By Angela Palo
AEP is here, and this is another big year of change in Medicare Advantage.
Approximately 3.1 million MA-PD members will have their current plans terminated at the end of 2026, including about 2.8 million members in individual MA-PD plans and another 300,000 in Special Needs Plans. When standalone Part D plans are included, approximately 4.3 million Medicare beneficiaries will have a private Medicare plan terminated at year-end. That is a lot of people who are going to need help.
While some already know their plan is going away, others may be dealing with other things beside a Service Area Reduction like changes to their providers, increased costs, changes to benefits or prescription drug coverage.
And the disruption is not the same everywhere. Prior-year data showed that rural members were disproportionately affected by plan terminations. Rural beneficiaries represented approximately 14% of individual MA-PD enrollment but 23% of the members affected by terminations.
Provider contracting is adding to the confusion. Hospitals and health systems continue to change which Medicare Advantage carriers and products they participate with.
CMS also finalized policies projecting a 2.48% net average increase in Medicare Advantage payments to plans for 2027. That does not mean every carrier or market receives the same increase. It also does not mean benefits, networks and formularies will not change.
We know there is disruption. The question is what we do with it.
Start with where the disruption is
Medicare Advantage is local. What is happening in one county can look completely different in the county next door. Organizations and licensed insurance agents need to know the following if they want to sell the right plan to their clients:
- Which plans are terminating
- Where there are Service Area Reductions
- Which carriers are expanding or pulling back
- Approximately how many members are affected
- Where significant provider changes are happening
- Which new products have entered the market
- Where members have more choices and where they have fewer
This is not about creating another spreadsheet just to have a spreadsheet. It’s about knowing where members are being affected and where licensed insurance agents should be spending their time.
Use the technology you already have
The good news is that you don’t have to build all of this from scratch. Enrollment platforms such as SunFire and Connecture already give licensed insurance agents significant plan comparison and enrollment capabilities.
Instead of manually building huge grids with every plan in every county, licensed insurance agents should use the technology already available to them. The process can be straightforward:
- Find the disruption
- Identify the member
- Understand what the member needs
- Compare the available options
- Verify the important details
- Enroll using the appropriate election period
- Document the interaction
That is what I mean by “Disruption to Direction.” It’s taking something that could be chaotic and turning it into a repeatable AEP process.
Start with the member, not the plan
This is one of the most important parts of the process.
The goal should not be: “What plan can I switch this member to?”
It should be: “What does this member need from their coverage in 2027?”
Many of today’s CRMs, including ours, can automate much of the member-specific needs review. That gives the licensed insurance agent a consistent process instead of depending on someone to remember every question during one of the busiest times of the year.
The needs review should include:
- Primary care doctor
- Specialists
- Preferred hospitals and health systems
- Prescription drugs
- Preferred pharmacies
- Premium and cost concerns
- Maximum out-of-pocket exposure
- Travel or multi-state needs
- Benefits that are important to the member
- Other healthcare and coverage priorities
Once the licensed insurance agent understands what matters to the member, SunFire, Connecture, or another enrollment platform can help narrow the available choices.
Technology makes the process faster, but it does not replace the licensed insurance agent. You still need to verify the information that matters most, especially providers, prescriptions, pharmacies, costs and eligibility, before the member makes a final decision.
Know your downlines
Finding the opportunity does not help if it ends up with a licensed insurance agent who cannot service it. There should be a straightforward routing process.
1. Make sure licensed insurance agents are ready
This means they must be properly licensed, appointed and certified for the products being discussed or enrolled.
2. Know which election period is being used, especially important this year
For members whose plans are terminating at the end of December, AEP gives us an immediate opportunity to help them evaluate their 2027 coverage. But it’s important to remember December 7 is not necessarily the end of the opportunity for members affected by a plan non-renewal or Service Area Reduction.
CMS provides special enrollment rights for beneficiaries affected by certain non-renewals and Service Area Reductions. That means we may still be able to help those members after AEP ends. That’s why it’s critical to identify the correct election period and confirm that the member qualifies before completing the enrollment.
A provider leaving a network is different. A doctor or hospital dropping out of a network does not automatically give every affected member a Special Enrollment Period. Eligibility must be verified.
3. Complete the member-specific needs review
The needs review should be completed before recommending a plan. If CRM or enrollment technology can automate the review, use it. Consistency matters if you value quality, especially when volume is high.
4. Use the enrollment platform
Take everything learned about the member and use SunFire, Connecture, or the applicable enrollment platform to compare available choices. The platform does much heavy lifting. The licensed insurance agent still brings the judgment.
5. Do not let compensation drive the recommendation
We need to know whether a licensed insurance agent is appointed and certified and whether a product is commissionable. Those are legitimate operational considerations. However, compensation should not determine which plan is presented as the right choice for the member. The member’s needs come first.
6. Document the interaction
Make sure the appropriate Scope of Appointment, permission-to-contact documentation, disclosures, needs analysis and enrollment records are completed and retained as required. This is where a repeatable process helps. It does not just make the process faster. It makes the process more consistent and creates a stronger compliance trail.
We are in AEP now
AEP started October 15 and runs through December 7, 2026. This isn’t something licensed insurance agents should start thinking about for later. You should be doing it right now.
Look at your book of business and ask:
- Which members are losing their plans?
- Which members are affected by an SAR?
- Which members are dealing with provider changes?
- Are you consistently completing a member-specific needs review?
- Are licensed insurance agents using the capabilities available in SunFire, Connecture and other resources available?
- Are members getting routed to licensed insurance agents who are properly licensed, appointed and certified?
- Are you tracking members whose enrollment opportunities may continue after AEP?
That’s the difference between being reactive during AEP and being proactive in assisting your clients.
Don’t stop on December 7
AEP ends December 7, but that does not necessarily mean the work ends December 7. Members affected by certain plan non-renewals or Service Area Reductions may have an enrollment opportunity beyond AEP under CMS rules. So, when AEP ends, do not shut down the process.
Identify the members who may still be eligible to make a change and keep the process moving:
- Identify the affected member
- Verify the election period
- Complete the needs review
- Compare the available options
- Verify doctors, prescriptions and pharmacies
- Complete the enrollment
- Document the interaction
That is why the turning Disruption into a directed sales approach is not just an AEP strategy. It is an AEP and post-AEP strategy. And remember, OEP Gives You Another Opportunity
From January 1 through March 31, the Medicare Advantage Open Enrollment Period (OEP) gives members who are already enrolled in a Medicare Advantage plan another opportunity to make a change. They can make one change to another Medicare Advantage plan or return to Original Medicare, with the option to add Part D when applicable. This is another reason to keep the process running beyond AEP. Members may realize after January 1 that their new plan isn’t working the way they expected, whether because of doctors, prescriptions, costs or other coverage needs. The same process still applies: understand what’s not working, complete the member-specific needs review, use the technology to compare the available options, verify the details and make sure the correct election period is being used.
Frequently asked questions
Why does this matter so much this year?
Because there are a lot of people who need help. Approximately 4 million MA-PD members are enrolled in plans terminating at the end of 2026. That is a significant number of beneficiaries who may need to evaluate their coverage options for 2027.
Do licensed insurance agents need to build their own plan grids?
Not necessarily. SunFire, Connecture and other enrollment platforms already do much of this work. The smarter approach is to take advantage of the technology already available.
Think of it this way:
- Market intelligence tells us where the disruption is.
- The CRM tells us what the member needs.
- The enrollment platform helps us compare the choices.
- The licensed insurance agent brings it all together.
Why is the member-specific needs review so important?
Finding out that a member’s plan is going away is only the beginning. It tells us why the member needs help. The needs review tells us what the member actually needs.
The member’s doctors, prescriptions, hospital, pharmacy and costs may matter much more than finding a plan that simply looks similar to the one being terminated.
What should the enrollment platform do?
The enrollment platform should make the licensed insurance agent faster and more efficient. Use the technology to narrow the options based on the member’s needs. Then verify the critical information and help the member understand the available choices. Technology supports the licensed insurance agent. It does not replace them.
Can we still help SAR members after December 7?
Potentially, yes, and this is important. Members affected by certain Medicare Advantage non-renewals or Service Area Reductions may have special enrollment rights that extend beyond AEP. CMS has specific guidance for non-renewals and Service Area Reductions. The key is identifying those members and verifying the applicable election period before enrolling them.
Does losing a doctor automatically give the member an SEP?
No. A doctor or hospital leaving a plan’s network does not automatically give every affected member an SEP. There are circumstances where special enrollment rights may apply because of a significant network change, but eligibility must be verified.
