When selling Medicare Advantage or Part D plans, agents are required to cover certain key topics with beneficiaries to ensure compliance with CMS guidelines. To help you stay on track, we’ve outlined the essentials here!
Before enrolling a client in a Medicare Advantage or Part D prescription drug plan, agents must discuss several CMS-mandated topics, including:
- Medicare eligibility
- Primary care providers and specialists
- Prescription drug costs and coverage
- Specific health care needs and associated costs
- Premiums and cost-sharing details
- Plan benefits
- The impact of switching Medicare coverage
- Administrative considerations
Below, we’ll provide a summary of these discussion points. For a full breakdown of all required topics and questions, refer to CMS’ 2025 Agent and Broker Training and Testing Guidelines. To dive deeper into the 2025 compliance rules, check out CMS’ 2025 Final Rule fact sheet and the complete 2025 Medicare Advantage & Part D Final Rule in the Federal Register. Additionally, feel free to download our all-inclusive MA & PDP Compliant Sales Checklist!
Medicare Eligibility
At the beginning of your conversation, it’s important to ensure your client has a basic understanding of their Medicare options, including both Original Medicare and Medicare Advantage. Explain that to be eligible for Medicare Advantage plans, individuals must be entitled to Medicare Part A, enrolled in Medicare Part B, and continue paying the Part B premium. Confirm their eligibility for Medicare Advantage, and check whether they might qualify for a special needs plan, such as a Dual-Eligible Special Needs Plan (D-SNP) or a Chronic Condition Special Needs Plan (C-SNP).
Make sure your client understands the key enrollment periods when they can sign up for, change, or disenroll from Medicare plans. For example, highlight special enrollment periods that apply when they move out of their plan’s service area, qualify for Medicaid or Extra Help, or move into an institution like a nursing home. Once they choose to enroll in a plan, review the effective date of their coverage with them.
Additionally, if applicable, discuss the following:
- The income-related monthly adjustment amount (IRMAA) for Part B and Part D.
- Part B and Part D late enrollment penalties, if relevant.
- Public assistance programs that may be available.
- Rules around Medicare Medical Savings Account (MSA) plans, including high deductibles, lack of drug coverage, eligibility, enrollment periods, and cancellation terms.
- Private Fee-for-Service (PFFS) plan rules, noting that doctors and hospitals can choose not to treat patients under these plans, except in emergencies, if they don’t accept the plan’s payment terms and conditions.
- Special Needs Plans (SNPs) and their specific eligibility requirements, including disenrollment rules for members who no longer meet the criteria.
Primary Care Providers & Specialists
When discussing healthcare providers, start by asking your client which primary care doctors and specialists they currently see or plan to see in the future. Then, confirm whether those providers, clinics, or facilities are included in the plan’s network.
It’s also essential to make sure your client understands the difference between in-network and out-of-network providers, along with the associated costs and coverage. You might explain it like this: “You’re required to use providers within the plan’s network, except in cases of emergency, urgent care, or when you’re out of the service area. If you receive routine care from out-of-network providers, neither Medicare nor the plan will cover the costs.”
For clients interested in a preferred provider organization (PPO) plan, be sure to go over both in-network and out-of-network costs. Additionally, show them how to look up providers within the plan’s network, or guide them through the process of doing so.
Medicare Prescription Drug Coverage & Costs
Many Medicare beneficiaries face challenges with the high cost of prescription drugs. When reviewing prescription drug coverage with your client, it’s important to discuss their specific prescription needs and how the plan will address both their medical and medication requirements. Be sure to check if their current medications are covered by the plan’s formulary. Additionally, provide a cost comparison of prescription drug coverage across different plans.
Explain the different Part D coverage stages, including any recent updates to the Part D redesign. Clarify how copays or coinsurance will apply to their preferred pharmacy, and highlight the benefits of using preferred pharmacists.
Ensure your client understands key concepts such as how to navigate the pharmacy directory, the processes of step therapy, prior authorization, and quantity limits. To help them plan for future prescription needs, guide them on how to verify if and how their medications are covered through the formulary.
Throughout the conversation, it’s essential to regularly review your client’s prescription drug requirements and make sure they understand how the selected plan impacts both their medical and prescription drug needs.
Specific Health Care Needs & Costs
As healthcare costs continue to rise, many Medicare beneficiaries are managing their expenses on a fixed income. It’s essential to ask your client about the healthcare services they currently use or may need in the future. Do they have a gym membership? Do they regularly see a chiropractor? Or do they prefer visiting urgent care over their family doctor when they’re sick?
Review how these services would impact their costs under a new plan and help them assess how these expenses fit into their budget. Ensure they understand key services such as preventive care, emergency room visits, and urgent care.
Also, ask if there are any specific health conditions they haven’t mentioned yet. Are they using, or planning to use, alternative medicine or durable medical equipment? Their answers to these questions could influence whether a particular plan is the best fit for them.
Remember, many clients might not fully understand important insurance concepts like deductibles, out-of-pocket maximums, copays, or coinsurance. In fact, a study by KFF revealed that only 4% of the public correctly answered 10 questions about basic health insurance terms.
To help your client grasp the costs of healthcare services, make sure they clearly understand these aspects of their coverage. When discussing copays, explain how costs can vary depending on whether they’re seeing an in-network or out-of-network provider, whether the hospital stay is inpatient or outpatient, and the difference in costs between seeing a specialist versus a primary care provider.
Premiums & Cost-Sharing
It’s important to ensure your clients understand that even when they enroll in a Medicare Advantage plan, they are still responsible for paying their Medicare Part A premium (if they don’t qualify for premium-free Part A) and their Medicare Part B premium, along with any premiums associated with their Medicare Advantage and Part D (if applicable). Don’t assume they know what a plan premium is—it’s always a good idea to ask!
While healthcare costs can fluctuate from month to month, your client should never be caught off guard by their monthly Medicare premiums or cost-sharing obligations, especially when enrolling in a new plan. These are expenses they can plan for. Make sure to go over all the premiums and cost-sharing amounts they’ll be responsible for, including specific dollar figures or percentages.
If their plan offers a Part B premium reduction or giveback, explain how that works and what they can expect to receive.
Although healthcare costs may vary, your client should always have a clear understanding of their monthly premiums and cost-sharing responsibilities.
Plan Benefits
Medicare Advantage plan benefits can vary widely from one plan to another. It’s important that your client understands that just because their neighbor or a family member has a Medicare Advantage or Part D plan, it doesn’t mean they have the same benefits. Be sure to review the specific benefits of their chosen plan and explain how these benefits, along with the associated costs, will affect them personally.
Also, make sure to discuss any potential limitations within the plan, especially regarding extras like dental, vision, and hearing coverage. This will help your client have a clear understanding of what they can expect from their plan and avoid any surprises.
Impact of Changing Medicare Coverage
Make sure your client understands the potential impact of enrolling in a new plan on any existing coverage. In some cases, choosing new coverage can result in automatic disenrollment from other plans, such as another Medicare Advantage plan or a Medicare Supplement policy. It’s crucial that the beneficiary knows if this will happen and what the consequences of losing that prior coverage might be.
Additionally, review the effective date of the new plan and clearly explain when their current coverage will end. This will help avoid any gaps in coverage and ensure they are fully informed about the transition.
Administrative Considerations
There are a few important administrative details that must always be covered with beneficiaries, even though they aren’t typical discussion points like those listed earlier. For instance, if your appointment is being held remotely, you’re required to disclose that the call is being recorded and state the third-party marketing organization disclaimer within the first minute. Whether the meeting is in-person or remote, it’s essential to clarify that you are not a representative of Medicare or the government.
Additionally, it’s good practice to start every appointment by identifying the specific products that will be discussed. Keep in mind, you can only talk about products listed in the Scope of Appointment (SOA), which must be obtained 48 hours before the meeting (with exceptions for beneficiaries who are four days or less from the end of a valid enrollment period or in beneficiary-initiated unscheduled meetings).
If the beneficiary expresses interest in discussing other products not included in the original SOA, you’ll need to either collect a new SOA or schedule a separate appointment, depending on the products in question.
It’s important to remember CMS regulations on Medicare Advantage enrollments regarding SOAs. You are not permitted to discuss certain products, such as annuities or life insurance, during a Medicare sales appointment. These should be addressed in separate meetings.
Other key items to cover during your appointment include the overall star ratings for the plans discussed and where the beneficiary can find them. Also, explain how they can file a complaint with Medicare or their health plan.
You’ll also need to go over the Evidence of Coverage (EOC) and the Medicare Pre-Enrollment Checklist (PECL). The PECL is a standardized document that helps enrollees understand important plan benefits and rules, and it’s often included with the Summary of Benefits in the plan’s enrollment kit.
While meeting CMS requirements when selling Medicare Advantage may seem daunting, these conversations should feel natural if you’re the trustworthy and ethical agent we know you are. These required topics are designed to help you make the best plan recommendation possible. When you put your clients’ best interests first, these requirements simply reflect good sales practices!
Note: This content has been updated to include information for the 2025 AEP.
Not affiliated with or endorsed by Medicare or any government agency.
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