Medicare Scope of Appointment Confirmation Form

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary. Please check what you want to discuss with the Licensed Sales Representative.

Please indicate the product(s) you agree to discuss by checking the applicable checkbox(es):

By submitting this form, you agree to meet with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.

If you are the authorized representative (inquiring for someone else), please sign above and print clearly and legibly below:

DISCLAIMER: By submitting your information you agree that a licensed agent may contact you at the above-listed email or phone number. I understand that consent is NOT a condition of purchase.


Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds
prescription drug coverage to Original Medicare, some Medicare Cost Plans, some
Medicare Private Fee-For-Service Plans, and Medicare Medical Savings Account Plans.

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan
that provides all Original Medicare Part A and Part B health coverage and
sometimes covers Part D prescription drug coverage. In most HMOs, you can only
get your care from doctors or hospitals in the plan’s network (except in

Medicare HMO Point-of-Service (HMO-POS) — A Medicare Advantage Plan that
provides all Original Medicare Part A and Part B health coverage and sometimes
covers Part D prescription drug coverage. HMO-POS plans may allow you to get
some services out of network for a higher copayment or coinsurance.

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan
that provides all Original Medicare Part A and Part B health coverage and
sometimes covers Part D prescription drug coverage. PPOs have network doctors,
providers and hospitals but you can also use out-of-network providers, usually at a
higher cost.

Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in
which you may go to any Medicare-approved doctor, hospital and provider that
accepts the plan’s payment, terms and conditions and agrees to treat you — not all
providers will. If you join a PFFS Plan that has a network, you can see any of the
network providers who have agreed to always treat plan members. You will usually
pay more to see out-of-network providers.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit
package designed for people with special health care needs. Examples of the
specific groups served include people who have both Medicare and Medicaid,
people who reside in nursing homes, and people who have certain chronic medical

Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high
deductible health plan with a bank account. The plan deposits money from
Medicare into the account. You can use it to pay your medical expenses until your
deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and
out of network. If you get services outside of the plan’s network, your Medicare-
covered services will be paid for under Original Medicare, but you will be
responsible for Medicare coinsurance and deductibles.


Dental/Vision/Hearing Products — Plans offering additional benefits for consumers
who are looking to cover needs for dental, vision, or hearing. These plans are not
affiliated or connected to Medicare.

Hospital Indemnity Products— Plans offering additional benefits; payable to
consumers based upon their medical utilization; sometimes used to defray
copays/coinsurance. These plans are not affiliated or connected to Medicare.

Medicare Supplement (Medigap) Products— Insurance plans that help pay some of
the out-of-pocket costs not paid by Original Medicare (Parts A and B) such as
deductibles and co-insurance amounts for Medicare approved services.

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