Do-Not-Engage Hard Stops — PEAK Agent Training

Before you ever run Discovery or recommend a plan, there are four situations where you stop and walk away. None of them are about whether a plan is a good fit — if any one of these is true, there is no fit to evaluate. Learning to recognize them in the first two minutes of a call protects the client, protects you, and protects the agency.

Read this before your first call If a prospect is in any of the four situations below, you do not proceed — not to “just take a look,” not to “get their information,” not to circle back later in the same call. You politely disengage, document the reason in the CRM, and move on. When in doubt, stop and ask your manager before doing anything else.

The four hard stops

Stop 01

Active employer coverage

The prospect currently has health coverage through an active employer (their own, a spouse’s, or a former employer still active).

RuleDo not sell against it.

WhyAdvising someone to drop or replace active employer coverage to enroll in a Medicare Advantage plan is a serious compliance violation.

Do thisConfirm whether the employer coverage is primary or secondary to Medicare, then disengage and document. Do not collect an application.

Stop 02

Nursing home / skilled nursing

The prospect currently resides in a nursing home or skilled nursing facility (long-term care, not short-term rehab with a discharge date).

RuleDo not engage.

WhyMarketing to or enrolling institutionalized individuals raises specific compliance and suitability concerns the agency has decided not to take on.

Do thisAsk where they’re living now and whether it’s permanent. If institutionalized, end the conversation and document.

Stop 03

Currently hospitalized

The prospect is an inpatient in a hospital right now, on this call.

RuleDo not engage.

WhySomeone mid-hospitalization is not in a position to make a coverage decision freely, and their care situation may change at discharge.

Do thisWish them well, note the hospitalization in the CRM, and tell them to reach out once they’re home and recovered.

Stop 04

TRICARE

The prospect is a TRICARE beneficiary (active-duty service member, retiree, or their family member using TRICARE).

RuleDo not engage.

WhyTRICARE beneficiaries already have coverage the agency does not sell against. This is company policy regardless of the specific TRICARE plan.

Do thisConfirm TRICARE status, decline to proceed, and document.

How to surface these early Don’t wait until you’re deep into Discovery to ask. Lead your first two minutes with a short screening script (below). Most people in a hard-stop situation will tell you directly once you ask plainly — the goal is to find out before either of you invests time.

The two-minute screening script

Use something close to this in your introduction. Keep it conversational, not like a checklist being read at someone.

Suggested screening language

“Before we get into plan options, I just need to confirm a couple of things to make sure we’re even the right people to help you…”
“Do you currently have health coverage through an employer — yours, a spouse’s, or a former employer?”
“Are you currently living in a nursing home or skilled nursing facility, or in the hospital right now?”
“And do you have TRICARE coverage through the military?”

When an answer lands you in a hard stop Don’t argue, don’t try to find a workaround, and don’t promise to revisit. A clean, honest exit builds trust and keeps the agency compliant: “Based on what you’ve told me, our agency actually isn’t able to help with a plan change in your situation — that’s a company policy, not a reflection on you. I’m going to note this in our system so no one reaches back out by mistake.” Then document and move on.

When MARx shows only A & B

MARx (the Medicare enrollment database) shows a beneficiary’s active Medicare parts — A, B, C (Medicare Advantage), and D. It does not show Medigap, employer coverage, VA benefits, or TRICARE. So “MARx shows only A and B” means the client has Original Medicare with no MA plan on file — it does not mean they have no other coverage.

If the client pays nothing at the doctor On Parts A & B alone, with no supplement, a client pays 20% coinsurance for Part B services and has no cap on out-of-pocket costs. So if a prospect tells you they “don’t pay anything at the doctor,” something is covering that gap — and finding out what is your job. Don’t assume they simply have A & B; dig for the supplemental coverage MARx won’t show you.

What it could be	What to do
Medigap (Plan G or Plan F)	A Medicare Supplement that pays the Part A & B cost-sharing. Legitimate to discuss whether Medicare Advantage fits them — you’re not selling against an active employer plan. Confirm the plan and the client’s goals before recommending a switch.
Standalone PDP (Part D only)	If they have drug coverage but no medical supplement, find out what’s covering their doctor visits. If nothing is, that’s a clean opening to talk about MA — but confirm first, don’t guess.
Active employer coverage	Their own, a spouse’s, or a former employer still active. Hard stop — do not sell against it.
Retiree / former-employer coverage	Has its own rules and may coordinate with Medicare. Verify the status with the employer benefits administrator before proceeding.
VA benefits	Separate federal coverage. Coordinate carefully; never assume it’s a substitute for proper enrollment verification.
TRICARE	Hard stop — do not engage. Applies to any TRICARE beneficiary.

Confirm before you enroll MARx is a starting point, not the full picture. A prospect saying “I just have A and B” while paying nothing at the doctor is a signal to keep asking — not a green light to write an application. Identify every form of coverage they have before recommending a plan, and treat any active employer or TRICARE situation as a hard stop.

What to do if you’re unsure

01
Stop the sale conversation.If a screening answer is ambiguous — say, “I think my old employer plan ended” or “I’m in rehab but leaving soon” — treat it as a hard stop until it’s resolved, not as a green light.
02
Document exactly what you heard.Note the client’s words in the CRM, which stop applies, and the date. Documentation is your protection if anything is ever questioned.
03
Ask your manager before proceeding.When in doubt, escalate first. A two-minute check with your manager is always cheaper than a compliance issue after the fact.

The non-negotiables Never advise, suggest, or imply that a prospect should drop employer coverage to enroll in a plan we offer. Never collect an application from someone in a nursing home, currently hospitalized, or on TRICARE. These apply on every call, every plan type, every time — including D-SNP and C-SNP conversations covered in Module 06. A qualifying condition or dual status does not override a hard stop.

Practice scenarios

Work through each one yourself first, then reveal the reasoning. The pattern you’re training is the same one you’ll use on live calls.

Scenario 1

Margaret, 67, calls in interested in a plan with dental. During screening she mentions her husband is still working and she’s on his employer’s group health plan as a dependent. What do you do?

Hard stop — employer coverage

Active employer coverage is Stop 01, regardless of whether she’s the primary or a dependent. Do not collect an application, do not run plan comparisons, and do not suggest she could drop his coverage. Confirm the employer plan, politely explain the agency can’t help in this situation, document it in the CRM, and end the call.

Scenario 2

James, 72, is interested in a D-SNP. He confirms he’s dual-eligible (Medicaid) and has diabetes — both genuine qualifying factors. He also mentions he’s calling from a hospital bed because he was admitted three days ago. What do you do?

Hard stop — currently hospitalized

Stop 03 overrides the qualifying factors. D-SNP eligibility (Module 06) does not get you past a hard stop — the compliance note above says so explicitly. Wish him a smooth recovery, tell him to reach out once he’s home, document the hospitalization, and do not proceed with enrollment. When he calls back discharged, you can pick up the D-SNP conversation normally.

Scenario 3

Robert, 68, mentions he’s a military retiree and uses TRICARE for Life. He says he’d still like to “see what’s out there” and is happy to compare. What do you do?

Hard stop — TRICARE

Stop 04 applies to any TRICARE beneficiary, including TRICARE for Life, and company policy holds regardless of the specific plan or his willingness to compare. Do not show him plan options to “just compare.” Explain the agency doesn’t sell against TRICARE, document, and disengage.

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