This form is to be completed by the Medicare beneficiary.
Please read the descriptions of the plan types below and check the boxes next to the plan types that you want the agent to discuss with you. If you do not want the agent to discuss a plan type with you, please leave the box empty.
1. Medicare Supplements
Medicare Supplements are plans that complement your Original Medicare Plan. Depending on the supplement, this may cover Part A and B deductibles, Part B excess and other services.
2. Stand-alone Medicare Presdcription Drug Plans (Part D)
Medicare Prescription Drug Plan (PDP) is a stand-alone drug plan that adds prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans and Medicare Medical Savings Account Plans.
3. Medicare Advantage (Part C), Medicare Advantage Prescription Drug Plans, and other Medicare Plans
Medicare Health Maintenance Organization (HMO) is a Medicare Advantage Plan that must cover all Part A and Part B health care. In most HMO's, you can only go to doctors, specialists or hospitals in the plan's network except in an emergency.
Medicare Preferred Provider Organization (PPO) Plan is a type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals and providers that belong to the network. You can use doctors, hospitals and providers outside of the network for an additional cost.
Medicare Private Fee-for Service (PFFS) Plan is a type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan's payment, terms and conditions.
Medicare Special Needs Plan (SNP) is a special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home or have certain chronic medical conditions.
Medicare Medical Savings Account (MSA) Plan combines a high deductible Medicare Advantage Plan and 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 is a type of health plan in which, if you get services outside the plan's network without referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services or urgently needed services).
4. Long-Term Care Insurance
Long-Term Care Insurance, whether it is a California Partnership for Long-Term Care, traditional or asset-based policy, is a stand-alone product, not associated with Medicare. Your Original Medicare Plan offers minimal coverage for long-term care under very specific conditions. Any long-term care beyond what Medicare provides would only be covered by a separate long-term care insurance policy or Medicaid.
5. Life Insurance
Life Insurance is a stand-alone product, not provided by or associated with Medicare.
Annuities are financial vehicles, not associated with Medicare, designed to provide lifetime income for an up-front premium. These products can also be linked to other benefits, such as long-term care or life