Five questions to ask every Medicare client before AEP

The last few  AEPs have been anything but normal. With a larger-than-expected payment increase that still doesn’t match medical trends, we’re expecting more plan disruption this year.

On top of that, Marketplace OEP will be definitively shortened to take place between November 1 and December 15. For those of you doing the mental math, we’ll help you out: That’s a really significant overlap with AEP.

If you’re managing a mixed book of business, you need a way to make the most of the limited time you’ll have to get everyone in the just-right plan next fall.

That work starts with client outreach in June – far enough from fall that nothing feels rushed, but close enough to know that what you learn is still current when enrollment season hits.

Sure, you won’t be able to make plan recommendations yet. But you can update health histories, refresh medication lists, and surface the changes in your clients’ lives that will drive conversations during enrollment season. That’s not a shortcut. It’s good service that strengthens your business relationships.

Plan to have these conversations before July. A Medicaid status change, a specialty drug situation, a spouse turning 65 — they all take a bit of effort to address. The more lead time you have, the more you can help.

Here’s how to do it in five questions.

The five questions

To be clear, you’re not conducting an interview. You’re starting a conversation. Each question is designed to be open-ended enough to keep your client talking about the things that matter most.

1. “Has anything changed with your health since we last talked?”

Start here, and then be quiet. Most clients will keep going if you don’t interrupt — bringing up new diagnoses, recent hospitalizations, upcoming procedures, new specialists, and health concerns they’ve been sitting on.

Even those things that turn out to be nothing matter. If your client brings it up, they’re still thinking about it. And that opens the door to a deep conversation — about their plan, and potentially about coverage gaps they haven’t considered.

Listen for: new diagnoses, hospitalizations or ER visits, planned procedures, new specialist referrals, and health concerns they’re monitoring.

2. “Are you still seeing the same doctors — and are you happy with how that’s working?”

You know that network always matters. Changes in who your client is seeing, or whether the provider is still in network, are one of the biggest reasons a plan stops making sense. This question starts that conversation without making it feel like a form.
The second half matters more than the first. A client who tells you their PCP retired, and they haven’t found a new one, is telling you something important about their network experience you won’t find elsewhere. And, it gives you another angle to learn more about changes in health conditions that may qualify your client for a C-SNP – a new nephrologist is a darn good sign that a plan targeting ESRD is in play.

Listen for: new primary care physician, added specialists, difficulty getting appointments, dissatisfaction with access or responsiveness.

3. “Have there been any changes in your medications — anything new, anything stopped, anything that’s gotten expensive?”

New prescriptions, discontinued prescriptions, and dosage changes can all affect out-of-pocket costs. Every plan tiers its drugs differently, and knowing about these changes up front could tip you off that it’s time for a plan change.

The cost question at the end is the most important part: non-adherence — clients quietly not filling prescriptions — often signals financial pressure. A different plan, an LIS application, maybe even a D-SNP, could be part of the solution. You won’t know unless you ask.

If a specialty medication has entered the picture, that’s another clue that you’ll have to do some formulary shopping – across PDPs. MAPDs, and D-SNPs alike.

Listen for: new prescriptions, discontinued medications, dosage changes, cost concerns, specialty drugs.

4. “Has anything changed in your household or your finances that I should know about?”

You’ll find out about eligibility and life events here – things like income changes that could affect IRMAA, a spouse approaching 65, or a loss of employer coverage. Lower-income earners might tell you about Medicaid status changes or offer signs that they may be getting close to spenddown eligibility.

Clients whose circumstances have changed often just don’t think to tell their agent. This question gives them a reason to.

Listen for: retirement, income changes, spouse turning 65, loss of employer coverage, Medicaid status changes, life events that could support an IRMAA appeal.

5. “When you actually needed your plan this year, how did it go?”

You’ll want to hear about whether clients actually like what they enrolled in, and this question invites them to tell a story. Satisfied clients will tell you a good one; frustrated clients will bring you problems that you might be able to solve.

Prior authorization surprises, billing issues, claims problems, costs they weren’t expecting — any or all of it could come up here. So does the client who never used their plan, and has no idea how it would work if they did. That’s another opportunity for education about supplemental benefits, and a clue about whether choosing a different plan, perhaps one with a Part B rebate, might be in the cards.

Listen for: billing or claims issues, prior authorization friction, out-of-pocket surprises, and overall satisfaction with how the plan actually functioned.

How to use these questions

If you’re meeting in person, print these out. Leave space under each question for notes. Whether you fall in the “take note while I listen” camp or the “summarize after the appointment” camp, you’ll have a spot to organize what you’ve heard.

If you’re talking on the phone or video call, you might still print these out. Or, you can take notes directly in your CRM or Agency Management System.

The goal is a conversation that communicates care for your clients’ changing situations, not a checklist that feels like paperwork. Five questions, asked well, will tell you more than a form letter or checklist.

And if something opens a door — a health scare, an upcoming surgery, a household change — run through it. The pre-AEP review isn’t just prep work. It’s probably the most valuable client touchpoint you have outside of AEP itself.