Plan Selection Framework — PEAK Agent Training

This is the module that makes you independent. Instead of memorizing plan features, work through the same decision path on every call — it will get you to the right category of plan before you ever start comparing specific ones.

Step 1

Is the client Medicaid-eligible — dual eligible?

YesVerify the exact type of dual eligibility, then evaluate a D-SNP. See Module 06.

NoContinue to Step 2.

Step 2

Does the client have a documented, CMS-qualifying chronic condition?

YesConfirm it against the 15 approved categories and evaluate a C-SNP. See Module 06.

NoNeither SNP category applies. Continue to Step 3 on a standard MA plan.

Step 3

Does the client have other creditable drug coverage they intend to keep?

YesConsider an MA-only plan instead of MAPD. Confirm creditable status first. See Module 07.

NoDefault to MAPD — bundled drug coverage, to avoid a Late Enrollment Penalty later.

Step 4

Apply the core criteria to every plan left on the shortlist — SNP or standard.

Provider access → formulary fit → benefits matched to Discovery → real costs → MOOP → star rating → year-over-year stability. Whichever plan wins on these, for this specific client, is the recommendation.

The core criteria, in detail

01
Provider accessAre the client's current doctors and specialists in-network? This is usually the first thing that can disqualify a plan outright.
02
Formulary fitAre their specific prescriptions covered, at what tier, and through which pharmacy network?
03
Extra benefits that match discovered needsDental, vision, hearing, OTC, transportation — only the ones that solve something the client already told you about.
04
Real costsPremium, deductible, and copays for the services this specific client actually uses — not the lowest advertised number.
05
Out-of-pocket maximum (MOOP)The client's worst-case annual cost if something serious happens.
06
Star ratingCMS's 1–5 star quality score for the plan. Also relevant for compliance — a 5-star plan opens its own special enrollment period, once per year.
07
Year-over-year stabilityHas this plan's network or benefits changed significantly in recent years? A cheap plan that changes every year isn't actually a stable fit.

This is the Soft Close, in practice A soft close that works sounds like: "You mentioned [discovered need]. This plan includes [benefit that solves it], your doctor at [provider] is in-network, and your worst-case cost for the year is capped at [MOOP]." That's three of the criteria above, tied directly to something the client said — and it earns a real yes before you move on to verifying every remaining detail.

Compliance note Steps 1, 2, and 3 all end in a verification requirement, not an assumption. A client saying "I think I'm on Medicaid" or "I have diabetes" is a reason to check — it's not itself the confirmation a SNP enrollment or an MA-only recommendation requires. Module 06 and 07 cover exactly what verification looks like for each.

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