Medicare Readiness Assessment Go Back Step 1 of 13 7% In order to develop your customized Medicare Blueprint, we will need to ask you some questions about you, your health insurance options at 65 and what your preference would be if you are looking at Medicare for your insurance coverage.Please know that this information will be strictly confidential and will not be sold to any other person(s) or organization.What zip code do you live in?*Are you inquiring about Medicare for yourself or someone else?*For MyselfFor Someone Else Save and Continue Later For Yourself...Are you Male or Female?*MaleFemaleAre you turning 65 in the next 12 months?*YesNoFor Someone Else...Please use their information to answer the following questions:Are you Male or Female?*MaleFemaleAre they turning 65 in the next 12 months?*YesNo Save and Continue Later Please Provide Your First Name?* Save and Continue Later What month do you turn 65?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWere you born on the FIRST day of the month?*NoYes Save and Continue Later Are you currently taking your Social Security retirement benefits?*YesNoDo you plan to have Medicare as your insurance when you turn 65?*YesNo Save and Continue Later Please indicate what insurance coverage you plan to have at age 65?*Employers Group PlanSpouses Employer GroupOther CoverageDoes your employer or spouses employer have 20 or more employees?*YesNo Save and Continue Later Please indicate what coverage you will have at age 65?*Retiree Health Plan Previous EmployerChampVACOBRA CoverageMedicaidTricareVAOther Save and Continue Later What Best Describes You?*I prefer a plan that while the monthly premium cost will be higher will leave me with little or no out-of-pocket cost when using medical services. For example an out-of-pocket cost of $0 or $183 (in 2017)I want the lowest cost plan even if I know I will have to pay out-of-pocket cost when I use medical services. For example copays for office visits and other services. My out-of-pocket cost could be as high as $6700 (in 2017) Save and Continue Later What Best Describes You?*I have a family doctor now and I do not want to change to another one.I have a family doctor now but I could change if I had to.I do not have a family doctor now so I would be fine going to one who is in a network. Save and Continue Later What Best Describes You?*I travel a bit and stay with my child in another state for extended periods each year.I travel occasionally but not for more than a week or so at a time.I rarely travel outside of the state I live in. Save and Continue Later What Best Describes You?*I currently do not take any prescription medications.I take a couple of medications but they are nearly all generics and the cost is minimal.I take a number of medications and one or more of them is quite expensive if you had to pay full price for it. Save and Continue Later What is your anticipated household income when you retire?*$5000 or More Per Month$3000 to $4999 Per Month$2000 to $2999 Per MonthLess Than $2000 Per Month Save and Continue Later What is your Email Address?* So we can email you the information that you have requested.What is your mobile phone number?NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.