What CMS Requires Agents to Review Before a Medicare Enrollment

Before enrolling a beneficiary into a Medicare Advantage (MA) or Part D Prescription Drug Plan (PDP), agents are required by CMS to discuss specific topics to ensure the client fully understands their coverage options and responsibilities.

Below is an overview of the key discussion points agents must cover during every enrollment conversation to remain compliant.

Required Discussion Topics

Agents must review and confirm understanding on the following areas:

  • Medicare Eligibility: Confirm the beneficiary’s eligibility for Medicare and the type of plans available to them.

  • Primary Care Providers & Specialists: Discuss whether their preferred doctors or specialists are included in the plan’s network.

  • Prescription Drug Coverage & Costs: Review how their current medications are covered under the plan and discuss any copays, tiers, or formulary restrictions.

  • Health Care Needs & Costs: Address the client’s expected medical usage and potential out-of-pocket expenses.

  • Premiums & Cost-Sharing: Explain the monthly premium, deductibles, copays, and maximum out-of-pocket limits.

  • Plan Benefits: Review all major plan benefits and any additional services, such as dental, vision, or hearing coverage.

  • Effect of Coverage Changes: Ensure the client understands how enrolling in a new plan could affect their existing Medicare or employer coverage.

  • Administrative Items: Go over enrollment forms, documentation requirements, and next steps for processing.

Stay Fully Compliant

For the complete list of required questions and discussion topics, refer to the CMS 2025 Agent and Broker Training and Testing Guidelines.

To stay current, agents should also review:

Medicare Eligibility

At the start of your discussion, confirm your client’s understanding of Medicare — including the difference between Original Medicare and Medicare Advantage (MA).

Explain that to be eligible for a Medicare Advantage plan, an individual must:

  • Be entitled to Medicare Part A

  • Be enrolled in Medicare Part B

  • Continue to pay their Part B premium

You should also verify that your client is eligible for MA coverage and determine if they qualify for a Special Needs Plan (SNP) such as a Dual-Eligible SNP (D-SNP) or Chronic Condition SNP (C-SNP).

Enrollment and Coverage Timing

Make sure your client understands when they can enroll, disenroll, or change plans, including:

  • The Annual Enrollment Period (AEP)

  • The Open Enrollment Period (OEP)

  • Special Enrollment Periods (SEPs), which may apply if they:

    • Move outside their plan’s service area

    • Qualify for Medicaid or Extra Help

    • Move into or out of an institution, such as a nursing home

Once your client selects a plan, review the effective date of coverage so they know exactly when their benefits will begin.

Additional Topics to Discuss (If Applicable)

  • Income-Related Monthly Adjustment Amount (IRMAA): Explain how higher-income individuals may pay an additional premium for Part B and/or Part D.

  • Late Enrollment Penalties: Review potential penalties for delaying enrollment in Part B or Part D.

  • Public Assistance Programs: Discuss any applicable state or federal programs that may help reduce out-of-pocket costs.

  • Private Fee-for-Service (PFFS) Plans: Clarify that a provider must agree to the plan’s payment terms and conditions before treating the member, except in emergency situations.

  • Special Needs Plan (SNP) Requirements: Explain eligibility criteria and the disenrollment rules if the beneficiary no longer meets SNP qualifications.

 

Primary Care Providers & Specialists

When discussing providers, start by asking your client which primary care doctors and specialists they currently see or would like to see in the future. Then confirm whether those providers, practices, or facilities are included in the plan’s network.

Be sure your client understands the difference between in-network and out-of-network care — and how it affects their coverage and costs.

You might explain it this way:

“You must use plan-approved providers except in emergencies, urgent care situations, or when you’re outside the plan’s service area. If you receive routine care from out-of-network providers, neither Medicare nor the plan will cover those costs.”

If your client is considering a Preferred Provider Organization (PPO) plan, review both in-network and out-of-network costs to help them make an informed choice. You can also demonstrate how to search for network providers using the carrier’s online directory or by contacting member services.

Medicare Prescription Drug Coverage & Costs

For many Medicare beneficiaries, prescription drug costs are one of the biggest concerns when choosing a plan.

When reviewing coverage options, help your clients understand how each plan affects their prescription needs — including whether their current medications are covered on the plan’s formulary and how much they might pay at the pharmacy.

Consider providing a side-by-side cost comparison of their prescriptions under different plans to illustrate potential savings and differences in coverage.

Be sure to explain the Part D coverage stages (including the latest Part D redesign updates) and review how copays or coinsurance can vary depending on the pharmacy network or whether the client uses a preferred pharmacy.

It’s also essential to discuss plan features such as:

  • Step therapy requirements

  • Prior authorization rules

  • Quantity limits for certain drugs

Finally, show clients how to navigate the plan’s pharmacy directory and formulary, so they know how to verify coverage or check new medications in the future. This helps them stay informed and avoid unexpected costs throughout the year.

Specific Health Care Needs & Costs

With health care costs continuing to rise, it’s crucial to help clients on fixed incomes understand how their plan choice will impact their personal health needs and overall budget.

Start by asking your client about the types of health care services they use regularly or anticipate needing in the future. For example:

  • Do they go to the gym or participate in wellness programs?

  • Do they visit a chiropractor or other specialists?

  • When they’re sick, do they usually go to urgent care or their primary care physician?

You’ll also want to review how much these services would cost under different plans and discuss how those costs fit within their monthly or annual budget.

Encourage clients to mention any specific health conditions, use of alternative therapies, or need for durable medical equipment (DME), since these factors can directly affect which plan provides the best coverage for them.

Understanding Coverage and Cost-Sharing

Many beneficiaries are unfamiliar with how deductibles, copays, coinsurance, and maximum out-of-pocket (MOOP) limits work. Take the time to explain each one clearly, using examples if possible.

When discussing copays, point out how they can vary depending on:

  • Whether care is in-network or out-of-network

  • Inpatient vs. outpatient hospital services

  • Specialist vs. primary care visits

By walking clients through these details, you’ll help them better anticipate their potential health care expenses — and choose a plan that fits both their medical needs and financial comfort.

Premiums & Cost-Sharing

When discussing costs, it’s important to confirm your clients understand that enrolling in a Medicare Advantage (MA) plan doesn’t eliminate their responsibility for Medicare premiums.

Even with an MA plan, beneficiaries must continue paying:

  • Their Medicare Part A premium (if not eligible for premium-free Part A)

  • Their Medicare Part B premium

  • Plus, any additional premium associated with their Medicare Advantage or Part D plan (if applicable)

Don’t assume they already know what a plan premium is — ask and clarify to ensure they fully understand.

Health care expenses can vary month to month, but premiums and cost-sharing should never come as a surprise. These are predictable costs your clients can plan and budget for.

What to Review

Be sure to clearly explain:

  • The specific premium amounts for each part of their coverage

  • Any copays or coinsurance they’ll be responsible for

  • The plan’s deductible and maximum out-of-pocket limit (MOOP)

If their plan includes a Part B premium reduction or “giveback”, take time to explain how it works and what they can expect in terms of reduced costs or reimbursements.

Helping clients understand these expenses upfront ensures they’re financially prepared and confident in their coverage decisions.

Plan Benefits

Medicare Advantage (MA) benefits can vary greatly from one plan to another. It’s important for clients to understand that just because their friend or family member has a Medicare plan doesn’t mean their benefits or costs will be the same.

Take time to review the plan’s benefits in detail with your client, explaining how each one — and its associated costs — will impact their specific needs and situation.

Be sure to highlight any limitations or exclusions, especially when discussing supplemental benefits like dental, vision, and hearing coverage. Clear communication here helps prevent confusion later and ensures your client knows exactly what their plan does — and doesn’t — include.

Effect of a Medicare Coverage Change

Before completing an enrollment, make sure your client understands how choosing a new Medicare plan may impact their existing coverage.

In some cases, enrolling in a new plan will automatically disenroll them from their current coverage — such as another Medicare Advantage plan, a Medicare Supplement (Medigap) policy, or a standalone Part D plan.

Clearly explain what this means and review the potential consequences of losing that prior coverage so there are no surprises later.

Also, confirm that your client knows the effective date of their new plan and when their previous coverage will end. Setting the right expectations helps ensure a smooth transition and prevents any gaps in coverage.

Administrative Items

In addition to the major discussion topics, there are several administrative requirements that agents must always review with beneficiaries before and during Medicare appointments. These ensure both transparency and compliance with CMS regulations.

Required Disclosures and Introductions

If you’re conducting the appointment remotely, you must:

  • Disclose that the call is being recorded, and

  • State the required Third-Party Marketing Organization (TPMO) disclaimer within the first minute of the conversation.

Whether meeting in person or virtually, always clarify that you are not a representative of Medicare or the federal government, but an independent licensed insurance agent authorized to help them review available plan options.

At the start of the appointment, identify the specific products you’ll be discussing. These must align with what’s documented in the Scope of Appointment (SOA).

Scope of Appointment (SOA) Requirements

You may only discuss products listed on the SOA, which should be obtained at least 48 hours prior to the appointment.
Exceptions include:

  • When the beneficiary is four days or fewer from the end of a valid enrollment period (e.g., AEP, OEP, SEP, or ICEP)

  • When the beneficiary initiates an unscheduled, in-person meeting

If the client asks to discuss additional products not covered by the current SOA, you must either complete a new SOA or schedule a separate appointment to cover those topics.

Note: CMS prohibits discussing non-health-related products — such as annuities or life insurance — during a Medicare sales appointment. Those must be addressed in a separate, non-Medicare meeting.

Other Important Items to Cover

During your appointment, you should also:

  • Review the plan’s overall Star Rating and explain where the beneficiary can find more information about it.

  • Explain how to file a complaint with Medicare or their health plan, should the need arise.

  • Review the Evidence of Coverage (EOC) and Pre-Enrollment Checklist (PECL) — both essential resources that help clients understand plan benefits, costs, and rules.

The PECL (often included in the plan’s Summary of Benefits) serves as a CMS-standardized tool to confirm that all required topics have been discussed. Agents can also reference it directly within the Medicare Communications and Marketing Guidelines (MCMG) for compliance verification.

Final Thoughts

While Medicare Advantage compliance rules can seem complex, these requirements are simply best practices formalized by CMS.

Discussing each topic thoroughly ensures your clients understand their choices, helps you make the most suitable plan recommendations, and reinforces your reputation as a trustworthy, ethical agent — the foundation of lasting success in this industry.

Not affiliated with or endorsed by Medicare or any government agency.

 

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