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MEDICARE NEEDS ASSESSMENT

This short needs assessment helps me understand your current Medicare coverage and what is important to you. We will review your answers together before considering specific Medicare plan options.

Your Current Coverage

What coverage or assistance do you currently have?

Check all that apply.

Your Current Coverage

Original Medicare

Medicare Advantage

Medicare Supplement (Medigap)

Prescription Drug Plan

Medicaid

Extra Help / LIS

Medicare Savings Program (MSP)

Other coverage or financial assistance

I'm not sure

What is important to you?

Check all that apply.

What is Important:

I have an ongoing health condition or treatment that should be considered when reviewing my coverage needs

Keeping my monthly premium as low as possible

Keeping my costs low when I receive healthcare (deductables, copays, coinsuraces or max out of pocket cost)

Keeping doctors, specialists, hospitals, or other providers that are important to me

Prescription drug coverage and costs

Dental, vision, or hearing benefits

Coverage for medical equipment, therapy, rehabilitation, or home health services

Transportation or other healthcare-access needs

Coverage that works when I travel or live away from home

Accessibility or language needs

I already have a Medicare coverage or plan type that I prefer

I'm not sure — I would like help understanding my options

Other

How do you feel about your current Medicare coverage?

Current Plan

I'm satisfied

It's okay, but I would like to review my options

I'm not satisfied

I'm new to Medicare / don't currently have Medicare coverage

I'm not sure

What do you particularly want to keep, change, or improve about your coverage?

Short answer

Anything else that is important to your healthcare access, coverage, or costs?

Short answer

Detail Review:

When reviewing specific Medicare plans, we will review applicable plan details, including your important healthcare providers, prescription medications, preferred pharmacy, costs, benefits, coverage rules, and other factors that may affect how a plan fits your stated needs and preferences.

Acknowledgment:

I have completed the information above, and it reflects my current Medicare coverage needs and preferences. I understand that the next step is to schedule an appointment to review my needs and discuss available Medicare options.and preferences.

*First name

*Last name

*Phone

Self-Guided Tools & Forms

Find a Medicare Advantage Plan
Add you Medical Information
Dental/Vision/Hearing
Hospital Indemnities
Under 65 Health Insurance (ACA)

Business Info

Me and Medicare LLC

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Disclaimer: The information provided on this website is for general educational purposes about Medicare Advantage (Part C), Medicare Part D, and related services. Costs, copays, coinsurance, benefits, and coverage rules vary by plan, provider network, and service area. You must continue to pay your Medicare Part B premium.

Me and Medicare LLC is a privately owned and operated insurance agency and is not affiliated with or endorsed by the U.S. government or the federal Medicare program.

We do not offer every plan available in your area: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

MEDICARE NEEDS ASSESSMENT

This short needs assessment helps me understand your current Medicare coverage and what is important to you. We will review your answers together before considering specific Medicare plan options.

Your Current Coverage

What is important to you?

How do you feel about your current Medicare coverage?

What do you particularly want to keep, change, or improve about your coverage?

Anything else that is important to your healthcare access, coverage, or costs?

Detail Review:

Acknowledgment:

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