Four essential topics to cover during your AEP appointments

I’ve gotten a number of calls this week from agents asking “Where do I start?” They’re wondering what’s the best way to compare beneficiaries’ choices for Medicare coverage during this busiest time of the year, the Annual Enrollment Period.

Do a simple needs analysis to figure out what your client’s greatest health needs are, then start a conversation that hits on these four topics: Doctor network (HMO, HMO-POS, PPO, etc.); maximum out of pocket cost (MOOP); prescription formulary and cost sharing. Of course, let your client lead the discussion.

Let’s break down this list some more to get an idea of what information you can give to your client to help them make the best decision.

With so many carrier acquisitions and health company mergers, doctor networks tend to be seniors’ No. 1 concern (“Is my doctor in my network?”). Most of my clients are very comfortable with their doctors, having been their patient for years. They’re typically not willing to give up their favorite PCP or specialist. However, I’ve noticed that some seniors are willing to give up their doctor in order to keep a nearby hospital in their network. Help your client make sure their preferred providers and hospitals are going to be accessible to them after their new plan goes into effect.

If your client has had a tough year financially or healthwise, are they going to be able to afford a plan’s maximum out of pocket cost? Most clients don’t seem to make MOOP a priority, but it has been my experience that agents need to stress how much their clients could have to pay out of pocket if something catastrophic happened during the new plan year —something like a stroke or a cancer diagnosis. Any of my clients who have hit their MOOP have always done so with a combination of issues, whether it be a stroke, an ambulance ride and PT or speech therapy to help them recover. I’ve had a few clients who have been diagnosed with cancer and held responsible for 20 percent of their chemo treatments.

Are their prescriptions covered in the plan formulary? Check each formulary and confirm your clients’ drugs are covered. If they’re not listed, explain how to get them covered or changed. For 2016 many plans are including a deductible on non-generic tiers, or their cost sharing is being raised. No, generics will not be spared either. If your clients change to a different plan this AEP, make sure they know what their prescriptions will cost. Getting a call the from your client asking why they now have a $5 co-pay on their tier 1 prescriptions when it cost them nothing last year is not a fun way to start the new year off right.

When discussing premiums and cost sharing with clients, the rule to keep in mind is “the larger the network, the more it will cost.” Some clients like the all-in-one delivery model that some HMOs are starting to transition into. Some will only sign up with a PPO to give them more control over who they can see. If a client is balking at the cost of a specialist visit, remind them that they will pay more for a larger network. If they have something more serious like cancer to attend to, the extra $10 to $15 it will cost for a specialist is nothing compared to the value of their health. If you know your client is going to have a hip or knee replaced, physical or occupational therapy may be high on their list too. At that time a $15 difference in co-payments could have a huge impact on whether they receive all of the therapy they require to recover fully.

Every client is different, and some may have certain preferences they can’t live without when shopping for a Medicare plan. Your needs analysis may lead you to a Medicare Supplement if they can afford it. In that case, you may want to call me at (800) 997 3107 or email me with the question, “Can they pass underwriting?”

It’s my pleasure to help agents get up to speed on what you should be asking your clients to best serve them and secure their loyal business.

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