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Annual Enrollment Period
Review Questionnaire – Appointment Scheduled
AEP Review Questionnaire – Already Scheduled
Please provide the date of your scheduled appointment with HTA
(Required)
MM slash DD slash YYYY
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
No
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Select which plans you would like to shop:
(Required)
Medicare Supplement Plan
Medicare Advantage Plan
Dental
Vision
Would you like to also shop for a spouse/partner?
(Required)
Yes
No
Spouse/Partner Information
First Name (as on Medicare ID Card)
(Required)
Last Name
(Required)
Email Address
(Required)
Phone Number
(Required)
Select which plans you would like to shop for your spouse/partner:
(Required)
Medicare Supplement Plan
Medicare Advantage Plan
Dental
Vision
Medicare Supplement Plan
The best time of year to shop your Medicare Supplement is when you receive your annual rate increase letter (typically 45 days before your policy anniversary). If you have not had a rate increase since the last time we shopped your plan, our recommendation likely has not changed. Clients typically find it most effective to shop their Medicare Supplement rates every 3-5 years.
YOUR Medical Info
Please answer the health questions below so we can best determine if you are eligible for a premium savings. Shopping a Medicare Supplement plan requires medical underwriting (in most states). Your health history can determine if you are eligible to change. Please indicate if you have been diagnosed or treated for any of the following health conditions in the last 10 years.
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)
Plan G
Plan F
Plan N
Plan High Deductible G (or F)
Medicare Advantage Plan
Other
Unsure
Current Premium
(Required)
Frequency
(Required)
Monthly
Quarterly
SemiAnnual
Annual
Have you recently received a rate increase notice?
(Required)
Yes
No
Date of Increase
(Required)
Premium after Increase
(Required)
Tobacco Use
(Required)
Yes
No
Congestive Heart Failure
(Required)
Yes
No
Heart Attack, Stroke or TIA
(Required)
Yes
No
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
No
Atrial Fibrillation
(Required)
Yes
No
Diabetes
(Required)
Yes
No
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
No
Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)
(Required)
Yes
No
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
No
Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)
(Required)
Yes
No
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis
(Required)
Yes
No
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
No
Any scheduled or recommended surgery or treatment in next 12 months?
(Required)
Yes
No
Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc
(Required)
Medicare Supplement Plan
The best time of year to shop your Medicare Supplement is when you receive your annual rate increase letter (typically 45 days before your policy anniversary). If you have not had a rate increase since the last time we shopped your plan, our recommendation likely has not changed. Clients typically find it most effective to shop their Medicare Supplement rates every 3-5 years.
SPOUSE/PARTNER'S Medical Info
Please answer the health questions below so we can best determine if you are eligible for a premium savings. Shopping a Medicare Supplement plan requires medical underwriting (in most states). Your health history can determine if you are eligible to change. Please indicate if you have been diagnosed or treated for any of the following health conditions in the last 10 years.
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)
Plan G
Plan F
Plan N
Plan High Deductible G (or F)
Medicare Advantage Plan
Other
Unsure
Current Premium
(Required)
Frequency
(Required)
Monthly
Quarterly
SemiAnnual
Annual
Has your spouse/partner recently received a rate increase notice?
(Required)
Yes
No
Date of Increase
(Required)
Premium after Increase
(Required)
Tobacco Use
(Required)
Yes
No
Congestive Heart Failure
(Required)
Yes
No
Heart Attack, Stroke or TIA
(Required)
Yes
No
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
No
Atrial Fibrillation
(Required)
Yes
No
Diabetes
(Required)
Yes
No
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
No
Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)
(Required)
Yes
No
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
No
Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)
(Required)
Yes
No
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis
(Required)
Yes
No
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
No
Any scheduled or recommended surgery or treatment in next 12 months?
(Required)
Yes
No
Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc
(Required)
Medicare Advantage- Your Insurance Coverage Preferences
Answering these questions will help us determine which types of plans may be most suitable to review with you. If you are interested in pursuing an MAPD plan, we will then gather a list of your doctors to confirm they participate with the plan.
How do you feel about premium vs medical costs?
(Required)
1-The most important thing is low premiums. I am willing to pay more for my medical care if necessary.
2-I am willing to pay a little more to have lower copays and less out of pocket risk.
3-I would prefer to pay more for a plan that will provide little to no out of pocket for my medical bills
How do you feel about provider networks?
(Required)
1-I don't mind picking my doctors and hospitals from a network listing
2-As long as I can still go to all of my current doctors and hospitals, I am not real picky
3-I would prefer to have freedom of choice of doctors and hospitals
Provider networks can differ from plan to plan (even within the same insurance carrier).
Will you need coverage in multiple states?
(Required)
1-I don't have a need for access to providers outside of my local area
2-It would be nice to have access to a few providers in other areas, but not a big concern.
3-It is very important for me to have access to providers anywhere in the US
Once your are diagnosed with certain medical conditions, some plans may not be available for purchase in the future.
Are you looking for ancillary benefits?
(Required)
1-I want ancillary benefits included in my plan for free (even if it means sacrificing on some other benefits)
2-I would be willing to pay more money for ancillary benefits if it means having better medical benefits.
3-I am not interested in any ancillary benefits
Some plans include some benefits for dental, vision, hearing, gym memberships and maybe even discounts on things like OTC meds or vitamins.
How do you feel about managed care?
(Required)
1-I don't mind managed care in exchange for lower premiums
2-I have no preference
3-I do not want the insurance company to have any authority over my care
Managed care is the insurance company working with your doctors to manage your care needs. Plans with managed care require prior authorization or approval on some services.
Would your answers change if you were in poor health?
(Required)
1-I prefer to save money now knowing I may not have access to lowest out of pocket plans later
2-I have no preference
3-I would rather pay more now to know I will be in a flexible plan with low medical costs if needed in the future
Once your are diagnosed with certain medical conditions, some plans may not be available for purchase in the future.
Medicare Advantage- SPOUSE/PARTNER'S Insurance Coverage Preferences
Answering these questions will help us determine which types of plans may be most suitable to review with you. If you are interested in pursuing an MAPD plan, we will then gather a list of your doctors to confirm they participate with the plan.
Insurance Coverage Preferences
My Coverage Preferences are the same as my Spouse/Partner's
My Coverage Preferences are different from my Spouse/Partner's
How do you feel about premium vs medical costs?
(Required)
1-The most important thing is low premiums. I am willing to pay more for my medical care if necessary.
2-I am willing to pay a little more to have lower copays and less out of pocket risk.
3-I would prefer to pay more for a plan that will provide little to no out of pocket for my medical bills
How do you feel about provider networks?
(Required)
1-I don't mind picking my doctors and hospitals from a network listing
2-As long as I can still go to all of my current doctors and hospitals, I am not real picky
3-I would prefer to have freedom of choice of doctors and hospitals
Provider networks can differ from plan to plan (even within the same insurance carrier).
Will you need coverage in multiple states?
(Required)
1-I don't have a need for access to providers outside of my local area
2-It would be nice to have access to a few providers in other areas, but not a big concern.
3-It is very important for me to have access to providers anywhere in the US
Once your are diagnosed with certain medical conditions, some plans may not be available for purchase in the future.
Are you looking for ancillary benefits?
(Required)
1-I want ancillary benefits included in my plan for free (even if it means sacrificing on some other benefits)
2-I would be willing to pay more money for ancillary benefits if it means having better medical benefits.
3-I am not interested in any ancillary benefits
Some plans include some benefits for dental, vision, hearing, gym memberships and maybe even discounts on things like OTC meds or vitamins.
How do you feel about managed care?
(Required)
1-I don't mind managed care in exchange for lower premiums
2-I have no preference
3-I do not want the insurance company to have any authority over my care
Managed care is the insurance company working with your doctors to manage your care needs. Plans with managed care require prior authorization or approval on some services.
Would your answers change if you were in poor health?
(Required)
1-I prefer to save money now knowing I may not have access to lowest out of pocket plans later
2-I have no preference
3-I would rather pay more now to know I will be in a flexible plan with low medical costs if needed in the future
Once your are diagnosed with certain medical conditions, some plans may not be available for purchase in the future.
Other Coverages
Let us know if you’d like HTA to contact you about any of these coverages in the future:
Auto Insurance
Homeowners Insurance
Δ
Differences between Medicare Supplement and Medicare Advantage
What kind of insurance do I have?
Who needs to take action during AEP
AEP Shopping Checklist-Part D
Best time to review Medicare Supplement Plan
What if I don't want to change my plan
