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This guide is for training purposes only and should be used in conjunction with current CMS guidelines and carrier-specific compliance requirements. All agents must stay up-to-date with the latest Medicare regulations and compliance standards. The examples provided are for illustrative purposes and should be adapted according to specific situations and requirements.

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Summary of Benefits

Category: Compliant Medicare Sales Calls

Last Updated: March 12, 2025

CMS Reference:

• 42 CFR § 422.111(a),(b) (Plan benefits must be disclosed in clear, accurate, and standardized form)
• 42 CFR § 422.2262(a)(1)(i),(iii) & 422.2268(a)(1),(2) (Prohibits misleading or inaccurate information)
• 42 CFR § 422.2264(c)(3)(ii)(D) (Permits review of beneficiary health care needs, medications, and financial concerns)
• 42 CFR § 422.2267(e)(4) (Requires review of PECL contents during telephonic enrollments)
• 42 CFR § 422.2267(e)(5) (Requires dissemination of highly utilized benefits with cost-sharing details)
• 42 CFR § 422.2274(c)(9)(i) (Requires confirming beneficiary understanding of plan rules)
• MMCM CH 2: 40.1.3 & 40.4.1 (Requires that enrollees be provided benefit and cost information before coverage starts)

Overview

The Summary of Benefits (SB) provides beneficiaries with a clear, standardized, and accurate description of a Medicare Advantage (MA) plan’s key features, including costs, benefits, and coverage rules.

Agents must:

✅ Review the Summary of Benefits during every sales call.

✅ Ensure the beneficiary fully understands the plan details before enrolling.