Your Medicare Book Before AEP: Who to Call First, and Why
Plan exits and their deadlines first, then dropped drugs and higher drug costs, then cost and benefit increases past your line. How to rank your Medicare clients before October 15.
Short answer: before Medicare's Open Enrollment Period opens on October 15, sort your Medicare clients by what next year's plan does to them. Call the clients whose plan is ending or leaving their county first, because their options come with deadlines. Next, call the clients who lose a drug they take or whose drugs will cost noticeably more. After them come the clients whose premium, copays or benefits get worse by more than you would accept, then the clients whose plan's star rating drops below your floor. Everyone else gets a routine review, in the order their enrollment anniversaries come up. Why the order matters Every Medicare Advantage and Part D plan sends its members an Annual Notice of Change (ANOC) describing what changes on January 1, and the member should have it by September 30 . Open Enrollment runs from October 15 to December 7 , and a change made then takes effect January 1. That's seven or eight weeks. Most clients need a quick check that their plan still fits. A few need a real conversation, and some of those have deadlines. The work is finding those few before you spend October on everyone else. 1. Plan exits: the calls with deadlines A plan exit means the client's plan is not offered next year, or it no longer serves the client's county. Either way the client has to choose something new. Special enrollment period. When a Medicare Advantage plan's contract isn't renewed, the client can switch plans between December 8 and the last day of February . A client who doesn't join another plan before the old one ends is enrolled in Original Medicare. Medigap guaranteed issue. A Medicare Advantage client whose plan is leaving Medicare or stops giving care in their area may have a guaranteed-issue right to buy a Medigap policy . The right applies only if they go back to Original Medicare. They can apply as early as 60 days before the coverage ends and no later than 63 days after. A plan that renews under a different plan number is not an exit. Check what the new plan changes and treat it like any other renewal. 2. Drugs: dropped, restricted, or more expensive For each client, check every medication they take against next year's drug list. Is it still covered? Did it move to a higher tier? Does it now need prior authorization or step therapy? Then put a dollar figure on it. A drug moving from a flat copay to coinsurance can cost a client hundreds of dollars more over the year, even when nothing is "dropped". Run a month's fill of each drug through next year's deductible, the plan's copays or coinsurance, and the Part D out-of-pocket cap, and compare it with this year. This check is only as good as the medication list you keep for the client, so this is the season to update it. 3. Cost and benefit increases past your line Compare this year's plan with next year's: Costs: monthly premium, in-network maximum out-of-pocket (MOOP), Part D deductible. Copays: primary care, specialist, emergency room, urgent care, outpatient surgery, a hospital stay. Extras clients notice: the dental maximum, eyewear and hearing aid allowances, the OTC allowance, the Part B giveback. Not every increase is worth a call. Decide your thresholds before you start, for example a premium increase of more than $10 a month, and hold every client to the same line. 4. Star ratings A plan whose star rating falls below your floor is worth a look even when nothing else changed. Check next year's rating once CMS publishes it. 5. Everyone else, by anniversary Clients with nothing over your thresholds still get a review, just not first. Working them in the order their enrollment anniversaries come up spreads the calls across the season. Know the alternatives before you call When a client's plan gets worse, the next question is what else is out there. Look at next year's plans in the client's county. Put the plans that cover every drug they take first, and compare yearly premium plus drug costs, not premium alone. Confirm the client's doctors with the carrier, because CMS doesn't publish provider networks, and have a signed Scope of Appointment before you discuss any plan. How AgencyView does this AEP Review is under Client Management in AgencyView from October 1 to December 31. It compares every active Medicare policy in your CRM with CMS's public plan files for next year and ranks the book in the order above. Plan exits show the special enrollment period and, for Medicare Advantage clients, the Medigap guaranteed-issue dates. The ANOC is compared line by line: premium, MOOP, drug deductible, star rating, copays and extras, this year against next. Drugs on file are checked against next year's formulary. Estimated drug costs show what the client's drugs cost this year and on next year's plan, priced at Medicare's national average cost of a 30-day fill or its negotiated price. It's an estimate, not a quote, and the page says so. Next year's plans in the client's county are ranked by yearly premium plus estimated drug costs, with the plans that cover every drug first. An Appointed badge marks the carriers the client's agent is appointed with in that state. Thresholds are set by each agency. The defaults are $10 a month on premium, $500 a year on MOOP, $100 on the drug deductible, $10 on copays, $300 a year on estimated drug costs, and 3 stars. Every client whose plan ends or gets worse also gets a Contact Alert on their record, and it clears when the review is marked done. Drug checks and drug cost estimates start once CMS posts next year's formulary files. The AI in this feature, used for matching plan names and recommending thresholds, sees public CMS data, plan names and counts. It never sees a client's name or medications. The screenshots show an illustrative sample: the plans, carriers and clients are fictional.
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