Since September 2023, CMS has required Medicare agents who sell Medicare Advantage and Part D plans to discuss specific topics with beneficiaries prior to enrollment. This list of topics is known as the pre-enrollment checklist (PECL). This requirement protects Medicare beneficiaries by ensuring they receive complete and accurate information about their Medicare coverage. It also provides agents with the information they need to make the best plan recommendations for their clients.
You will find the PECL included with carriers’ Summary of Benefits or built into carriers’ enrollment platforms.
For all carriers, the specific CMS topics required on every PECL are as follows:
Medicare Eligibility
Confirm your clients’ eligibility for Part A and Part B and the effective dates. Ask them to bring a copy of their Medicare card and a photo ID to their appointment with you. If you have a meeting with someone who is enrolling another person, ask for a copy of the Power of Attorney that provides this person with the applicable legal authority.
Primary Care Provider and Specialists
Ask your clients to bring a list of their doctors (including their PCPs and specialists) as well as any facilities or hospitals they prefer to use. This will allow you to verify that these healthcare providers and facilities are in a particular plan’s network. Make sure clients understand what in and out of network means and how the coverage and costs vary.
If a plan includes dental, hearing, and/or vision coverage, confirm it has a special network for these providers and check if your client’s doctors are in those networks.
Prescription Drug Coverage and Costs
Ask your clients to bring a list of their medications and dosages to the appointment. This will enable you to provide a detailed breakdown of pharmacy coverage and costs. Confirm the medications are covered on the plan’s formulary and check which tier they fall under. Review any specific requirements for medications, such as prior authorizations, step edits, quantity limits, or mail order requirements. Confirm your clients’ preferred pharmacies are in the plans’ pharmacy networks. Discuss any out-of-pocket costs, including premiums, deductibles, copays, and coinsurance.
Educate your clients on the prescription drug changes for 2025, including the $2,000 out-of-pocket maximum and the new Medicare Prescription Payment Plan, which allows beneficiaries to break up their RX costs over the year in monthly payments.
Specific Health Care Costs and Needs
Discuss any specific health care needs your clients have. Do they have chronic health conditions for which they receive ongoing treatment? Do they go to physical therapy or use DME supplies regularly? Are dental, vision, or hearing benefits important to them? Discussing this will ensure you don’t overlook any benefits or services that may be significant for choosing the right coverage. You will need to review the costs of these services and consider how they vary between plans.
Premiums and Cost-Sharing
Ensure your clients understand all the different components of their out-of-pocket costs. Make sure they understand they will be paying their Part A (if they don’t receive premium-free Part A) and Part B monthly premiums in addition to the plan’s monthly premium. Explain when deductibles, copays, and coinsurances apply. Educate clients on the difference between in-network benefits and out-of-network benefits, including the difference in cost. Explain how the annual out-of-pocket maximum works.
Review your clients’ current plans and their current out-of-pocket expenses. Compare these costs to any new plans you are recommending. This is a good time to ask your clients if they find their current coverage affordable. This will provide insights into what types of plans may be a good fit for your clients’ budgets.
Current Plan Benefits
Review your clients’ current plans and benefits. Compare these benefits to any new plans they are enrolling in. Ask them how their current coverage is working for them. Are there benefits they don’t have that they wish they did? Are they paying for benefits they don’t use or need?
Effects of a Coverage Change
Ensure your clients understand all the changes that will occur when they enroll in a new plan. This requires a detailed review of the new plans’ costs and benefits. Explain what happens to their current coverage as a result of enrolling in a new plan. If they have another MA plan or Supplement plan, they will be disenrolled from that coverage. Provide the effective date of the new coverage and the date their current coverage will end. Make sure they fully understand all the impacts of changing plans.
Administrative Tasks
Make sure you remain fully compliant during your appointment. If you are not meeting in person, you must disclose call recordings and use the TPMO disclaimer. You should only discuss products documented in the SOA. Make sure you cover all the topics on the PECL and confirm that you have completed all enrollment tasks, including the application.
Next Steps
Before you wrap up your appointment, let your clients know what to expect next. Let them know when they will receive the carrier welcome kit and their new ID cards. Explain how they should use any rewards or OTC benefits. Include plan contact information for Member Services, Grievance and Appeals, and Prior Authorizations. Remind clients that you are there to assist if any issues arise or if their circumstances change.
Do you have questions about the PECL? The dedicated team at Western Asset Protection is committed to your success. Contact us today.