Scope of Sales Appointment Confirmation Form

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

A new SOA is required if the beneficary requests information regarding a different plan type than previously agreed upon.

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

There is no obligation to enroll. Current or future Medicare enrollment status will not be impacted, and automatic enrollment will not occur. 

To be completed by Agent. All fields are required.

Scope of Appointment documentation is subject to CMS record retention requirements and is completed and submitted for all scheduled appointments (including no-shows, cancelled appointments, and for those that do not result in a sale).

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)

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 cover- age. 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 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 Supplement (Medigap) Products

Medicare Supplement (Medigap) Plan - Plans offering a supplemental policy to fill "gaps" in Original Medicare coverage. A Medigap policy typically pays some or all the deductible and coinsurance amount 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.

Ancillary Products

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.

DISCLAIMERS

• Plans are insured or covered by a Medicare Advantage (HMO, PPO and PFFS) organization with a Medicare contract and/or a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.
• We do not offer every plan available in your area.  Currently we represent ten organizations which offer forty-four products in your area.  Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.
• When you call the number listed on this website, you will be directed to a licensed insurance sales agent or broker.
• This website is a solicitation for insurance. By providing us with your contact information, you agree that an authorized representative or licensed insurance agent/producer may contact you by telephone, email or mail to answer your questions or provide additional information about Medicare Advantage, Part D or Medicare Supplement Insurance plans.
• The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex.

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