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Digital Signature for Scope of Appointment

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

By entering your information below and clicking Submit, you are giving permission to have a licensed sales agent contact you by email, telephone or cell phone to provide additional information about products and services. Your consent is voluntary and allows us to contact you via email and phone for marketing purposes. You may contact us to change your preferences at any time.

This is a solicitation for insurance. By submitting this form, you agree to be contacted by a licensed sales agent to discuss the types of products you selected 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,

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

Glossary:

 

Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Prescription Drug Plans (PDP)

Medicare Prescription Drug Plan (PD) – A stand-alone drug plan that adds prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private-Fee-For-Service Plans, and Medicare Medical Savings Account Plans.

Medicare Advantage (Part C), Medicare Advantage Prescription Drug Plans, and Other Medicare Plans

Medicare Health Maintenance Organization (HMO) – A Medicare Advantage Plan that must cover all Part A and Part B healthcare. In most HMOs, you can only go to doctors, specialists, or hospitals in the plan’s network except in an emergency.

Medicare Preferred Provider Organization (PPO) Plan – A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Private Fee-For-Service (PFFS) Plan- A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment terms and conditions.

Medicare Special Needs Plan (SNP) – A special type of Medicare Advantage Plan that provides more focused and specialized healthcare for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan – MSA Plans combine a high-deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare in the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan – In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services or urgently needed services).