Before an agent enrolls someone in a Medicare Advantage or Part D plan, CMS requires a set of checks, in 42 CFR 422.2274(c)(12) and 423.2274(c)(12). Among them, agents need to cover:
- whether the consumer’s prescription drugs are on the plan’s formulary;
- whether the consumer’s pharmacy is in the plan’s network;
- whether the consumer’s doctors are in the plan’s network;
- the consumer’s cost preferences, such as premiums and out-of-pocket costs.
These checks exist for a good reason. The reasons members most often give for leaving a plan are costs, access to their doctors and hospitals, and problems with drug coverage. The checklist asks the agent to catch those problems before the consumer signs.
The problem: it all happens on the call
In most enrollments today, those checks happen during the sales conversation, one plan at a time, with the consumer reading pill bottles over the phone. It takes time, and it’s easy to rush when the queue is full in AEP. It also leaves little record of why a plan was chosen.
Covering it before the conversation starts
Plan alignment moves that work to the start. When a consumer shares their drugs, doctors, pharmacy and cost preferences right after they raise a hand, every plan available to them can be checked against all four, and ranked by what that person is likely to spend.
By the time they reach an agent:
- the checklist items are already covered for every plan, not just the one being pitched;
- the agent starts from the consumer’s own best-fit plans and confirms them, instead of discovering them one by one;
- every enrollment carries a documented, needs-based reason for the plan choice.
That saves about 30 minutes per sale by our estimate, and it gives compliance teams something they rarely have: a record showing the consumer’s needs were checked against every plan, and that the plan they chose fits.
Compliance as a byproduct
Nobody gets into this business for the paperwork. When the consumer’s own answer comes first, compliance stops being a burden added at the end of the call and becomes a natural result of doing the work in the right order.