First Name *

Last Name *

Email *

Date of birth *

What is your current health coverage? (Please include your monthly premium, deductible and max out of pocket if you know it) *

Employer Coverage, Marketplace (Obamacare), etc.

Tell me a little about your health history (any chronic conditions, recent surgeries in the past 5 years, etc.): *

Please list any full names of doctors you would like to keep seeing:

Please list names AND dosages of any prescriptions you currently take:

Is dental and vision coverage important to you? *

Yes

Do you have a strong preference yet towards a Medicare Advantage or Medicare Supplement? *

Medicare Advantage

Medicare Supplement

No Preference

So if you remember from the video — or if you didn’t get a chance to watch it yet — there are still a few major exposures that Medicare doesn’t fully protect you from.

These gaps exist whether you go with a Supplement or Advantage plan. That’s why we always recommend what we call umbrella coverage — to protect against the big stuff Medicare doesn’t handle well. The first one is cancer, heart attack, and stroke — I call them the Big Three.

Medicare helps with some of the medical treatment, but even with great coverage, people are often shocked at what’s not fully paid for — high-cost prescriptions, outpatient infusions, or non-Medicare-approved treatments that don’t count toward your max.

Then you’ve got the non-medical side: travel, time off work for your spouse, or needing help at home. That’s why umbrella coverage is so critical.

Do you have any personal or family history with cancer, heart attack, or stroke? *

Yes

The second big gap no one talks about is skilled nursing and rehab — things like a recovery stay after surgery, a fall, or a stroke.

Medicare will help, but it only goes up to 100 days. After that, you’re completely on your own — and it can get expensive fast. Not a lot of people know about this and not a lot of people talk about this, but it’s one of the biggest exposures we see wreck people’s savings. It’s a real asset eater.

Do you have any personal or family history with skilled nursing or home health care? *

Yes

Because it can affect your Original Medicare premiums from the government, what is your estimated annual income? *

Has that income been consistent for the past two years? *

Yes

As you're transitioning your financial picture, do you have any questions around retirement or retirement accounts? *

Yes

If so, we can loop in our financial specialist after we handle the Medicare piece.

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