Scope of 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.

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.

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

By signing this form, I have read and understand the contents of teh Scope of Appointment form, and that I confirm that the information I have provided is accurate. If submitted by an authorized individual (as described above), this submission certifies that 1) this person is authorized under State law to complete the Scope of Appointment form, and 2) documentation of this authority is available upon request by Medicare.

Please fill out the following details:

Note: Each person enrolled in Medicare receives a Medicare Beneficiary Identifier number (MBI) on their Medicare card. Enter the information of the primary Medicare beneficiary (cardholder).

Agent: ANDREW FALIGOWSKI

Phone: 503-668-6100

By signing this form, I confirm the information represented here is true and accurate. I authorize my signature on the Scope of Appointment form using this information.

Medicare Overview

Medicare Part C, or Medicare Advantage, combines the benefits of Medicare Parts A, B and typically D. Medicare Advantage plans typically come with additional benefits taht Original Medicare doesn't have and are distributed by private insurance companies. In may cases, you'll need to use health care providers who participate in the plan's network and service area for the lowest costs. These plans set a limit on what you'll have to pay out-of-pocket each year for covered services, which could help protect you from unexpected costs.

Stand-alone Medicare Prescription Drug Plan (Part D)

Medicare Part D only helps pay for prescription drugs - following federal rules. Part D is often added to Original Medicare (Part A and B) or Medicare Advantage plans taht are offered by private insurance companies. You pay a monthly plan premium for Part D coverage to the insurance provider. Since the coverage rules of Medicare Part D are regulated by the federal government, the prescription drugs it covers may vary from year to year.

Medicare Advantage Plans (Part C)

Medicare Part C, or Medicare Advantage, combines the benefits of Medicare Parts A, B and typically D. Medicare Advantage plans typically come with additional benefits that Original Medicare doesn’t have and are distributed by private insurance companies. In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, which could help protect you from unexpected costs.

Examples of Medicare Advantage Plans include:

• Medicare Health Maintenance Organization (HMO) – Provides all the benefits of Original Medicare and sometimes includes Part D. 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 – Provides all the benefits of Original Medicare and sometimes covers Part D. PPOs have network doctors and hospitals but you can also use out-of-network providers, typically at a higher cost.
• Medicare Private Fee-For-Services (PFFS) Plan – A plan that allows you to go to any Medicare-approved doctor, hospital and provider. The health provider must agree to treat you and accept the PFFS plan’s payment, terms and conditions. If your PFFS plan has a network, you can see any of the network providers who have agreed to treat members of the plan. You typically will pay more for out-of-network providers.
• Medicare Special Needs Plan (SNP) – A plan that has specific benefits intended for people with special health needs. Examples of special health needs include:

                 People who qualify for both Medicare and Medicaid
                 People in nursing homes
                 People with approved chronic health conditions

Medicare Supplement (Medigap) Products

Medigap is Medicare Supplement Insurance that helps fill “gaps” in Original Medicare and is sold by private companies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like:

Copayments
Coinsurance
Deductibles

You must have Medicare Part A and Part B to get a Medicare Supplement plan. A Medigap plan is different from Medicare Part C because it only supplements your Original Medicare benefits. So, Medigap does not include Original Medicare or Part D coverage by itself.

Ancillary Products

You can get ancillary or secondary products through private insurance companies. These plans offer additional benefits to people who want separate coverage for things like dental, vision and hearing. Ancillary plans are not Medicare products.