Health Care/LTC Cost Assessment Fact Finder

  • Client and spouse/partner information

    Couples and partners sharing a household should complete all of the fields below, even if you are planning for only one spouse or partner. The assessment considers the availability of receiving care from a spouse or partner in determining the health care and long-term care cost estimate.
  • First NameLast NameGenderCurrent AgeRetirement Age
  • State(s)City* (Cities)County 
  • First NameLast NameGenderCurrent AgeRetirement Age
  • State(s)City* (Cities)County 

  • Assessment questions Check Yes or No

  • CURRENT HEALTH Assessment is not designed for persons already diagnosed with Alzheimer's, Parkinson's or other disqualifying conditions.

  • LIFESTYLE & HEALTH HISTORY

  • Annual income in retirement

    Select the range that best fits your actual or estimated post-retirement income (not your income level before retirement.) Use your modified adjusted gross income (MAGI) and assume today's dollars. Your retirement income helps determine the cost for Medicare Parts B & D.

  • Medicare coverage (select only one option)

    All Medicare premiums plus additional medical costs will be used as the default option if no other option is selected. Not required for LTC-only reports.

  • * City/metro data will be used if available, if unavailable state-wide averages will be used.

Confirm Exit

I understand that all applicable CMS and carrier presentation and enrollment guidelines must be maintained.

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