How to Prepare for New AEP Rules
The Centers for Medicare and Medicaid Services has changed some of the rules around how we work, while carriers are changing benefits, networks, eligibility requirements and supplemental programs. Here’s what agents need to know to be prepared for Annual Election Period.
CMS finalized the Contract Year 2027 Medicare Advantage and Part D rule on April 2. Several changes affect how you conduct business during AEP.
These changes include:
The 48-hour Scope of Appointment waiting period is gone. Licensed insurance agents can discuss a plan immediately after an SOA.
Superlatives are no longer categorically prohibited. Terms such as "best" or "top" are no longer subject to the prior blanket prohibition, but any claims must be accurate and supportable.
Record retention is changing. CMS is reducing the required period from 10 years to six years, with specific requirements for how calls must be maintained.
Educational and marketing event rules have been loosened. The physical separation requirements have been reduced.
Third-party marketing organization disclaimer requirements are changing. You must provide the disclaimer before discussing specific plan benefits, instead of relying on the former 60-second framework.
Don’t continue to operate under last year’s rules; understand the new rules and sell what best fits your client’s needs.
The bigger story: Benefits are changing
The defining story of this AEP is benefit design and selling compliantly. Carriers are looking closely at utilization, costs and the sustainability of supplemental benefits. That means you need to look beyond the Summary of Benefits and ask a much more important question: What does this benefit mean for this client?
Transportation, over-the-counter, food, dental, vision and other supplemental benefits can change year to year. And even when a benefit remains, its eligibility requirements, dollar amount or participating vendors may change.
C-SNPs and SSBCI will require a different level of preparation
Chronic Condition Special Needs Plans (C-SNPs) are designed for people with qualifying chronic conditions, and CMS maintains specific criteria governing which chronic conditions can qualify. But here's the important part: Having a chronic condition doesn't automatically mean a client qualifies for every benefit associated with a C-SNP or SSBCI program.
Special Supplemental Benefits for the Chronically Ill (SSBCI) are benefits that plans can offer qualifying chronically ill members when the benefit meets CMS requirements. CMS continues tightening the guardrails. For 2027, that means clarifying SSBCI eligibility requirements, requiring plans to post their own SSBCI criteria publicly, and adding new requirements around debit-card administration and real-time verification of eligible products and services.
One carrier's qualifying criterion may not match another carrier's. One plan may require documentation, a particular diagnosis, a health-risk assessment, a provider confirmation or another qualification process before a benefit can be accessed. You can’t simply tell a client, "You have diabetes, so you get the grocery benefit."
The right conversation is: “Let's determine whether you qualify for this specific benefit under this specific plan and understand what the carrier requires to activate or access it."
MA vs. Medigap: Match the product to the person
The right answer isn't always the plan with the lowest premium. When working with Medicare Advantage clients, look at networks, prescription drugs, prior authorization, maximum out-of-pocket exposure and the supplemental benefits they value.
When working with Medigap clients, look at premium, provider access, underwriting considerations and the client's expected healthcare needs.
Ask every client these three simple questions:
How much unpredictability can your budget absorb?
How important is access to specific doctors and hospitals?
What healthcare needs do you anticipate over the next few years?
Run the cost conversation differently this AEP
Don't sell this AEP on a one-year premium snapshot. Look at the bigger picture. Compare premiums, Part D costs, maximum out-of-pocket exposure, provider access, drug coverage and the benefits the client uses. And remember: the richest benefit isn’t valuable if the client can’t access it.
That's why carrier-specific training will be so important this year. You need to know not only what a carrier offers, but who qualifies, what documentation may be required, how the benefit is activated, where it can be used and what limitations apply. That will separate prepared, licensed insurance agents like you from those simply quoting plans.