Medicare Cost Discovery Questions: 3 Questions to Ask Before You Quote
If you quote a plan based on premium alone, you’re basically buying a one-way ticket to “Let me think about it.”
Because clients don’t just buy a premium. They buy a total cost experience:
- What they pay each month
- What they pay at the pharmacy
- What they pay if something big happens (MRI, surgery, chemo)
- And what surprises show up in July when the IRS and Social Security start “helping” with IRMAA
These three questions help you uncover hidden costs early so your recommendation feels like a fit—and not a guess.
This is Pillar 3: Sales. It’s also how you become the agent clients trust.
Question #1: “What’s Your Household Income (Roughly), and Has It Changed Lately?”
Yes, this question feels personal. That’s why you ask it with care.
Why You Ask It
High-income Medicare clients may pay an extra amount for Part B and Part D called IRMAA (Income-Related Monthly Adjustment Amount). SSA generally looks back at tax returns from two years ago, so a client’s 2026 IRMAA is commonly based on 2024 income.
That means someone who retired last year may still be paying “working income” premiums this year—unless they appeal.
How to Ask It Without Making It Weird
Agent: “Quick question so I don’t accidentally recommend the wrong thing—Medicare costs can change based on income. Are you comfortable telling me a ballpark for your household income? Even a range is fine.”
Follow-up:
- “Did you retire recently?”
- “Did you sell a business or property?”
- “Any big one-time income last year?”
What You Do With the Answer
- If income is high: you set expectations (“You might see IRMAA.”)
- If income dropped: you offer an appeal conversation (“There are life-change appeals.”)
- Either way: you prevent the summer surprise.
Question #2: “Do You Use Any Specialty Meds, Mail-Order, or Manufacturer Coupons?”
This is the most ignored question—and it’s the one that saves your sale.
Why You Ask It
Drug costs aren’t just “generic vs brand.” They’re about:
- Tier level (especially specialty tiers)
- Preferred vs standard pharmacies
- Prior authorizations
- And whether coupons can be used (often not with Medicare rules)
A plan can look perfect… until a client fills one medication and says, “Why was that $600?”
How to Ask It (Simple Version)
Agent: “Any medications that are expensive, new, or hard to get? Or anything you pick up at a specialty pharmacy?”
If they say yes, ask:
- “Do you have a list of meds or a photo of the labels?”
- “Are you using mail-order today?”
- “Any biologics, injections, infusion meds, or cancer meds?”
What You Do With the Answer
You check:
- Formulary coverage (is it covered at all?)
- Tier level and restrictions
- Pharmacy network
- Realistic monthly cost
This is how you avoid the dreaded “It wasn’t covered!” call.
Question #3: “Do You Have Anything Big Planned in the Next 6–12 Months?”
Clients often forget to mention the big stuff because it’s not “today.”
But in Medicare world, planned care changes everything:
- Outpatient surgery
- Diagnostic imaging
- Physical therapy
- Specialist visits
- Chemo or infusion
- Durable medical equipment
How to Ask It
Agent: “Any surgeries, procedures, or big tests coming up this year? Even something like an MRI, cataract surgery, or a heart test?”
Then listen. Really listen.
What You Do With the Answer
You match the plan to the reality:
- Lower copays for specialists if they see specialists often
- Stronger hospital/outpatient coverage if a procedure is coming
- Drug coverage aligned to the meds that follow the procedure
The “July Surprise” and How You Stop It
Why July? Because that’s when people notice:
- IRMAA changes
- Drug tier changes
- Pharmacy switches
- And “Wait, why is my cost different now?”
When you ask these three questions up front, you can say:
Agent: “I’m asking this now because I don’t want you to get a surprise mid-year. I’d rather build a plan that works in real life.”
That line alone makes you sound like the adult in the room.
A 90-Second Discovery Flow (Use This on Every Call)
- “What’s your main goal—lowest monthly premium, or lowest worst-case cost?”
- “Any income changes I should know about?”
- “Any expensive or specialty medications?”
- “Any big procedures coming up?”
- “Okay—based on that, I’m going to narrow this to the top 2 options.”
Now your quoting is fast, confident, and consultative.
From Guessing to Guiding
These three questions shift your role from order-taker to advisor. When you uncover hidden costs before they become complaints, you’re not just quoting—you’re architecting a plan that lasts.
