug coverage that covers their prescription costs at least as well as a standard Part D plan) and then eventually sign up for Part D coverage, they will have to pay the Part D late enrollment penalty for as long as they remain enrolled in a Medicare drug plan.

If your client is currently taking a prescription, you’ll want to confirm how the drug is covered and how much it costs with any plan being considered.

9. Don’t ignore quality.

The next thing I like to look at is quality. Medicare rates all Medicare Advantage and Medicare Part D plans every year using a five-star rating system. This point in the process is a good time to eliminate any low-performing plans (typically rated 2 stars or lower by Medicare).

10. Guide their decision.

By now, you should have just a few plans from which to choose. It might feel like splitting hairs at this point, but this is where you really display your value. Some of the final deciding factors I like to weigh include:

• Extra supplemental benefits, which might include things like non-emergency transportation costs, gym and wellness program memberships, home meal delivery and more
• Customer experience (online member portals, mobile apps)
• Company reputation and credit ratings

It’s OK to let your client sleep on their decision. After all, you’ve just thrown a lot of information at them. But be sure to schedule a follow-up call and remind your client of their enrollment deadline and of the late enrollment penalties that can ensue.

Use this 10-step process as a template for guiding your clients through AEP so you can both cross that finish line together.

Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options. His work has been featured in outlets such as Vox, MSN and The Washington Post, and he is a frequent contributor to health care and finance blogs.