Quick Snapshot: Your Current Coverage in One Line

• Tell me in a sentence how you currently receive Medicare benefits, for example original Medicare with a supplement or a Medicare Advantage plan Options: Original Medicare with Medigap or supplement, Medicare Advantage HMO, Medicare Advantage PPO, Dual-eligible plan, Not yet enrolled, Other
• How long have you been on this coverage arrangement? Options: Less than 1 year, 1 to 3 years, 4 to 6 years, 7 or more years, Not enrolled
• When was the last time you actively compared other Medicare choices or reviewed your prescription costs with your plan Options: This year, Within 1 to 2 years, 3 to 4 years ago, More than 4 years ago, Never
• Describe a recent experience with your coverage, either one that made you feel secure or one that left you frustrated
• What's the one coverage issue that, if unresolved, would make you switch plans immediately
• Are you working with an agent, a community counselor, family, or managing decisions mostly on your own Options: Agent or broker, Community counselor or navigator, Family or caregiver, I manage decisions myself, Other

When Care and Coverage Don't Match

• Point to the specific moments when your current coverage has failed you at the point of care, for example scheduled specialist visits, hospital care, or follow up after discharge
• List the doctors, clinics, or hospital systems you must keep access to for ongoing care
• Which medical specialties do you see regularly and how often Options: Primary care, monthly or more, Primary care, less often, Cardiology, Oncology, Endocrinology, Orthopedics, Mental health, Other
• How often in the last 12 months have you been told a provider was out of network when you tried to schedule care Options: Never, Once, A few times, Often, Unsure
• If a key specialist were out of network, what would you do instead and what would that cost you in time, travel, or stress
• If your primary provider were not in a plan network, would that alone stop you from enrolling Options: Yes, No, Maybe, depends on the provider

The Medicines That Matter Most

• Which current prescription or treatment would be hardest to replace or manage under a different formulary
• Please list each active medication including dose, how often you take it, and the pharmacy you use
• How many unique prescription drugs do you take each month Options: None, 1 to 3, 4 to 6, 7 to 10, 11 or more
• How often in the past year did you encounter prior authorization, step therapy, or surprise copay tiers when filling a prescription Options: Never, Once, A few times, Many times, Unsure
• Is there a single medication that, if not covered with equivalent cost sharing, would prevent you from switching plans Options: Yes, No, Maybe, need details
• Would you be willing to change pharmacies or accept mail order for a lower cost if it preserved access to your medications Options: Yes, mail order is fine, Prefer local pharmacy, Depends on the medication, No

Counting the Costs You Care About

• Which cost matters most to you when comparing plans, the monthly premium or the plan's maximum out-of-pocket for the year Options: Monthly premium, Maximum out-of-pocket, Copays and coinsurance, Prescription costs dominate, All matter equally
• For a typical month of care with your current providers and prescriptions, estimate your total out-of-pocket spend including premiums, copays, and drug costs Options: Under $50, $50 to $200, $201 to $500, $501 to $1000, Over $1000
• Which trade-offs would you accept to lower your premium Options: Narrower provider network, Higher copays for specialists, Step therapy for some drugs, Restricted pharmacy options, None of the above
• How comfortable are you with unpredictable medical bills compared with predictable copays Options: Prefer predictable copays, Comfortable with some unpredictability, Accept unpredictable if OOP max is low, Unsure
• If a plan cut your premium in half but raised your yearly maximum out-of-pocket by $4,000, would you consider switching Options: Yes, No, Maybe, need details
• Are supplemental benefits like dental, vision, hearing, or OTC allowances important enough to sway your choice Options: Yes, very important, Somewhat important, Not important, Unsure

What's Most Likely to Slow or Stop the Change

• Point to the one risk that typically makes people delay switching plans, such as lost provider access, uncovered meds, paperwork, or short enrollment windows
• Have you experienced claim denials, surprise bills, or gaps in coverage in the last two years Options: Claim denials, Surprise bills, Gaps in coverage, None of the above, Other
• Which people would need to be involved or sign off for you to change coverage Options: You alone, Spouse or partner, Adult child or caregiver, Agent or broker, Care manager or legal rep, Other
• How much time could you and your support network realistically spend resolving an enrollment or claims problem if it arose Options: A few hours, One business day, A few days, A week or more
• If a prior authorization or claim issue took two months to resolve, would that keep you from switching plans now Options: Yes, No, Maybe

The Other Options on Your Table

• Why would you keep your current coverage instead of moving to a different plan
• Which alternatives are you actively evaluating right now Options: Keep original Medicare with a supplement, Switch to a different Medicare Advantage plan, Stay with the incumbent plan, Manage care out of pocket, Dual-eligible or Medicaid option, Other
• Has anyone suggested solving the problem without changing plans, for example paying out of pocket, switching pharmacies, or asking providers for assistance Options: Yes, pay out of pocket, Yes, switch pharmacy, Yes, ask provider for exceptions, No one has suggested that, Other
• What condition would have to be true about your current plan for you to decide to stay with it instead of changing
• If a plan matched your top priorities for providers and medicines but cost a bit more in premium, would you still consider switching Options: Yes, No, Maybe, depending on details

Can We Complete Enrollment Smoothly, or Are There Practical Gates

• Which documentation or technical gaps could stop enrollment from completing on schedule, for example missing ID, power of attorney, or medication histories
• Is your medication history and recent medical record available in one place that we can access if needed Options: Yes, readily available, Partially available, Not available, Unsure
• Do you have a preferred pharmacy that must be in any plan you choose Options: Yes, a specific local pharmacy, Mail order preferred, No strong pharmacy preference, Unsure
• Are there consent, signature, language, or accessibility needs that would change how we collect enrollment paperwork Options: Large print materials, Interpreter or translated materials, Hearing assistance, Electronic signature not possible, No special needs, Other
• If we needed a signed enrollment form within 7 calendar days to hold a rate, could you provide it Options: Yes, No, Maybe with assistance

If Everything Lines Up, What Would Make You Move

• If we could guarantee your critical providers and medicines would be covered, what timeline would make you ready to enroll Options: Immediately, Within 1 to 2 weeks, During the upcoming enrollment period, Next year, Unsure
• Which communication method do you prefer for step by step enrollment support Options: Phone call with an agent, Secure online portal, Email with attachments, Paper mail, In-person appointment
• Would you want an agent or community counselor to walk through the enrollment form with you Options: Yes, Maybe, No
• Which person should be our main contact to finalize details and receive sensitive forms Options: You, Spouse or partner, Adult child or caregiver, Agent or broker, Authorized representative
• If we provided a clear plan summary that matched your top priorities within 48 hours, would you be willing to start enrollment Options: Yes, Maybe, need more info, No

• Plan Comparison Experience

• Confirm your current coverage and gaps
• You confirm the recorded current state and accept the quantified cost and service disruption consequences.
• Run a full provider network check and formulary coverage lookup for the provided list of providers, medications, and preferred pharmacies, and deliver a side-by-side summary before the next review.
• Quantify the consequence of gaps
• You validate at least one plan scenario that meets your provider access and total out-of-pocket expectations.
• Prepare three modeled total-cost scenarios (lowest premium, lowest out-of-pocket, best provider fit) for the shortlisted plans and share the comparison table.
• Walk through plan type tradeoffs with your providers
• Provide the final, validated list of your current providers, medications (including dosages), and preferred pharmacies.
• You identify any remaining enrollment constraints or data gaps required to finalize plan selection.
• Confirm your target enrollment date and note any special eligibility constraints or assistance programs to consider.
• Model total out-of-pocket scenarios
• Validate prescription coverage against your medication list
• Confirm the recommended path

• Plan Comparison Experience
• Plan Comparison Deck
• Plan Comparison Solution Brief

• meeting
• slides
• document

• Process member enrollment and issue ID card
• Activate medical and hospital coverage
• Activate prescription drug (Part D) coverage
• Assign primary care provider and coordinate care
• Deliver chronic-condition care coordination programs
• Provide 24/7 nurse advice line access
• Provide transitions-of-care support after discharge
• Manage prior authorizations and utilization review
• Process claims and member cost-sharing
• Provide dental, vision, and hearing benefits
• Provide fitness and wellness program access
• Administer over-the-counter allowance and benefits
• Maintain provider network directory access
• Submit risk-adjustment and coding data
• Deliver preventive care reminders and outreach

Process member enrollment and issue ID card

• Enrollment file type you will use for batch onboarding (CMS 834, secure portal spreadsheet, manual fax)? Options: CMS 834 electronic enrollment, Secure portal spreadsheet upload, Agent-submitted fax/phone enrollment, Individual online enrollments
• Member identifier format required on the enrollment feed (Medicare Beneficiary Identifier, HICN legacy, other)? Options: Medicare Beneficiary Identifier (MBI), Legacy HICN with crosswalk, Custom member ID mapping required
• ID card delivery preference for members (mailed paper card, printable PDF, digital wallet pass)? Options: Mailed paper card, Printable PDF via secure portal, Digital wallet pass / mobile app
• Address verification: will you provide validated mailing addresses or require address-standardization services for card mailing? Options: We will supply USPS-validated addresses, We need address-standardization service from the plan, Mixed — some validated, some need service
• Agent acknowledgement and HIPAA consent: do you have signed broker/agent attestation forms to include with electronic enrollments? Options: Yes – forms provided per member, No – we need the broker attestation workflow enabled, Some agents provide, some do not
• What evidence will validate a completed enrollment and ID issuance (example: CMS 834 acknowledgment, print-ready ID proof, tracking number)? Options: 834 ACK from CMS / clearinghouse, Printable ID PDF with card number, USPS tracking for mailed card

Activate medical and hospital coverage

• Effective date logic to apply when activating benefits (requested effective date, CMS enrollment effective, first of next month)? Options: Requested effective date when allowed, CMS-determined effective date only, First of next month rule
• Primary product type to activate (HMO, PPO, Special Needs Plan) for the enrolled cohort? Options: HMO, PPO, Dual-eligible / Special Needs Plan (SNP)
• Provider assignment on activation: should members be auto-assigned to a network PCP based on ZIP and PCP panel capacity or manually selected at enrollment? Options: Auto-assign by ZIP and panel capacity, Member/agent selects PCP at enrollment, Assign later during welcome call
• Hospital network tiering and in-network facility list: will you provide a signed provider file (NPI, taxonomy, facility ID) for activation mapping? Options: We will provide NPI and facility list file, We need plan to map providers from directory, Partial provider file available
• If members have pending inpatient stays spanning activation, how should concurrent hospitalization claims be handled (retroactive coverage start, prior authorization requirement)? Options: Retroactive coverage for inpatient stay, Require review / transition-of-care PA, Handle case-by-case via care management
• Which document will confirm activation to the member (welcome packet, activation email, portal notification)? Options: Mailed welcome packet with ID, Secure email with activation notice, Portal notification only

Activate prescription drug (Part D) coverage

• Formulary identifier to enroll the member onto (Part D formulary name or ID used for coverage mapping)?
• Which pharmacy routing values must be set for members (BIN, PCN, payer ID) to ensure claim adjudication at first fill?
• Mail-order preference: will members default to an in-network retail pharmacy, plan mail-order vendor, or allow both at point of sale? Options: Default to retail network, Default to plan mail-order, Allow member choice at POS
• Specialty drug handling: identify any high-cost drugs on members' med lists that require specialty pharmacy routing or prior authorization (list drug names and NDCs).
• Preferred formulary exception workflow for uncovered drugs: provide the form route (ePA, paper prior auth, pharmacy-initiated PA)? Options: Electronic prior authorization (ePA), Paper prior authorization form, Pharmacy-initiated DUR/PA
• What evidence will validate Part D activation and drug routing is correct (first-fill adjudication success, PBM response code, member's pharmacy BIN confirmation)? Options: First-fill adjudication accepted by PBM, PBM routing confirmation (BIN/PCN match), Member sees formulary coverage in portal

Assign primary care provider and coordinate care

• Primary care physician identifier to use during assignment (PCP NPI and practice location NPI)?
• Member choice for PCP selection: will you allow members to change PCP during welcome period, or lock assignment for 90 days? Options: Allow immediate PCP change, Lock PCP for 90 days after activation, Allow change with agent assistance only
• Care coordination handoff: which document should be sent to the assigned PCP on member activation (care summary, medication list, problem list)? Options: Transition care summary (CCD/CCDA), Problem and medication list PDF, No automatic handoff — manual on request
• Identify the PCP panel capacity threshold you require before auto-assignment (max patients per PCP NPI).
• Behavior for out-of-area PCPs: if a member lists a non-network PCP, should we initiate network outreach for continuity or require member selection of an in-network PCP? Options: Initiate outreach to onboard PCP to network, Require member to select in-network PCP, Allow temporary out-of-network PCP with referral
• Who on your team will own PCP enrollment exceptions and overrides (name or role)?

Deliver chronic-condition care coordination programs

• Which chronic conditions should trigger enrollment in care coordination (diabetes — ICD-10 E11, CHF — I50, COPD — J44)? Options: Diabetes (E11), Congestive heart failure (I50), Chronic obstructive pulmonary disease (J44), Other — specify
• Care program intensity: do you require telephonic nurse care management, in-person community RN visits, or hybrid for flagged members? Options: Telephonic nurse care management, In-person community RN visits, Hybrid telephonic + in-person
• Preferred clinical workflow to enroll members into disease management (claims trigger, HEDIS gap list, PCP referral)? Options: Claims-based trigger, HEDIS gap identification, PCP or specialist referral
• Data feeds required to run programs (lab results LOINC feed, medication fill history, hospital admission-discharge-transfer ADT feed)? Options: ADT hospital feeds, Pharmacy fill history (PBM feed), Lab results (LOINC)
• Measurement and reporting cadence for the program (monthly care touches, quarterly outcomes, annual HEDIS measures)? Options: Monthly care touches report, Quarterly clinical outcomes, Annual HEDIS-aligned reporting
• Identify required caregiver or authorized representative information to include in outreach (name, phone, power of attorney documentation).

Provide 24/7 nurse advice line access

• After-hours nurse line phone number provision: will you use an existing vendor line or request the plan to provision a dedicated number and script? Options: Use existing vendor number, Plan to provision dedicated number and script, Use national hotline routing
• Clinical protocols to apply on nurse triage calls (condition-specific triage scripts, ED diversion criteria, referral to urgent care)? Options: Condition-specific triage scripts, Emergency department diversion criteria, Referral to urgent care protocols
• Call documentation requirements: what EHR or CRM fields must be recorded from each nurse call (symptom checklist, disposition code, follow-up timeframe)?
• Integration needs: do you require secure SFTP or HL7 interface to push triage logs into your care management system? Options: SFTP file transfers, HL7 interface, Manual CSV export
• Response SLA for urgent nurse callbacks (minutes/hours) and escalation path to on-call physician? Options: 15 minutes, 1 hour, 4 hours
• Which member ID and consent artifact should nurses verify on calls (MBI, verbal consent script, recorded consent)? Options: MBI plus verbal consent script, MBI only, Recorded consent required

Provide transitions-of-care support after discharge

• Discharge notification source to trigger transitions workflow (hospital ADT feed, member self-report, claims ingestion)? Options: ADT hospital feed, Member self-report via hotline, Claims-based admission alert
• Post-discharge follow-up timing required (call within 48 hours, clinic visit within 7 days, medication reconciliation within 48 hours)? Options: Call within 48 hours, Clinic visit within 7 days, Medication reconciliation within 48 hours
• Medication reconciliation artifact: do you require a reconciled med list returned to discharging hospital and PCP (CCDA/CCD format)? Options: Return reconciled med list CCDA/CCD, Summary PDF only, No automatic return required
• Home health or durable medical equipment (DME) ordering: should transitions team place DME orders on behalf of the patient or provide referrals to contracted vendors? Options: Place DME orders, Provide referrals to contracted vendors, Refer to PCP for orders
• Identify the escalation criteria that require a case manager visit within 24 hours after discharge (recent ICU stay, 3+ meds changed, high fall risk).
• Preferred reporting back to hospital case management: discharge follow-up completion status via secure portal or periodic CSV? Options: Secure portal status updates, Periodic CSV reports, No reporting required

Manage prior authorizations and utilization review

• Prior authorization intake methods to accept (electronic prior auth ePA, faxed clinicals, web portal upload)? Options: Electronic prior authorization (ePA), Faxed clinical documents, Web portal upload
• Utilization review turnaround time SLA for standard and urgent requests (standard 7 days, urgent 72 hours)? Options: Standard 7 business days, Urgent 72 hours, Custom SLA — specify
• Clinical documentation required for PA decisions (operative notes, imaging study DICOM report, specialist letter)?
• Which coding set must reviewers reference for UR decisions (CPT/HCPCS, ICD-10, CMS LCD/NCD policies)? Options: CPT/HCPCS, ICD-10, CMS LCD/NCD guidance
• Denial and appeal workflow: who receives adverse determination notices and via which channel (member mail, provider portal, secure email)? Options: Member mail, Provider portal, Secure email
• Identify any high-volume service lines needing automated PA rules (imaging MRI, elective surgeries, infusion therapies).

Process claims and member cost-sharing

• Claims submission formats required (837 Professional, 837 Institutional) and clearinghouse routing instructions? Options: 837 Professional, 837 Institutional, Both 837P and 837I
• Member cost-sharing rules to apply by benefit phase (primary care copay, specialist copay, deductible if applicable)?
• Coordination of benefits: what payer order and COB documents will you supply when members have dual coverage (Medicare secondary to group plan)? Options: Provide COB order file and EOB, Plan to handle on claim adjudication, Manual COB handling
• Claim turnaround and remittance advice cadence required (daily EDI 835 remits, weekly batch)? Options: Daily EDI 835, Weekly batch remittance, Ad-hoc/manual remits
• Adjustments and retrospective payments: define the allowed lookback window for retroactive payment corrections (90 days, 6 months, 12 months). Options: 90 days, 6 months, 12 months
• Which explanation-of-benefit (EOB) templates should be used for members showing cost-share and coverage details? Options: Standard EOB template, Detailed benefit-level EOB, Custom member-friendly summary

Provide dental, vision, and hearing benefits

• Benefit scope: which dental services are included (preventive exams, crowns, dentures) and what frequency limits apply? Options: Preventive only (cleanings/exams), Preventive + basic restorative, Comprehensive including dentures/crowns
• Provider credentialing: will you supply a contracted ancillary provider file (NPI, specialty, clinic address) for dental/vision/hearing networks? Options: We will supply contracted provider file, Plan to map network from directory, No contracted ancillary network provided
• Member access tools: should in-scope members see dental/vision/hearing coverage and allowances in the member portal benefit summary? Options: Yes — include benefit summary, No — separate ancillary portal, Limited summary with link to full benefit guide
• Hearing aid or vision frame allowances: specify annual dollar allowance or frequency (e.g., $1,000 every 24 months).
• Prior authorization rules for high-cost dental or hearing appliances: require PA for prosthetics above a dollar threshold? Options: PA required above threshold, No PA required, PA for specific CDT codes only
• Which member ID or benefit code must ancillary providers send on claims to route to ancillary benefit adjudication?

• Medicare Advantage Enrollment Agreement
• Electronic Signature & Communications Consent
• Authorization to Release Medical and Prescription Information
• Agent/Broker Acknowledgement and Compensation Disclosure
• Eligibility Documentation Attestation & Upload
• Premium Payment Authorization
• Coordination of Benefits and Other Coverage Attestation
• Prescription Drug Enrollment & Pharmacy Routing Consent
• Primary Care Provider Assignment Confirmation

• Go-live Health Check (Weeks 1-4)
• First Measurement Review (Weeks 4-10)
• Acceptance Gate, Onboarding Outcomes (Around Day 90)
• Quarterly Member Outcomes Review

• Publish the quarterly member outcomes summary and updated issue tracker to the shared workspace.
• Publish updated member communications clarifying PCP assignment and pharmacy routing timelines.
• Restate acceptance criteria and numeric targets
• Produce a documented acceptance decision: pass, conditional pass with remediation, or fail.
• For any failed or conditional criteria, agree remediation tasks and target completion dates to close the gap.
• Confirm the transition plan to the ongoing monitoring cadence if accepted.
• Publish the acceptance decision and the agreed remediation plan within 48 hours.
• Schedule follow-up validation checkpoints for any conditional remediation items on their completion dates.
• Update the onboarding runbook and operational playbooks to reflect lessons learned and mitigations required after the acceptance review.
• Quarterly trend review for CSAT and average issue resolution time
• Confirm whether member satisfaction and issue resolution time meet targets or require further action.
• Close resolved remediation items and convert persistent problems into tracked operational tickets with SLAs.
• Maintain a shared channel and process for handling member issues, appeals, and benefit updates with agreed response SLAs.
• Close any remediation items resolved during the quarter and archive status updates.
• Create operational tickets for persistent issues with target SLAs and expected closure dates.
• Confirm scope, success criteria, and owners
• Validate which activation tasks completed successfully and which require remediation.
• Agree a time-boxed remediation plan for all open blockers with named owners and target dates.
• Document all failed activation events with required corrective steps and target resolution dates.
• Publish an updated onboarding checklist reflecting any interim workarounds or rollback steps.
• Present measured outcomes vs targets for PCP assignment and prescription fulfillment
• Determine whether PCP assignment and prescription fulfillment metrics are on track to meet acceptance thresholds.
• Agree a prioritized remediation backlog with target completion dates before the Acceptance Gate.
• Confirm data sources and reporting cadence for the Acceptance Gate meeting.
• Run a data audit on PCP assignment records and report discrepancies within 5 business days.
• Implement identified prescription routing fixes and report measured improvement within two weeks.
• Deployment and activation validation
• Prescription fulfillment and provider access performance
• Present outcome data and supporting evidence
• Diagnose root causes for any gaps
• Appeals and escalations summary
• Document pass, conditional pass, or failed criteria
• Review member experience signals
• Early adoption signals and usage patterns
• Agree corrective actions and timeline to acceptance gate
• Blockers and open issues
• Record acceptance decision and next steps
• Status of outstanding remediation items from Acceptance Gate
• Agree immediate remediation actions
• Agree next-quarter operational improvements and monitoring items
• Agree post-acceptance monitoring cadence