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The

Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any sales meeting

to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed below.

Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They

do not

work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.
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Signing

this form does NOT obligate you to enroll in a plan,

affect your current enrollment, or enroll you in a Medicare plan.

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Please type your initials below beside the type of product(s) you want the agent to discuss.
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Medicare Supplement (Medigap) ProductsFor individuals who opt for Traditional Medicare, these plans are a supplemental policy to fill “gaps” in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.

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 PlansMedicare Advantage Plans replace Original Medicare but must provide at least what Medicare Part A and Part B health covers. Additionally, sometimes these plans cover Part D prescription drug coverage as well as other benefits in exchange for the beneficiary having higher out of pocket costs when seeking treatment.

By initialing, you are authorizing the agent to discuss any or all of the following Medicare Advantage plan types, as applicable, if they are available in your area.
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Preferred Provider Organization (PPO) - These provide a network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.
Health Maintenance Organization (HMO) - With these plans, in most cases, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).
Private Fee-For-Service (PFFS) - With these plans, 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.
Point of Service (POS) - This plan type combines the best feature of an HMO with an out-of-network benefit. Like the HMO, members are required to designate an in-network physician to be the primary health care provider. You can use doctors, hospitals, and providers outside of the network for an additional cost.
Special Needs Plan (SNP) - This plan type is 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 conditions.
Medical Savings Account (MSA) - This plan type combines 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 ProductsPlans 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 ProductsPlans 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.

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Scope of Sales Appointment Confirmation Form