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  • Scope of Appointment Confirmation Form

    PLEASE READ: The Centers for Medicare and Medicaid Services (CMS) 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. 

    According to Medicare rules, we also need your permission to contact you to discuss your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products you have chosen. The person who will be discussing plan options with you is with or contracted by a Medicare health plan or prescription drug plan that is not the Federal Government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

  • Please initial below under the type of product(s) you want the agent to discuss. You must select at least one.

    (Refer to page 2 below for product type descriptions.) Insurance All-Stars requires at least 3 product options to be selected. Medicare Advantage, Medicare Supplements, and Part D prescription plans. Not that we intend to speak to you about all three, but in the event you have a question, we will be able to continue our conversation without the disruption of signing this form all over again. Our intentions are always with your best interests in mind and we will not speak to you about anything you do not wish to hear. We hope you understand.
  • By signing this form, you agree to a meeting with a licensed sales agent to discuss the types of products you initialed 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 or future enrollment, or enroll you in a Medicare plan.

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

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

     

    ***PLEASE SCROLL DOWN TO THE BOTTOM OF THE PAGE TO COMPLETE THE FORM***

  • 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 Medicate 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 physicians 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. 

    Other Health-Related 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.

    Hospital Indemnity Products— Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray co-pays/co-insurance. These plans are not affiliated or connected to Medicare.

    Medicare Supplement (Medigap) Products— Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare (Parts A and B) such as deductibles and coinsurance amounts for Medicare approved services.

  • Agent Name: Angela Setzer 

    To be completed by the Agent (print clearly and legibly): Agent Phone:Agent Writing Number: 352-702-2929

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  • "Insurance All-Stars are independent insurance agents that do not work directly for the federal government or Medicare. We may or may not offer every plan in your area. We do currently represent 12 organizations which offer 91 products in the Lake, Marion, and Sumter areas where we are primarily located (but are not limited to). Please contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.”

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