Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face 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.

 

 

Please select below beside the type of product(s) you want the agent to discuss.

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 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 onl network (except in emergencies).

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 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 ma go to any Medicare-approved docto

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 conditions.

Medicare Medical Savings Account (MSA) Plan MSA Plans combine a high deductible healt

plan with a bank account. The plan deposits money from Medicare into the account. You can use it t 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. -covered services will be paid for

under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Plans offering a supplemental policy to fill “gaps” in Medicare Supplement (Medigap) Plan - OriginalMedicare coverage. A Medigap policy typically pays some or all of the deductible andcoinsurance 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.

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.

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

 

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

If you are the authorized representitive, please sign above and print below:

*Scope of Appointment documentation is subject to CMS record retention requirements *

Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting: