Medicare Retention and Utilization Review: Your Game Plan - Western Asset Protection
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Medicare Retention and Utilization Review: Your Game Plan

Are your clients making the most of their Medicare Advantage and prescription drug plans? It’s a good idea to check in with your clients to make sure they’re happy with their coverage and using the benefits they’re entitled to. These tips and reminders will help you stay compliant while conducting a utilization review to boost Medicare retention.

MA-OEP: Do’s and Don’ts

The Medicare Advantage Open Enrollment Period (MA-OEP) ends on March 31. During MA-OEP, Medicare Advantage enrollees are allowed to make a one-time switch to a different Medicare Advantage plan or back to Original Medicare. This is a great opportunity for enrollees who are unhappy with their plan selection. If your clients contact you because they’re having problems with their plan and want to switch, make sure their new selection is completed by the end of March.

However, CMS has strict marketing prohibitions. During MA-OEP, organizations CANNOT:

  • Send unsolicited materials advertising the ability to make an enrollment change or referencing MA-OEP.
  • Target beneficiaries because they made a selection during AEP.
  • Engage in broker activities that target the OEP as an opportunity to make further sales.
  • Contact former enrollees who have a selected a new plan during AEP.

While reaching out to your clients, be mindful of the CMS restrictions against marketing for the MA-OEP. Make sure you are adhering to the rules. For more information on the MA-OEP, see Time to Tackle Your OEP Plan. For more information on marketing rules, see the Medicare Advantage Marketing Regulations.

Checking in with Clients, Compliantly

It’s a smart idea to reach out to your existing clients during the year. When following up with your clients, here are some questions to ask:

  • Did you get your insurance cards? Enrollees should have the cards they need to use their coverage. If they haven’t received them, it may have gotten lost in the mail, and they may need to request new cards.
  • Are your prescriptions covered? Your clients have probably had to refill their prescriptions this year, so they should know the costs. Hopefully, they checked the formulary ahead of time and there were no surprises, but it’s possible that they are taking new prescriptions that aren’t covered.
  • Have you had any issues since you started on this plan? Hopefully, your clients aren’t having any trouble with their costs or coverage. If they are having trouble, they may need guidance on contacting their plan for more information or appealing a coverage decision.
  • Have you been to the doctor? Medicare enrollees are entitled to an annual wellness visit as well as various screenings, vaccines and other preventative care. These benefits can help enrollees stay healthy, so it’s important to use them.

Plan Utilization

When you enrolled your clients, you went over the providers in the network, the prescription drugs in the formulary, and the additional coverages available. Now that clients have had time to use their benefits, it’s a good time to doublecheck that these benefits are actually being used.

Benefits can include coverages that are available to all Medicare enrollees – such as annual wellness visits and COVID-19 vaccines – as well as extra benefits offered by individual plans. For example, if a Medicare Advantage plan includes gym memberships, check to see if the enrollee is using it.

Because benefits can vary significantly from plan to plan, you may want to conduct a carrier-specific review on group basis. To do this, invite all of your clients with a particular plan to a video conference meeting so you can review the available coverage and encourage them to take advantage of every plan feature.

This is a great way to re-establish a connection with your clients, and the efforts you make may help with retention during the next AEP. You and your clients may also gain valuable insights into which coverages are the most useful, and that can inform future plan selections.

You’re here for your clients, and Western Asset Protection is here for you. If you have any questions, contact us.