• Scope of Sales Appointment Confirmation Form

    The Centers for Medicare and Medicaid Services requires agents to document the scope of a personal marketingappointment at least 48 hours prior to any individual sales meeting to ensure understanding of what will be discussedbetween the agent and the Medicare beneficiary (or their authorized representative). All information provided on thisform is confidential and should be completed by each person with Medicare or his/her authorized representative.

  • Please check the type of product(s) you want the agent to discuss

    (Refer below for product type descriptions)

  • By signing this form, you agree to a meeting with a sales agent to discuss the types of products markedabove.
    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. If you would like to discuss additional products not marked above, a new form must be completed. This scope of appointment is only valid for 12 months after your signature date. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

     

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

  • 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 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 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 Point of Service (POS) Plan: A type of Medicare Advantage Plan available in a local or regional area
    which 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.
    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 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.
    Medicare Medicaid Plan (MMP): An MMP is a private health plan designed to provide integrated and
    coordinated Medicare and Medicaid benefits for dual eligible Medicare beneficiaries.


    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.
    Supplemental Health 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
    Plans offering 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.

    Scope of Appointment documentation is subject to CMS record retention requirements. Aetna Medicare is an HMO,
    PPO plan with a Medicare contract. Our DSNPs also have contracts with State Medicaid programs. Enrollment in
    our plans depends on contract renewal. SilverScript is a Prescription Drug Plan with a Medicare contract marketed
    through Aetna Medicare. Enrollment in SilverScript depends on contract renewal.
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