- HTA Insurance Services

Annual Enrollment Period

ZOOM Review Questionnaire

If you are looking to review a Medicare Advantage Plan, please pick a schedule date BETWEEN October 15th and December 7th.

Scheduling Your ZOOM Appointment

Complete the form below first.

After submitting, you’ll be redirected to our scheduling page where you can choose a convenient date and time for your zoom 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)

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

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 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)

Medicare Supplement Plan

SPOUSE/PARTNER'S Medical Info

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

Has your spouse/partner 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)

Medicare Advantage- Your Insurance Coverage Preferences

Please complete before your Medicare Advantage Plan Review.

What prompted you to schedule a review?(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.

Annual Enrollment Period

ZOOM Review Questionnaire

If you are looking to review a Medicare Advantage Plan, please pick a schedule date BETWEEN October 15th and December 7th.

Scheduling Your ZOOM Appointment

Spouse/Partner Information

Medicare Supplement Plan

YOUR Medical Info

Medicare Supplement Plan

SPOUSE/PARTNER'S Medical Info

Medicare Advantage- Your Insurance Coverage Preferences

Medicare Advantage- SPOUSE/PARTNER'S Insurance Coverage Preferences

If you are looking to review a Medicare Advantage Plan, please pick a schedule date BETWEEN October 15th and December 7th.

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