Medicare: Initial Intake Logo

  • Medicare Initial Intake

    We’ve crafted this form to be highly efficient and comprehensive. The required fields capture essential information crucial for initiating our conversation. As you answer specific questions, you may notice additional optional fields designed to gather further specialized details, enabling us to thoroughly evaluate your unique situation and needs. Whether you provide this information now or later, being prepared will enhance our dialogue, ensure a more productive conversation, and hopefully give a smoother overall process.

  • Contact Information

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  • Address

    Medicare plans (Supplement, Prescription Drug, and Advantage) require your zip code for quoting and your home and mailing address when enrolling.
    • Mailing Address 
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  • Quoting & Enrollment

    Rates are based on the first day of the month you are requesting coverage to begin.
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  • Financial Considerations

    Income adjustments, prescription drug penalties, and/or Health Savings Accounts can significantly influence our recommendations in certain situations. Providing us with this information up front helps save you time by limiting the requoting process.
    • IRMAA Open 

    • Receiving an "IRMAA determination notice," means you've received a notification from the Social Security Administration stating that based on your income, you will be required to pay an additional amount on your Medicare Part B and/or Part D premiums, known as the Income Related Monthly Adjustment Amount (IRMAA); essentially, if you get this notice, it means your income is above a certain threshold, and you will have a higher Medicare premium due to that income level.

    • IRMAA Close 
    • HSA Open 

    • If you enroll in Medicare, you and your employer must stop contributing to your HSA up to six months before enrolling. You can still use your HSA to pay for certain Medicare expenses, such as premiums for Part A, Part B, Part C, and Part D.

    • HSA Close 

  • Medicare Enrollment Status

    Understanding your Medicare enrollment status helps us properly advise you of any time sensitivities or guide you through the underwriting or enrollment process.
    • MBI Information 

    • Medicare Beneficiary Information

      Your MBI is required for enrolling and can help us determine your current coverage should you need help remembering which plans you are enrolled in or if you have a lapse in coverage.
    • MBI Text 
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    • MBI Picture 
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    • Applied & Waiting 
    • Applied Waiting Closed 

    • Current Coverages

      Understanding your current coverages helps us help you navigate your initial election period, guaranteed issue opportunities, and special election periods, as well as evaluate your options in relation to your current coverages.
    • Medicare Supplement 

    • Medicare Supplement

    • Prescription Drug 

    • Prescription Drug Plan (Part D)

    • Medicare Advantage 

    • Medicare Advantage (Part C)

    • Medicare Advantage Text 

    • Medicare Advantage Details

    • Medicare Advantage Upload Picture 

    • Medicare Advantage Upload Card

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    • Group Health Plan 

    • Group Health Plan

    • Individual Health Plan 

    • Individual Health Plan

    • TRS/Military/City/Gov 

    • Teach / Military / Union / City & Government Coverages

      Your benefits summary is a crucial piece of the puzzle that will help us better understand your coverage's unique structure. If you have it accessible, please upload it for us. If you need to request, find, or download it, e-mail us at medicare@benefitsdallas.com or text 214-340-0115.
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  • Potential Discounts

    Knowing if you receive government assistance or if you are eligible for a carrier discount can make a big difference. Not only are we looking at what is the lowest cost, but we also want to evaluate what will be your best long-term value.

  • Government Program Discounts

  • If you are eligible, state and federal programs can help reduce your Medicare health and drug costs. Please let us know if you currently receive any of these benefits to evaluate your options properly.

    • Medicaid: A joint federal and state program for certain people with limited income and resources. Your state might call this something different, like Medi-Cal or BadgerCare.
    • Supplemental Security Income (SSI): A monthly Social Security benefit for people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits are different from Social Security retirement or disability benefits.
    • Medicare Savings Program (MSP): State-run programs that help people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.
    • Extra Help: A program that helps people with limited income and resources pay Medicare drug costs (Part D).

  • Carrier & Household Discounts

  • Final Thoughts

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