Tell Me About Today — A Quick Snapshot

• What prompted you to start looking at Medicare Advantage (or review your coverage) right now? Options: Annual Enrollment Period (AEP), Turning 65 / New to Medicare, Open Enrollment / Special Enrollment, Doctor change or move, Rising costs, A friend or event recommendation, Other
• Which of these best describes your current coverage? Options: Original Medicare only (Parts A & B), Original Medicare + Medigap (Supplement), Medicare Advantage (MA) plan, Dual eligible (Medicare & Medicaid), Not enrolled yet / evaluating
• Who do you usually rely on when making important healthcare or plan decisions? Options: Myself, Spouse/partner, Adult child or family member, Insurance agent or broker, Community counselor/SHIIP, Healthcare provider, Other
• What are the top three things you want this conversation to help you with? Options: Keeping my current doctors, Lowering total out-of-pocket costs, Getting better prescription coverage, Access to extra benefits (dental, vision, hearing), Simpler paperwork and support, Understanding plan differences, Other
• How soon are you hoping to make a decision or enroll? Options: Immediately / Today, Within a week, Within this enrollment period, Next few months, Unsure / just exploring

What’s Really Not Working (Even If You’ve Learned To Live With It)

• When you think about your current coverage, what’s the single thing you’re most frustrated by?
• How often do those frustrations come up in a way that changes your care or your day-to-day life? Options: Almost every week, A few times a month, Occasionally, Rarely
• Tell me about the last time coverage got in the way—what happened, and how long have you been dealing with that issue?
• Which of these problems do you most worry will continue if you switch plans? Options: Losing my doctor, Higher out-of-pocket costs, Running out of medication coverage, Complex paperwork or denials, Care coordination failures, Other
• If you were to pick one thing you’d fix right now, what would it be and why?

If a Plan Could Change One Thing, What Would It Be?

• Imagine your ideal coverage for a year—what is the first difference you’d notice that would make you feel relieved?
• How important is preserving access to your current specialists compared with lowering your monthly premium? Options: Keep specialists even if premium is higher, Some trade-off is acceptable, Lower premium is more important, Unsure / need help weighing
• What extra benefits (beyond Original Medicare) would feel like real value to you? Options: Dental, Vision, Hearing, Fitness / gym membership, Over-the-counter allowance, Meal delivery, Transportation to appointments, Home health support, Other
• If a plan could guarantee one measurable outcome in the next 12 months, what would you pick? Options: No surprise hospital bills, All my meds covered, All my doctors in-network, Lower yearly total cost, Better care coordination, Other
• How would achieving that outcome change your day-to-day life or peace of mind?

Your Doctors, Your Meds — How Close Are They to Being Safe?

• Do you have specific doctors or clinics you must keep seeing? Options: Primary care physician, Cardiologist, Oncologist, Endocrinologist/diabetes specialist, Orthopedist, Pulmonologist, Behavioral health provider, No specific requirement
• Please list the names and locations of any providers you consider essential (or upload later) — include the one you’d be most upset to lose.
• Which prescription medicines are you taking regularly that absolutely must be covered?
• Are you open to switching pharmacies (including mail-order) if it ensures consistent access to your medications? Options: Yes, mail-order is fine, Prefer local pharmacy only, Open to either with support, Not sure / need guidance
• Do you currently face any prior authorization, step therapy, or coverage denials for treatments or meds? Options: Yes, frequently, Occasionally, Not recently, Unsure
• Do you have any upcoming appointments, surgeries, or care transitions in the next 3 months we should keep in mind? Options: Doctor visit, Specialist appointment, Planned surgery, Hospital discharge/transition, None, Unsure

Money Matters — The Trade-offs You're Willing To Make

• If you had to choose, which matters more to you: a lower monthly premium or lower expected total annual cost? Options: Lower monthly premium, Lower total annual cost, Prefer balance between both, Unsure / need help modeling
• What is the most you would be comfortable paying in a year for all medical costs (excluding Medicare premiums you already pay)? Options: Under $1,000, $1,000–$2,500, $2,500–$5,000, $5,000–$10,000, Over $10,000, Unsure
• How much did you pay out-of-pocket for healthcare and prescriptions in the last 12 months (estimate)? Options: Under $500, $500–$2,000, $2,000–$5,000, $5,000–$10,000, Over $10,000, Unsure
• Which types of costs worry you most about unexpected bills? Options: Hospital / ER bills, Specialist visits, Prescription costs, Out-of-network charges, Home health or durable medical equipment, Other
• Are you comfortable with cost-sharing (copays, coinsurance) if it means more benefits, or do you prefer predictable fixed costs? Options: Prefer predictable fixed costs, Comfortable with some cost-sharing, Only if capped by OOP maximum, Unsure

Decision Drivers — Who and What Will Tip the Scale?

• What or who will most influence your final choice of plan? Options: Insurance agent/broker recommendation, Primary care or specialist advice, Family member or caregiver, Cost comparison (total out-of-pocket), Plan's Star rating, Marketing materials, Other
• How involved would you like an agent or plan representative to be after enrollment (help with claims, provider questions, transitions)? Options: Very involved, Occasional check-ins, Only at enrollment, Prefer self-serve
• When someone suggests a plan, what makes you trust that suggestion? Options: Doctor endorsement, Personal referral from friend/family, Clear cost comparison, High Star rating, Transparent provider lists, Agent transparency about commissions, Other
• Who will need to sign off on the change—just you, or family/caregivers as well? Options: Just me, Spouse/partner, Adult child, Power of attorney / caregiver, Other
• Are there any legal, language, or accessibility needs we should prepare for during enrollment? Options: Language interpretation, Large print materials, Hearing assistance, Legal power of attorney, Mobility accommodations, None

Practical Timeline & Next Steps — What Would Make This Easy?

• How ready are you to move forward if we confirm a plan that meets your must-haves? Options: Ready today, Within a few days, Within this enrollment window, Need more time / unsure
• Which documents would you be comfortable sharing to confirm eligibility and enrollment (we can explain each)? Options: Medicare card (Part A/B), Photo ID, Proof of residency, Current plan ID card, None yet / need help
• What communication channel works best for coordinating next steps and paperwork? Options: Phone call, Text message, Email, Video call, In-person meeting, Postal mail
• What would feel like an acceptable first step after this conversation? Options: Run a provider & drug check, See 2–3 tailored plan options, Schedule a follow-up call with an agent, Get a written comparison, Other
• Are there any obstacles (transportation, cognition, hearing, memory, technology) that could get in the way of completing enrollment? Options: Transportation, Hearing impairment, Vision impairment, Memory or cognition concerns, Limited internet access, None
• If we could do one practical thing right away to reduce your worry about switching, what should it be?

The Unsaid Stuff — Anything You Haven’t Told Anyone?

• What’s one fear or hesitation about changing plans that you haven’t voiced yet?
• Is there a personal story or experience with healthcare that shapes how you feel about switching plans?
• Are there cultural, language, or privacy concerns that would affect your comfort with how we handle your information? Options: Yes, cultural sensitivity needed, Prefer specific language support, Privacy concerns about data sharing, No special concerns
• If everything went well in the first 90 days on a new plan, what three signs would convince you you made the right choice?
• Who should we thank or copy on follow-ups (family, caregiver, agent), and how would you like them involved? Options: No one, Spouse/partner, Adult child, Agent/Broker, Caregiver/POA, Other

• Pre-Experience Intake — Medication & Provider Snapshot
• Personalized Solution Walkthrough — Diagnosis, Proof, Validation
• Total Cost & Out-of-Pocket Risk Modeling
• Benefits & Access Validation — Network & Formulary Final Checks
• Decision Readiness & Consent Review

• Eliminate provider and formulary uncertainty by documenting final confirmations or acceptable mitigations.
• Agent to update plan shortlist and scoring weights based on confirmed customer priorities.
• Agent to flag any drugs requiring prior authorization or step therapy and outline estimated resolution timelines.
• Agent to prepare a one-page comparison summary showing provider continuity, drug coverage, and modeled OOP across scenarios.
• Customer to confirm availability for a Benefits Validation session to finalize network and formulary verifications.
• Recap Inputs & Modeling Assumptions
• Enable the customer to compare expected and worst-case OOP across candidate plans using transparent assumptions.
• Force validation that the modeled consequences align with the customer's real financial concerns.
• Agree the financial priority that will determine the recommended plan.
• Agent to finalize the cost model spreadsheet and export a customer-facing two-page summary showing assumptions and outcomes.
• Agent to annotate the summary with the customer's affirmed priority (e.g., lowest catastrophic risk) for use in plan selection scoring.
• Customer to review the exported summary offline and flag any missing utilization items within 48 hours.
• Recap Validated Priorities
• Welcome & Objectives
• Establish clear timelines for any prior authorizations or transition-of-care prescriptions required at enrollment.
• Create a contingency plan in case a provider drops from network or a medication's coverage changes pre-enrollment.
• Agent to obtain written confirmation of provider participation (if possible) and attach to the customer's file.
• Agent to submit any required formulary exception or prior authorization requests and record expected resolution dates.
• Agent to prepare pharmacy transition instructions and a list of nearby in-network pharmacies if a change is required.
• One-sentence Current vs Future State Re-check
• Secure explicit customer confirmation that the recommended plan delivers the defined future state and addresses the consequence.
• Obtain enrollment intent and all necessary consents and documentation commitments to move to Enrollment Deployment.
• Ensure everyone understands the immediate next steps, owners, and timelines before handoff to enrollment operations.
• Customer to provide digital or physical copies of required ID, Medicare card, and any signed consents within agreed timeframe.
• Agent to package verified proofs, chosen plan details, and consents into the enrollment packet and hand off to Enrollment Deployment.
• Agent to schedule a brief post-enrollment check-in date to confirm acceptance and explain next communications.
• Obtain a single-sentence current-state summary that precisely captures coverage, provider dependencies, and care gaps.
• Collect a complete medication list and any prior authorization or coverage problems that must be tested against candidate plans.
• Document explicit cost concerns and a quantified example of the customer's worst-case OOP scenario.
• Secure consent to run network and formulary checks and to prepare personalized cost models for the Solution Walkthrough.
• Agent to run provider network participation checks for all listed providers and note any out-of-network risks.
• Agent to run formulary checks for each medication, capturing tiers, prior authorization requirements, and equivalent alternatives.
• Agent to prepare two-year out-of-pocket cost scenarios (low, average, high) using the customer's fill history and typical utilization.
• Customer to share any pharmacy preference and provide copies/photos of current plan/member ID cards if available.
• Re-state Current State & Consequence
• Prove—using the customer's real providers and meds—how each candidate plan changes access and drug coverage.
• Show concrete OOP dollar differences under realistic utilization scenarios and link them to the customer's stated consequence.
• Obtain explicit customer validation of the accuracy of provider and drug findings or capture required corrections.
• Elicit and record priority trade-offs to be used as the selection scoring rubric.
• Confirm Current State (One-sentence)
• Recommendation & Rationale
• Provider Network Finalization
• Target Future State (One-sentence)
• Model Walkthrough: Typical Year
• Plan-by-Plan Proofs (Provider & Drug Examples)
• Medication Reconciliation
• Confirm Trade-offs & Final Questions
• Model Walkthrough: High-Cost Year (Catastrophic Risk)
• Formulary Finalization & Pharmacy Routing
• Consent, Roles & Documentation Checklist
• Provider & Access Priorities
• What-If Sensitivity Analysis
• Tied Consequence: Scenario Walkthroughs
• Prior Auths, Step Therapy & Transition Policies
• Tie Back to Consequences & Validation
• Interactive Validation Checks
• Cost Concerns & Consequences
• Confirm Future State Proof
• Next Steps to Enrollment Deployment
• Escalation & Contingency Plan

• Issue member ID cards and welcome packet
• Activate 24/7 nurse advice line access
• Assign primary care physician and provide PCP contact
• Deliver transitions-of-care support after hospital discharge
• Process prior authorization requests
• Adjudicate medical and pharmacy claims
• Administer Part D prescription coverage and mail-order fulfillment
• Deliver chronic condition management services
• Authorize and pay for durable medical equipment
• Provide dental, vision, and hearing benefit payments
• Disburse over-the-counter (OTC) benefit allowances
• Maintain and provide up-to-date provider network directory
• Process member appeals and grievances
• Enforce annual maximum out-of-pocket limit on claims

Issue member ID cards and welcome packet

• Do you require physical mailed ID cards, digital/member-portal ID cards, or both? Options: Physical (mailed), Digital (portal/app), Both
• What is the expected monthly volume of new member ID packets to issue? Options: Under 100, 100-1,000, 1,000-5,000, 5,000+
• What turnaround time is required from enrollment confirmation to card delivery? Options: 1-3 business days, 4-7 business days, 8-14 business days, Custom
• Should the welcome packet include plan documents (Summary of Benefits), contact cards, PCP contact, and instructions for pharmacy access? Options: Yes, No, Include some - specify below
• Are there language or accessibility requirements for the welcome packet (e.g., Spanish, large print, braille)? If yes, list languages/formats.
• Do you need automated notifications to members and agents/brokers when ID cards and packets are issued? Options: Yes, No

Activate 24/7 nurse advice line access

• Do you want the nurse advice line active for all members or scoped to specific products/populations? Options: All members, Specific plans only, Pilot group
• Should the nurse line support multiple languages and interpreter services? Options: Yes, No
• What hours of live nurse staffing are required vs. recorded messaging? Options: 24/7 live nurses, Weekdays only, Business hours only, 24/7 with after-hours recording
• Do you require integration with member records so nurses can view recent claims, PCP, and care plans? Options: Yes, No
• What reporting metrics do you need from the nurse line (e.g., call volumes, call resolution, referral rates)?
• Are escalation paths required from the nurse line to care managers or emergency services? If yes, describe required workflows.

Assign primary care physician and provide PCP contact

• Should PCP assignment be automated based on member address and network preferences or manually selected by agent/member? Options: Automated (algorithmic), Manual selection by agent/member, Hybrid
• Do members require the ability to change PCP online/phone after initial assignment? Options: Yes, No
• What information must be provided with PCP assignment (name, phone, office hours, directions, patient portal link)?
• Are there special routing rules for assigning PCPs for members with chronic conditions or special needs? Options: Yes, No
• Do you require confirmation outreach to PCP offices to notify them of new assigned members? Options: Yes, No
• What SLA is required for updating PCP contact information when provider data changes? Options: 24 hours, 3 business days, 1 week, Custom

Deliver transitions-of-care support after hospital discharge

• Which members qualify for transitions-of-care support (all discharges, high-risk, specific conditions)? Options: All discharges, High-risk only, Specific conditions, Referral-based
• What services are required post-discharge (medication reconciliation, home visit, PCP follow-up scheduling, durable medical equipment setup)? Options: Medication reconciliation, Home visit, PCP follow-up scheduling, DME setup, Other
• What is the required timeframe to initiate contact after discharge? Options: Within 24 hours, 24-48 hours, 3-7 days, As soon as possible
• Do you require integration with hospitals or HIE feeds for automatic discharge notifications? Options: Yes, No
• What reporting and KPIs are required (readmission rate, follow-up visit completion, medication adherence)?
• Are there preferred vendors or internal teams to perform home visits or care coordination that must be used? Options: Use internal team, Use preferred vendors, Open vendor selection

Process prior authorization requests

• Do you want prior authorizations handled via electronic prior authorization (ePA), fax, phone, or all methods? Options: ePA, Fax, Phone, All methods
• What is the expected monthly volume of PA requests by type (medical vs pharmacy)? Options: Under 100, 100-1,000, 1,000-5,000, 5,000+
• What target turnaround times are required for standard and expedited PAs? Options: Standard: 7 days, Expedited: 72 hours, Standard: 14 days, Expedited: 48 hours, Custom
• Should PA decisions be integrated to member portal and provider portals with automated status updates? Options: Yes, No
• Do you require clinical criteria and forms built into the PA workflow (guidelines, attachments, denial reasons)? Options: Yes, No
• Are appeal/peer-to-peer pathways required to be triggered automatically on PA denial? Options: Yes, No

Adjudicate medical and pharmacy claims

• Will claims adjudication be handled in-house or by a third-party administrator (TPA)? Options: In-house, Third-party administrator, Hybrid
• What volumes do you anticipate (monthly medical claims, monthly pharmacy claims)?
• What turnaround SLAs do you require for claim adjudication and remittance? Options: 7 business days, 14 business days, 30 days, Custom
• Do you require real-time eligibility and benefits checks at point-of-service integrated with adjudication? Options: Yes, No
• Are there specific edits, bundling rules, or state/CMS rules that must be enforced? Options: Yes - list in details, No
• What reporting and analytics are required from claims (denial rates, turn times, by provider)?

Administer Part D prescription coverage and mail-order fulfillment

• Do you plan to use an external PBM, internal pharmacy team, or a hybrid for Part D administration? Options: External PBM, Internal team, Hybrid
• Do you require mail-order pharmacy services, retail network only, or both? Options: Mail-order, Retail network only, Both
• What formulary management features are required (step therapy, tiering, exceptions, generic first policies)? Options: Step therapy, Tiering, Exceptions process, Generic-first, All of the above
• What turnaround times are required for pharmacy prior authorizations and exceptions? Options: 24-48 hours, 72 hours, 7 days, Custom
• Are medication synchronization and multi-month fills required for chronic meds? Options: Yes, No
• Do you require member-facing tools for drug look-up and coverage estimation integrated with CMS files? Options: Yes, No

Deliver chronic condition management services

• Which chronic conditions should be in scope (e.g., diabetes, CHF, COPD, hypertension)? Options: Diabetes, CHF/Heart Failure, COPD, Hypertension, Multiple/Custom
• What intensity of services are needed: outreach only, coaching, remote monitoring, or in-home visits? Options: Outreach only, Coaching, Remote monitoring, In-home visits, Combination
• What enrollment method is preferred for programs: automatic risk-based enrollment, opt-in, or referral-based? Options: Automatic (risk-based), Opt-in, Referral-based, Hybrid
• What outcome metrics should be tracked (A1c control, hospitalizations, medication adherence)?
• Do you require integration with remote monitoring devices and vendor platforms? Options: Yes, No
• Are there care manager-to-PCP communication workflows and documentation templates required? Options: Yes, No

Authorize and pay for durable medical equipment

• Which types of DME should be funded (oxygen, mobility aids, hospital beds, walkers, CPAP)? Options: Oxygen, Mobility aids, Hospital beds, Walkers, CPAP, Other
• Should DME require prior authorization and clinical documentation before approval? Options: Yes, No
• What is the preferred procurement model: in-network DME vendors, open vendor selection, or managed vendor network? Options: In-network vendors, Open vendor selection, Managed vendor network
• What turnaround time is required from approval to equipment delivery/install? Options: 24-72 hours, 3-7 days, 7-14 days, Custom
• Do you require DME maintenance and repair management and tracking? Options: Yes, No
• Are there billing rules or caps per DME item that must be enforced? Options: Yes, No

Provide dental, vision, and hearing benefit payments

• Which ancillary benefits should be administered (dental, vision, hearing) and at what coverage levels? Options: Dental, Vision, Hearing, All
• Do you require network-based benefit payments, fee schedules, or claim reimbursement for out-of-network providers? Options: Network-based only, Fee schedule, Out-of-network reimbursement available
• What member cost-sharing or limits apply (annual maxs, per-service copays)?
• Do benefits require authorization for higher-cost services (e.g., dentures, specialty lenses, cochlear evals)? Options: Yes, No
• Do you require benefit cards, vendor directories, or scheduling support for these services? Options: Yes, No
• Are there reporting needs for utilization and member satisfaction for ancillary benefits? Options: Yes, No

• Plan Election & Enrollment Authorization
• Agent/Broker Appointment & Compensation Agreement
• Statement of Work (SOW) — Enrollment Services
• HIPAA Authorization & PHI Release
• Prescription Drug/ Formulary Acknowledgement
• Provider Network & PCP Assignment Confirmation
• Proof of Eligibility & Documentation Consent
• Electronic Communications & E-Sign Consent
• Premium Payment Authorization
• Replacement/Coordination of Coverage Attestation
• Third-Party Representative & Caregiver Authorization

• Welcome & Coverage Activation Review
• Provider & Prescription Access Confirmation (Live Check)
• Issue Resolution & Medication Access Escalation
• Ongoing Support & Benefits Enhancement Channel Setup

• Document and publish the agreed success metrics and monitoring plan in the shared channel.
• Submit any required prior authorization requests within 24-48 hours for medications flagged as requiring approval.
• If a preferred provider is out-of-network, initiate network outreach to confirm participation or identify equivalent in-network clinicians.
• If transitional fills are needed, coordinate with the pharmacy and prescribing clinician to secure a short-term supply.
• Rapid Recap of Outstanding Issues
• Create a prioritized, time-bound action plan for every outstanding access issue.
• Assign clear owners and single points of contact for prior auths, appeals, pharmacy coordination, and provider negotiations.
• Ensure no member faces an immediate medication interruption by authorizing transitional supplies where needed.
• Submit required prior authorization packets with complete clinical documentation to pharmacy/medical review within 24 hours.
• Coordinate with prescribing clinician to request transitional medication fills and notify the pharmacy.
• Open a network exception request or single-case agreement for critical out-of-network providers and track escalation.
• Provide the member with a status summary and expected resolution timeline within 48 hours.
• Confirm Preferred Communication Channels
• Establish a persistent, member-accessible support channel for issues and enhancement requests.
• Enroll the member in appropriate care coordination or value-add programs that improve access and outcomes.
• Agree a recurring review cadence and two measurable success metrics to track post-enrollment health of coverage.
• Create and invite the member (and caregiver, if applicable) to the shared CustomerNode channel and verify access.
• Enroll the member in nurse line and any eligible care management programs discussed.
• Schedule the first 30-day and 90-day check-ins and add calendar invites to the shared channel.
• Introductions & Meeting Objectives
• Verify and document that the enrollment is active and the effective date is confirmed.
• Ensure the member has received or can access their ID card and credentials to use the member portal.
• Identify any activation gaps that require immediate escalation and set timelines for resolution.
• Establish the next communication touchpoint and owner for outstanding items.
• Send digital copy of member ID card and portal login instructions immediately after meeting.
• If enrollment shows pending/hold, escalate to enrollment operations with documented evidence within 24 hours.
• Create a brief one-page 'what to show providers' handout for the member outlining interim proof options.
• One-sentence Current State Summary
• Confirm in-network status for PCP and top specialists or identify concrete in-network alternatives.
• Determine formulary coverage for all active medications and identify which require prior authorization or step therapy.
• Agree a remediation plan for each identified gap with owners and target resolution dates.
• Validate the member's acceptance of alternatives or remediation approaches.
• Document and share the live provider and formulary lookup results with the member.
• Activate Shared Support Channel
• Current Activation Status
• Prior Authorization & Appeals Triage
• Consequence Framing
• Introduce Care Coordination & Value-Add Programs
• Live Network Verification
• Why Activation Timing Matters
• Transitional Medication Strategy
• Network Exceptions & Out-of-Network Denials
• Access Artifacts & Portal Walkthrough
• Formulary Matching & Coverage Details
• Benefits Enhancement Opportunities
• Timeline, Owners & Reporting
• Interim Coverage Guidance
• Recurring Check-in Cadence & Success Metrics
• Proof Points — Show Evidence
• Define Future State & Remediation Plan
• Confirm Next Steps & Communication Plan
• Member Validation