Planning and Review Worksheet
Helping you plan for joining a Medicare Plan or reviewing current coverage
Do you or your spouse currently work for an employer that has over 20 employees?
*
When will this end or When did this end?
*
Does this employer currently provide your health insurance?
*
What is your current or former company's name (or spouse’s)?
What Medical and prescription drug coverage do you have now?
How much do you pay for your Medical Coverage per month?
How much do you pay for your prescription coverage (if not included in your Medical plan) per month?
What Medications do you take (dosage and quantity please)
Which pharmacy do you use?
Which doctors do you use? (name, specialty, and phone please)
Do you need new coverage
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1
2
3
4
5
6
7
8
9
10
No
Absolutely
1 is No, 10 is Absolutely
My plan covers all the health care services I need.
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1
2
3
4
5
6
7
8
9
10
No
Everything, and then some
1 is No, 10 is Everything, and then some
I am confident I can go to any doctor or hospital that I want.
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1
2
3
4
5
6
7
8
9
10
Not at all
Definitely
1 is Not at all, 10 is Definitely
The Options
Evaluate plan features on your opinion and values
Health Insurance Plan
Rows
Not at all
Not really
Somewhat
Mostly
Definitely
I would rather pay less monthly and take a chance paying much more if I use the plan quite a bit.
I would rather pay more each month and not have surprise bills and limitations when I use my insurance.
My plan is adequate to cover my changing healthcare needs.
My plan works well with other coverage I have (if applicable).
My plan premiums fit my budget.
My overall out-of-pocket costs are what I expect and am comfortable with.
My plan pays appropriately for the care and services that I expect and need covered.
I am happy with my Plan overall and would recommend it to a friend.
My plan has wonderful customer service.
I understand what my plan pays and why.
My plan includes prescription drugs
What problems have you encountered with previous health insurance or questions/concerns do you have?
Overall rate the satisfaction with your current medical, dental, and prescription drug coverage?
1
2
3
4
5
6
7
8
9
10
Terrible
Great
1 is Terrible, 10 is Great
Why did you choose this?
Your Name
First Name
Last Name
E-mail
Phone Number
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Area Code
Phone Number
Zip code
Date of birth
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Month
-
Day
Year
Date
Do you have coverage available to you through work, spouses work, or previous employment as a retiree?
*
Yes
No
Are you currently drawing Social Security currently?
*
Yes
No
I have filed and it starts soon
Have you applied for Medicare yet (if so when will it begin or what is the current effective date) for part A and B?
*
Have you been deemed disabled by Social Security?
Do you or your spouse work full time currently?
Yes
No
Retirement date
-
Month
-
Day
Year
Date
Do you think you could be eligible for extra help on Medication costs or Medicaid due to limited income and/or resources?
Do you think you may have to or are you paying more than the standard Part B and D premium based on your Adjusted Gross Income from 2 years ago?
Any final comments?
Submit Form
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