Avoid Common Compliance Pitfalls This AEP

Avoid Common Triggers and Protect Your Reputation

Every Annual Enrollment Period (AEP) brings incredible opportunities for growth — but also an increase in compliance scrutiny. Each year, CMS sees a spike in Complaint Tracking Module (CTM) cases, many of which could have been prevented with better communication, documentation, and clarity during the sales process.

For insurance agents, avoiding complaints isn’t just about compliance — it’s about protecting your reputation, maintaining carrier relationships, and building lasting trust with clients. Below are some of the most common complaint drivers and how to prevent them this AEP.

[Related - https://www.psmbrokerage.com/blog/agent-compliance-tips-for-the-2026-aep]

1. Present Benefits Clearly and Accurately

A large percentage of CMS complaints come from beneficiaries feeling they weren’t fully informed about what their plan includes — or excludes.

Before you start presenting benefits, make sure you fully understand the plan’s structure, costs, and coverage limits. Communicate those details in a simple, transparent way and confirm that you’re speaking with the actual decision-maker.

Be extra cautious when discussing high-interest benefits like spending account cards, dental, vision, hearing, transportation, or flex benefits. These tend to generate the most confusion when expectations don’t match reality.

Tip: Review plan summaries before each appointment. Avoid assumptions — if you’re unsure about a specific benefit or rule, check with your upline or carrier before explaining it to the client.

2. Confirm You’re Enrolling the Right Person

Never assume the person on the call or in the meeting is the one making healthcare decisions. Ask directly if they handle their own healthcare choices.

If a Power of Attorney (POA) or legal guardian is present, verify their authorization before proceeding. CMS may request proof later, and agents are responsible for ensuring proper documentation is available.

This small step can prevent significant compliance issues later and demonstrates professionalism in how you handle sensitive situations.

3. Explain Common Areas of Confusion Upfront

Many complaints stem from clients feeling “surprised” after enrollment. By proactively explaining certain topics, you can eliminate most of those situations before they start.

Late Enrollment Penalty (LEP): Let beneficiaries know that failing to maintain creditable drug coverage can result in a penalty if they go more than 63 days without it.

Chronic Condition Special Needs Plans (C-SNPs): Clearly explain eligibility requirements and the need for their physician to complete the Verification of Chronic Condition (VCC) form. Remind them that failing to return it within two months can lead to disenrollment.

Part B Giveback: Many beneficiaries misunderstand how this works. Make sure they know it can take up to three months before the giveback appears, depending on whether they pay premiums through Social Security, Medicare directly, or Railroad Retirement.

Setting expectations early shows you’re knowledgeable and transparent — and helps clients stay patient while waiting for their benefits to activate.

4. Handle Veteran and Dual-Eligible Cases with Care

Veterans and dual-eligible beneficiaries often have overlapping benefits, which can make their situations more complex. A little extra care goes a long way in preventing confusion.

If your client has TRICARE for Life, CHAMPVA, or VA benefits, explain how Medicare Advantage plans work alongside their current coverage. Make sure they understand that:

• VA and Medicare are separate programs — they do not coordinate benefits.

• VA healthcare typically only covers services provided by VA physicians or facilities.

• Non-VA prescriptions usually cannot be filled at VA pharmacies unless approved by a VA doctor.

For veterans considering an Honors Plan, be sure to review how the plan could impact their existing benefits before enrollment.

5. Build Trust Through Consistent Communication

The foundation of compliance is trust — and trust is built through honesty, clarity, and consistency.

Before enrolling anyone, recap key benefits, verify understanding, and invite questions. Make sure the client knows exactly what they’re signing up for, what their responsibilities are, and when their coverage will begin.

Even a simple statement like, “I just want to make sure I’ve explained everything clearly — do you have any questions before we move forward?” can prevent a complaint later.

Clients appreciate thoroughness. When you take the time to educate them, you’re not only protecting yourself — you’re building a stronger, longer-lasting relationship.

The Bottom Line

Most compliance issues aren’t caused by bad actors — they’re caused by miscommunication. As AEP ramps up, take a few extra minutes with each client to ensure they understand their plan, the timing of benefits, and what to expect next.

A little extra effort today can prevent a lot of frustration later.

Clarity builds trust. Trust builds business. Stay compliant, stay confident, and make this your best AEP yet.