By Susan Stewart, Licensed Insurance Agent
Did you know that licensed agents have to follow rules? The Centers for Medicare & Medicaid Services (CMS) require insurance agents like me to adhere to a variety of regulations to protect consumers like you. Breaking requirements can cause, at the very least, an unhappy client. At the most? I’d lose my license and potentially my job, face penalties for myself and my employer, and even risk jail time.
Understanding the rules insurance agents operate by can help you make more effective decisions about your healthcare and avoid unscrupulous agents. Here are a few rules that govern every call I take:
- Identify myself, the company I represent, and state that I’m a licensed insurance agent at the beginning of every call, whether outbound or inbound. Even if we just got disconnected, I’ll need to do this again. This is true even if I talk to you frequently enough that I know your voice, and if you know mine.
- Ask you for three proofs of identity, such as name, date of birth, address, phone number, and zip code. Again, I must do this every time we talk. This information helps me protect your Personal Health Information (PHI). It is also required to know what plans are in your area.
- Inform you that we don’t offer every plan available in your area. I must also share where you can go to look at every plan in your area
- Ask if you have other health insurance besides Medicare. Group insurance may, or may not, be affected by a Medicare plan.
- Confirm if you have Veteran, TriCare for Life, or ChampVA coverage. This affects your options for a Medicare plan.
- Ask if you make your own healthcare decisions. This is to protect vulnerable beneficiaries who need assistance from a power of attorney or a family member. I also must pay attention if I believe a beneficiary doesn’t seem to understand what we are doing. If so, I will find a way to gently end the call.
- Receive your Medicare Beneficiary ID number or social security number. I must confirm eligibility. It’s a bonus that beneficiaries can learn about their own coverage because of what I see when I access the Medicare database.
Does that seem like a lot? Well, that just covers what rules and regulations stipulate I do in the first 15 minutes of a call!
If you’re considering a Medicare Advantage plan, I’ll ask questions about what matters to you. Your list of doctors, medications, and durable medical equipment needs. Then, when you choose your plan, I must conduct a final review that includes:
- Confirm the plan carrier, name, and type. Is it an HMO, PPO, HMO-POS, or PFFS plan?
- Verify network requirements. Are you aware of the higher cost to go out of network with a PPO, or that your bills will not be paid if you go out of network with an HMO?
- Review key coverage details. Are the most important providers and facilities for your care included in your network?
- Confirm key dates. When will your coverage begin? When is the election period that allows for this change?
- Reaffirm the costs of premiums, deductibles, and copays. How much will you pay every month? Will your plan require a deductible, copays for primary care or specialist doctors, or inpatient or outpatient visits to the hospital?
- Review extra benefits. Does your plan offer dental, vision, and hearing? Are they important to you?
- Provide a full breakdown of incidental benefits if they are currently important to you. What will your physical therapy copays look like? What brands of diabetic supplies are covered?
- Unpack the plan’s prescription drug costs, even if you don’t take any. Additionally, is your favorite pharmacy preferred or standard with the plan you’ve chosen?
- Verify that you’re happy and want the plan. After everything we’ve gone over together, is your answer still “yes?” I must hear it to move forward. Then, I need to tell you that you have the right to cancel or file a complaint and then explain how to do that.
This process can seem cumbersome, but it protects you. It’s about being transparent and having integrity as an agent and a company. I know it’s a lot to take in, but it leaves room for questions. It deepens your understanding. It builds trust. If you speak to an agent and they don’t do these things, think twice about working with them. Be your own advocate and pay attention.