🛡️ Medically & Compliantly Reviewed·Verified by Paul Barrett (Licensed Medicare Advisor)
Choosing the right Medicare coverage requires asking the right questions. Whether you're working with an independent broker or a carrier agent, use this structured checklist to protect your healthcare options and avoid costly surprises.
Quick Summary
Before contacting a Medicare agent, ask which companies and plan types they represent, whether they serve your area, how your doctors and prescriptions will be checked, what costs may apply, and how they will follow up. Compare the answers before deciding whether to enroll.
What is the monthly plan premium, and will I still need to pay my standard Part B premium?
What is the annual plan deductible before comprehensive benefits kick in?
What is the Maximum Out-of-Pocket (MOOP) threshold on this policy?
What are the exact copays for primary care doctor visits versus specialists?
What are the per-day inpatient hospital copays, and for how many days do they apply?
What will I pay out-of-pocket for diagnostic imaging like MRIs, CT scans, and PET scans?
Are outpatient surgeries billed with flat copays or a 20% coinsurance?
What are the out-of-pocket costs for urgent care and emergency room visits?
2. Questions About Doctors & Prescriptions
Are my current primary care doctors and specialists verified as in-network?
Did you cross-reference every one of my prescription medications against this plan's drug formulary?
What tier does each of my medications fall into, and are there quantity limits or prior authorization rules?
Which local pharmacies or mail-order delivery services offer preferred lower copays?
Is this doctor network an HMO, PPO, or POS network?
Do I need a referral from a primary physician before booking an appointment with a specialist?
What happens if I see an out-of-network physician for non-emergency medical care?
Which local hospital networks and urgent care centers are considered fully in-network?
3. Questions About Medicare Advantage Specifics
Does this plan require prior authorization for major medical tests, therapies, or procedures?
What exact dental benefits are covered (routine cleanings vs. comprehensive root canals, crowns, or implants)?
What is the annual maximum dollar limit on dental, vision, and hearing allowances?
Are over-the-counter (OTC) grocery/health allowances distributed monthly or quarterly, and do they roll over?
What is this plan's official CMS Star Rating for the current contract year?
Are non-emergency transportation benefits restricted strictly to medical appointments?
Does the plan include wellness benefits like SilverSneakers or gym memberships?
What are my rights if this insurance carrier drops out of my county at the end of the year?
4. Questions About Medigap Specifics
How does Plan G compare directly to Plan N in premiums and benefits for my age and ZIP code?
Is this Medigap policy priced as Community-Rated, Issue-Age-Rated, or Attained-Age-Rated?
What has this carrier's average annual rate increase percentage been over the past 3 to 5 years in my state?
Can I visit any hospital or medical specialist nationwide that accepts Original Medicare?
Does this policy pay the annual Medicare Part B deductible?
Is a household premium discount applied if my spouse or partner also holds a policy with this company?
Does this insurer offer extra discount perks for hearing, vision, or gym access?
If I choose Plan N, what exact copays will apply to office visits and emergency room admissions?
5. Questions About Enrollment Timing & Agent Representation
Which exact enrollment window (Initial Enrollment, Annual Enrollment, or Special Enrollment) are we utilizing today?
Am I currently eligible for Guaranteed Issue rights, or will I be subject to medical underwriting?
If I apply outside my open enrollment window, can a carrier decline my application due to pre-existing conditions?
Are you an independent broker appointed with multiple carriers or a captive agent representing one company?
How many insurance carriers and Medicare plans do you actively represent in my county?
Will you review my policy and drug formulary each year during the Annual Enrollment Period (AEP)?
What is your National Producer Number (NPN) and direct support phone number?
Can you provide a Scope of Appointment (SOA) form detailing the plan types we will discuss today?
Take This Checklist With You
Print or save this question list to keep in front of you during your agent consultation call.
🚩 8 Red Flags to Watch Out For
Claims to work directly for Medicare or the Federal Government: Legitimate agents represent private insurance companies, never CMS or Medicare directly.
Urgent "Today Only" pricing pressure: Medicare plan rates and enrollment deadlines are federally regulated; costs do not change day-to-day.
Fails to ask for your complete prescription drug list: Choosing a plan without running prescription formularies can lead to massive out-of-pocket drug bills.
Shows up uninvited at your home: Unsolicited, door-to-door sales visits are strictly prohibited under CMS marketing regulations.
Promises "all your doctors are covered" without checking: An agent must verify each specific doctor and medical group in the carrier's directory.
Refuses to provide a Scope of Appointment (SOA): Licensed agents must present an SOA form 48 hours prior to an appointment per regulations.
Offers only one plan choice: You deserve transparent side-by-side comparisons between Medicare Advantage and Medigap options.
Demands financial or Social Security data prematurely: Sensitive billing information should only be shared during the actual, agreed-upon application.
Frequently Asked Questions
1. Do Medicare agents charge a fee for their help?
No. Licensed Medicare agents and brokers do not charge beneficiaries any fees. They are compensated directly by insurance carriers if and when you enroll.
2. What is the difference between an independent broker and a captive agent?
A captive agent represents only one carrier. An independent broker contracts with multiple insurance companies to compare several plans across your area.
3. What is a Scope of Appointment (SOA) form?
An SOA is a CMS-mandated document that details the specific Medicare plan types you agree to discuss prior to meeting with an agent.
4. Can a Medicare agent verify if my prescriptions are covered?
Yes. You should provide your drug names, dosages, and refill frequencies so the agent can check carrier formularies and calculate out-of-pocket costs.
5. Is an agent required to show me every plan available in my county?
Agents only present plans from carriers they are appointed with. Under CMS rules, they must inform you if they do not represent all plans in your area.
6. Can I switch to a different Medicare agent later?
Yes. You are free to work with any licensed agent during valid enrollment windows without losing your active insurance plan.
7. How can I verify if an agent is legitimately licensed?
You can check an agent's license status on your state Department of Insurance (DOI) website or ask for their National Producer Number (NPN).
8. Can an agent visit my home without an appointment?
No. CMS strictly prohibits door-to-door sales calls and unsolicited home visits by Medicare sales representatives.
9. Will my Medigap premium increase every year?
Most Medigap plans adjust rates over time due to age or medical inflation. Always ask your agent about a carrier's historical rate adjustments.
10. What happens if my agent leaves the insurance business?
Your insurance policy remains active directly with the insurance carrier. You can also assign another licensed broker at any time.
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