Medicare Assessment

Medicare Assessment
This form is optional. However, providing this information helps us greatly as we determine whether you should enroll in Medicare in the first place, and which Medicare health plans could be suitable for you.

For married couples, you can submit one Assessment. For your spouse's medications and medical providers, enter their name and information in the Overflow textbox in those sections.

Your information will be kept confidential and will NOT be shared with any 3rd party.
Contact Info

Medicare-eligible individual (or soon-to-be eligible)
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home County
(i.e. Hamilton, Butler, Montgomery)
Marital Status

SingleMarriedDivorced or SeparatedWidowedEngaged

MEDICATIONS
Do you take any regularly prescribed medications? [ignore OTC, vitamins]*

YesNo
- DO NOT include OTC, vitamins, supplements, or ED drugs.
- If you take the generic version of a drug, just list the generic name...NOT the brand name.
- If you do indeed take the brand version of a drug, list the brand name.
- Make note if it's a TABLET or CAPSULE
- Make note if it's Extended Release (ER) or Slow Release (SR)
- If you take any drugs PRN (as needed), be specific with the dosage and how often it is filled (i.e. 30 tabs every 3 months)
- For insulins, please list how many pens or vials you use every month or 3 months. We cannot calculate daily values.
- For inhalers, please list how many you use every month, 3 months, 6 months, or annually. We cannot calculate by metered spray.
  
  Use the table below to fill in your medications. Reference the examples on how to enter the data.
  
  EXAMPLES:
  Metoprolol Succ ER | 25mg tablet | 1x/day
  Combigan 0.2%/0.5% | 1 drop daily | 5mL bottle/month
  Clobetasol cream | 0.05% | 30gm tube/3 months
  Lantus Solostar | 100U/mL pens | 1 box of 5 pens/month
Your Preferred Pharmacy (just the name) or Mail Order*
(i.e. CVS, Kroger, Walgreens, Mail Order)

MEDICAL PROVIDERS
Do you have any medical providers you need access to on a regular basis?*

YesNo, I don't have a doctor or don't particularly care who I see
List the medical providers you see regularly or have seen in the past 1-2 years. You can include dentists and vision providers too.

If you wish to have access to certain hospitals or facilities, please make note.

Use the table below to fill in your medical providers. Reference the examples on how to enter the data.

Derrick Wilhelm | Primary | Mason, OH
Christine Myers | Cardiologist | West Chester, OH
Cleveland Clinic | Hospital | Cleveland, OH

INSURANCE PREFERENCES
Are you familiar with the differences between Original Medicare with a Medigap plan...versus...a Medicare Advantage plan?
Medical provider access -- Which do you prefer?

Nationwide access with no network or referral requirementsNetwork sensitive PPO or HMO is fine, as long as my doctors are in-network
Monthly insurance premiums & medical expense exposure -- Choose ALL that apply

I'm fine with a higher overall premium, if it means my medical expenses will be low...no matter my health situationI want a lower overall premium, and I'll pay for medical expenses as needed (up to a max out-of-pocket limit)I would like a good balance...a low-to-moderate overall premium, but not too high of a max out-of-pocket limit
2nd home and travel plans -- choose ALL that apply

I'm a snowbird or have a second home in another stateI plan to travel throughout the US and/or internationallyI don't travel much or at all
How important are built-in additional benefits, such as dental, vision, hearing, a no-cost fitness membership, over-the-counter (OTC) benefits, etc?
Tells us anything else you feel is important to you about your medical and prescription drug coverage.

INCOME

Your MAGI (Modified Adjusted Gross Income) determines your Medicare premiums paid to the government
How do you file your taxes each year?
In 2021, what was your Modified Adjusted Gross Income (Form 1040 Line 11 plus Line 2a)?
In 2022, what was your Modified Adjusted Gross Income (Form 1040 Line 11 plus Line 2a)? -- If you haven't filed your 2022 taxes, use an estimate for now
In 2023, what do you anticipate your Modified Adjusted Gross Income to be?
Are you planning to retire from employment, or did you retire in the past few years?
Are you receiving Social Security benefits?*

CURRENT HEALTH INSURANCE
Are you enrolled in any part of Medicare? [Note: If you're receiving Social Security benefits and are age 65+, you already have at least Part A]
Current health insurance is through:
Who is covered?
Current insurance carrier:
(i.e. Anthem, Humana, United Healthcare, etc)
How many employees does your employer have? [or your spouse's employer...whichever employer provides your health insurance]
What is your health plan premium? [$ amount and how often]
(i.e. $40/week, $75 twice/month, $80 every 2 weeks, $150/month)
What is your health plan deductible? [individual amount, not family amount]
What is your health plan max out-of-pocket limit? [individual amount, not family amount]
Are you contributing to an HSA (Health Savings Account) or have an existing HSA?
Are you losing health insurance within the next 6 months?
Health insurance loss of coverage date (estimate if not sure):
Do you have access to a retiree health insurance program through a current or former employer? If so, which one?
Do you have access to medical and/or drug coverage based on your military service? If so, which one?
Additional Notes:
Submit Form
Ready to submit? Choose YES and then click Submit at the bottom.*

YES
Should be Empty:

	DRUG NAME (e.g., Metoprolol Succ ER	DOSAGE (e.g., 25mg tablet; specify capsule or tablet	QUANTITY & FREQUENCY (e.g., 1x/day)
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Contact Info