- HTA Insurance Services

Medicare Supplement Review

Phone Review Questionnaire

Scheduling Your Medicare Supplement Review

Complete the Health Questionnaire below first.

Many Medicare Supplement plans require medical underwriting when changing coverage, so we need your health information before scheduling your review.

After submitting the questionnaire, you’ll be redirected to our scheduling page where you can choose a convenient date and time for your appointment.

First Name (as on Medicare ID Card)(Required)

Last Name(Required)

Email Address(Required)

Phone Number(Required)

Has your Home Address (Primary Residence) changed in the last 12 months?(Required)

Yes

Address(Required)

City(Required)

State(Required)

Zip(Required)

Would you like to also shop for a spouse/partner?(Required)

Yes

Spouse/Partner Information

First Name (as on Medicare ID Card)(Required)

Last Name(Required)

Email Address(Required)

Phone Number(Required)

Medicare Supplement Plan

The best time to review your Medicare Supplement plan is typically around your policy renewal, when you receive your annual rate increase notice. If your rate has not changed since your last review, your options may be similar. Many clients find it helpful to compare rates every 3–5 years.

YOUR Medical Info

In most states, changing Medicare Supplement plans requires medical underwriting. Please answer the health questions below so we can better determine whether you may qualify to change plans and potentially lower your premium.

Change Preference (check all that apply)(Required)

I want to see if there is a lower premium for the same benefits i have now

I would be willing to consider lower benefits to save money

Current Plan(Required)

Current Premium(Required)

Frequency(Required)

Monthly

Quarterly

SemiAnnual

Annual

Have you recently received a rate increase notice?(Required)

Yes

Date of Increase(Required)

Premium after Increase(Required)

Tobacco Use(Required)

Yes

Congestive Heart Failure(Required)

Yes

Heart Attack, Stroke or TIA(Required)

Yes

Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)

Internal Cancer or Melanoma(Required)

Yes

Atrial Fibrillation(Required)

Yes

Diabetes(Required)

Yes

Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)

Diabetes with insulin use(Required)

Yes

Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)(Required)

Yes

Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc(Required)

Kidney or Liver Disease(Required)

Yes

Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required)

Yes

Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required)

Yes

Details on Kidney, Liver, Osteoporosis, Parkinsons, Arthritis or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)

Any physical, occupational or speech therapy- in past 6 months, current, or recommended?(Required)

Yes

Any scheduled or recommended surgery or treatment in next 12 months?(Required)

Yes

Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc(Required)

SPOUSE/PARTNER'S Medical Info