Personalized Medicare Roadmap Personalized Medicare Roadmap Step-by-Step Action Guide for Medicare Enrollment Prepared by: Adam Cooper (870) 215-3136 (Call or Text) Email: [email protected] Date: Client Information Name Date of Birth Age Phone Email Physical Address Mailing Address Same as Physical Address? Yes No Medicare Number (if available) Part A Effective Date Part B Effective Date Eligibility Status Turning 65 Disability Continue Working Other: Possible Retirement Date Are you currently receiving a Social Security Check? Yes No When do you plan to draw your Social Security check? Current Coverage Current Insurance Employer Plan HSA Non-HSA Medicaid VA/Military ACA/ObamaCare None Other: Details of Current Coverage Needs Assessment Key Health Conditions Prescription Medications Preferred Doctors/Hospitals Budget Constraints Coverage Priorities Hospital Coverage Medical Services Prescription Drugs Dental/Vision/Hearing Other: Recommended Action Steps Based on our discussion, here are the steps you should take to proceed with your Medicare enrollment or plan selection. Please follow these instructions carefully and contact me if you have questions. Follow-Up Actions Next Steps for Agent Follow-Up Date Additional Notes My Medicare Cost Summary Below is a side-by-side cost comparison of the Medicare Supplement and Medicare Advantage options discussed, including associated plans. Please note that the plans discussed are subject to change, and you should verify current plan details before enrolling. Extra Help for Medicare Part D Yes No Eligible for Medicaid? Yes No Unsure Medicaid Coverage Type Full Partial Medicare Part B Monthly Premium Subject to IRMAA (Income-Related Monthly Adjustment Amount)? Yes No Medicare Supplement Option Medicare Supplement Plan Medicare Part D Drug Plan Dental, Vision, and/or Hearing Plan Critical Illness Plan Cancer, Heart Attack/Stroke Cash Cancer Only Additional Plans Discussed Total Estimated Monthly Cost Medicare Advantage Option Medicare Advantage Plan Critical Illness Plan Cancer, Heart Attack/Stroke Cash Cancer Only Hospital Indemnity Plan Additional Plans Discussed Total Estimated Monthly Cost Client Acknowledgment I have received this Personalized Medicare Roadmap and understand the recommended steps. I acknowledge that this is general guidance and not a contract or enrollment in any specific plan. The costs discussed are subject to change depending on when the enrollment is submitted to the insurance company, and all costs will be re-verified before submitting an enrollment application. Disclaimer Save and Print
