LPPO & HMO D-SNP Sales Tips for AEP

As AEP continues, we’re resurfacing key reminders that can help you and your teams prevent avoidable member complaints—especially with LPPO and HMO D-SNP enrollments. The most common post-sale issues stem from misunderstandings about provider access, how plans work, and benefit usage. Clear, proactive conversations solve most of them.

Quick refresher: LPPO & HMO D-SNP plans

 LPPO (Local Preferred Provider Organization)

• In-network and out-of-network access, with different cost-sharing.

• Out-of-network providers can refuse to see members unless it’s an emergency.

• Network access is limited to a local service area (often a few counties).

• Misconception to correct: “I can see any doctor.” → You must verify each provider’s network status.

  HMO D-SNP (Dual Eligible Special Needs Plan)

• For people who qualify for both Medicare and Medicaid.

• Requires in-network providers (except emergencies).

• Misconception to correct: “Any Medicaid provider will accept my plan.” → Providers must be contracted with the HMO D-SNP.

• Often includes extra benefits (e.g., transportation, dental) that vary by plan and should be explained.

• PCPs are usually required; referrals may be needed.

 Provider access: set expectations

• Treat provider verification as non-negotiable:

  • Confirm full name + office address for every doctor/specialist.

  • Use the plan’s online directory or provider lookup in real time during the appointment.

• Clarify HMO D-SNP rules:

  • Not all Medicaid providers accept the member’s D-SNP. They must be contracted with the D-SNP.

• If any providers are out-of-network:

  • Explain higher costs and possible refusal of service (PPOs are not required to see non-members outside emergencies).

  • Reinforce this language: “Out-of-network doesn’t mean covered. Providers can decline to see PPO members.”

  • If the member’s PCP is OON, help select a new in-network PCP on the spot.

  • Offer a printed directory or show how to search on the plan’s site.

Micro-script you can use:
“Let’s lock in your doctors. I’ll check your PCP and specialists by name and location to confirm they’re in-network for this plan. If anyone isn’t, I’ll explain what that means and help you pick a new in-network option if needed.”

 Spending cards: cover the details

• Name the card type and scope: Flex, OTC, Healthy Options, SSBCI, etc.

• Explain how to activate and use the card (in-store vs. online, participating retailers, reload timing).

• Clarify eligible items (e.g., groceries, utilities, OTC meds) and restrictions.

• If excitement is high, go deeper—these benefits are a top source of confusion. More clarity now = fewer issues later.

Micro-script:
“You’ll receive a [Card Type] that you can use for [eligible categories]. Let’s walk through where it works, how to activate it, and common limitations so you know exactly what to expect.”

  RX accuracy: slow is smooth, smooth is fast

• Ask the member to read directly from the prescription bottles (avoid memory or handwritten lists whenever possible).

• Use the plan’s formulary lookup for each drug; check for PA, step therapy, and quantity limits.

• Explain terms in plain language:
  “Prior authorization means your doctor may need to send the plan more information before the medication is approved.”

• Never guarantee coverage/approval, even if covered last year or by another plan.

• If the member is unwilling to switch meds or manage PA, consider another plan.

Micro-script:
“Let’s check each medication in the formulary together. If any need extra steps, I’ll explain what that looks like and whether a different plan might fit better.”

Other common complaint drivers

• ID cards: Set the timeline expectation and show how to print/request one online if needed.

• LEP (Late Enrollment Penalty): Ask about continuous drug coverage; explain how LEP works and that it may appear as a premium charge.

• Note: LEP presence should not drive you to recommend MA-only instead of MAPD. Fit the coverage to the member.

• Wellness & extras: Explain what’s included, how to access, and whether registration/scheduling is required (transportation, fitness, etc.).

Ask, don’t assume (engagement > presentation)

Use open questions to surface the details that matter:

• “How do you usually get your care—primary, specialists, clinics?”

• “Would you like me to double-check your doctors in the network right now?”

• “Any dental or transportation needs we should plan around?”

Members who feel heard and informed complain less and stay longer.

Agent checklist (save for your binder)

• ☐ SOA completed and on file for all Medicare topics to be discussed

• ☐ Providers verified by name + address in the correct plan directory

• ☐ OON implications explained; in-network PCP selected if needed

• ☐ Spending card type, activation, eligible uses, and limits explained

• ☐ RX list read from bottles; formulary/PA/step therapy checked live

• ☐ ID card timeline covered; portal access shown if applicable

• ☐ LEP reviewed when relevant; plan still based on member need

• ☐ Wellness/extra benefits explained with access steps

• ☐ All confirmations and education documented in your CRM

Need compliant materials? Use the PSM Marketing Hub

The PSM Marketing Hub provides ready-to-use, compliance-friendly resources:

• Appointment checklists, provider verification scripts, RX review templates

• Member education one-pagers (spending cards, transportation, dental, etc.)

• Email/SMS follow-ups and “welcome” sequences to reduce day-30 confusion

• Tutorials for using plan directories and formulary lookups during appointments

👉 PSM-contracted agents get these at no cost. If you need custom versions with your branding, our team can help.

Visit the Marketing Hub

Final word

Most grievances are preventable. When you verify providers, clarify benefits, and check prescriptions live, you set realistic expectations and earn trust. That means fewer complaints, fewer avoidable disenrollments, and a better member experience.

Compliance note: Follow current CMS rules, carrier policies, and state regulations. Maintain SOAs and documentation per retention requirements. For consumer-facing materials, include required disclaimers (e.g., TPMO) based on your distribution model and state rules.