It is October 15th. A member enrolled 11 months ago calls to say their Explanation of Benefits shows a specialist visit billed out-of-network. The specialist was in-network when they enrolled. She is not anymore. The plan renewed in January without anyone checking the provider directory. The member has already paid two out-of-network bills this year. The broker's name is on the enrollment confirmation from last November. This is the call the annual review prevents.
Key Takeaways
- Auto-renewal keeps members covered but does not keep them on the right plan. A member who auto-renews every year may be paying $200 more per month than a comparable current-year plan, or staying in a network that dropped their specialist.
- The annual review call belongs in October, not November. Brokers who start in November are competing for attention with every other OEP outreach in the industry.
- Three things change year to year that affect every member: plan premiums, the SLCSP benchmark, and carrier network composition. Any of the three can make last year's right answer wrong for this year.
- Members who receive a review call are significantly more likely to stay with their broker through the following renewal. The call does not need to change the plan. It needs to show the broker looked.
- Prioritize the review queue by risk: members with income changes, members on plans with carrier exits, and members whose specialist relationships depend on a specific network get contacted first.
Why auto-renewal is not a retention strategy
Auto-renewal is the Marketplace's fallback for members who do not actively re-enroll. It keeps them covered. It does not keep them on the right plan. Three things change every plan year that affect nearly every member: plan premiums, the SLCSP benchmark that determines APTC, and carrier network composition. A plan that was the right call in November may be the wrong one by the following October for reasons that have nothing to do with the member's situation.
The broker who calls in October to review is not selling anything. They are confirming that the plan still fits, or finding the one that does. That call is the reason the member stays with the same broker through the next three renewals. Brokers who skip it are relying on inertia rather than value.
The review call checklist
| Review item | What to check | Action if changed |
|---|---|---|
| Income change | Did the member's projected household MAGI change from what was reported at enrollment? | Update the income estimate in the Marketplace account. Recalculate APTC. Reassess metal tier if the CSR band changed. |
| Household composition | Marriage, birth, adoption, household member turning 26 and aging off the plan? | Update household size in the application. Rerun APTC and CSR eligibility with the new household. |
| Premium change | Has the current plan's premium increased for the new plan year? By how much relative to alternatives? | Run a full plan comparison for the new year. A $80/month premium increase may have a comparable alternative plan. |
| SLCSP and APTC shift | Has the SLCSP changed in the rating area? APTC is recalculated annually against the new benchmark. | Rerun the subsidy estimate for the new plan year to confirm the net cost is what the member expects. |
| Network and specialist | Is the member's primary care physician, specialist, or hospital still in-network on the current plan? | Check the plan's new-year directory. If the provider dropped out, compare networks across available plans. |
| Formulary | Are the member's maintenance prescriptions still covered at the same tier and cost? | Run the formulary check on the current plan for the new year. If a drug moved tiers or was excluded, compare alternatives. |
| Plan or carrier exit | Is the member's current plan still available in the new plan year? Has the carrier exited the market? | Member must actively select a new plan. Auto-renewal into a carrier exit enrolls them in a default plan the carrier selected, which may not be right. |
How to prioritize a large review queue
A broker with 200 active members cannot do a 30-minute review call for every one of them in October. The queue needs to be ordered. Three categories of members get contacted first.
Members on plans with carrier exits or significant changes. If a carrier announced they are leaving a market or discontinuing a plan, those members must choose a new plan actively. Auto-renewal puts them into a carrier-selected alternative that may be poorly matched. These members need a full review call, not an email.
Members with significant income changes. A member whose income moved meaningfully since enrollment has a different APTC calculation and possibly a different CSR eligibility level. The plan that was right for their old income may not be right for the new one. Income changes also create reconciliation risk on if the Marketplace APTC was not updated during the year. For how the tax reconciliation works, read and Form 8962: what brokers need to know at tax time.
Members whose care depends on a specific provider. Any member who is actively treating a condition with a specific specialist or using a specific hospital needs a provider directory check for the new plan year. Networks are renegotiated annually and providers come in and out. A member in active cancer treatment whose oncologist drops out of network cannot wait until February to find out. For a framework on how network type affects which members are most exposed, read ACA network types: HMO, PPO, EPO, and POS explained.
Running the review call
Before the call: pull the member record, confirm the current plan is still offered in the new year, note the premium change if any, and run a preliminary APTC estimate for the new year. Five minutes of prep makes the call feel like the broker has been paying attention all year, because they have.
During the call: confirm the household and income are unchanged or capture the changes. Run a plan comparison live on screen with the member if there is any reason to consider switching. The plan comparison on live Marketplace data takes less than two minutes once the household information is current. If the current plan is still the right call, confirm that explicitly. Members want to know the broker looked, not just that the plan renewed.
After the call: send the same-day email confirming what was decided and the coverage start date for the new year. If the plan changed, confirm the new plan name, premium, and APTC. If it did not change, confirm the plan is renewing and note anything the member should watch for in the new year. For how to structure the ongoing communication cadence between reviews, read member follow-up cadences that do not feel spammy.
October, not November
New plan year data hits the Marketplace in late October. OEP starts November 1. Brokers who begin their review outreach in October complete most of their calls before the high-volume stretch of November and December, when carrier outreach, CMS notifications, and every other OEP communication is competing for the member's attention.
An October review call is also the only one that has time to resolve complications before the enrollment deadline pressure arrives. A member whose specialist network situation needs investigation has more time to sort it out in October than in the last week of December. For the full AEP preparation framework including pre-season outreach timing, read the AEP 2026 prep checklist for brokers.
FAQ
Questions brokers ask about managing the annual member review process.
What happens if a member does not review their plan and auto-renews?
The member stays enrolled in a plan, either the same plan if it is still available, or a carrier-selected alternative if it is not. Auto-renewal does not check whether the premium changed, whether the provider is still in-network, whether the formulary still covers their medications, or whether their income changed in a way that affects their APTC. The member is covered. They may not be covered well.
How long does an annual review call take?
For most members with no major life changes, 15 to 20 minutes. The bulk of that is pulling the current plan details and the new-year comparison on screen. For members with income changes, household changes, or carrier exits, allow 30 to 40 minutes. The prep work before the call, pulling the member record, checking the current plan's new-year status, running a preliminary APTC estimate, takes another 10 minutes and makes the call itself faster.
When is the right time to start annual review outreach?
October. New plan year data is typically available in the Marketplace by late October, and OEP starts November 1. Brokers who begin outreach in October complete most of their review calls before the high-volume weeks of November and December. Brokers who wait until November are competing with carrier outreach, CMS notifications, and every other OEP touchpoint the member receives at the same time.
Should I review every member every year?
Yes, at least a brief check. For members with no life changes and a stable plan, the review can be a short email or voicemail confirming the plan is still appropriate and inviting them to call if anything has changed. The full 20-minute call is warranted for members with income changes, household changes, specialist dependencies, or plans that had significant premium movement.
What if a member says they do not want to do a review?
Document that the broker offered the review and the member declined. Send a brief email confirming the current plan will auto-renew and noting two or three things that could change the math: income change, a new prescription, or a provider moving out of network. The email gives the member a reason to call back if any of those things happen, and it documents the broker's effort if the member later has a complaint about the renewal.
