Scope of Appointment Confirmation Form

    Representative Information

    Medicare Beneficiary Information

    Beneficiary Address

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    Medicare Advantage (Part C) Plans and Cost Plans

    HMO (Health Maintenance Organization)

    • Usually requires members to use doctors and hospitals within the plan's network, except for emergencies or other situations allowed by the plan.

    • Members generally select a primary care provider who coordinates their care.

    HMO-POS (Health Maintenance Organization – Point of Service)

    • Combines features of an HMO with the ability to receive certain services outside the plan's network.

    • Out-of-network services may have higher costs.

    PPO (Preferred Provider Organization)

    • Allows members to receive care from both in-network and out-of-network providers.

    • Members generally pay less when using providers within the plan's network.

    PFFS (Private Fee-for-Service)

    • Determines how much the plan will pay doctors and other healthcare providers and how much the member will pay.

    • Members may be able to see providers that accept the plan's payment terms.

    SNP (Special Needs Plan)

    • Designed for people with specific health or financial circumstances.

    • Includes plans for people who live in institutions, have certain chronic conditions, or qualify for both Medicare and Medicaid.

    MSA (Medicare Medical Savings Account)

    • Combines a high-deductible Medicare Advantage plan with a medical savings account.

    • The plan deposits money into the account to help pay for qualified medical expenses.

    Medicare Cost Plan

    • A type of Medicare health plan that may allow members to receive services outside the plan's network.

    • Members may return to Original Medicare for certain services.


    Standalone Medicare Prescription Drug (Part D) Plans

    Medicare Prescription Drug Plan (PDP)

    • A standalone Medicare Part D plan that provides prescription drug coverage.

    • These plans are generally used with Original Medicare and may also coordinate with certain other Medicare coverage.


    Medicare Supplement (Medigap) Products

    Medicare Supplement (Medigap)

    • Private insurance policies that help pay some healthcare costs that Original Medicare does not cover.

    • Depending on the policy, this may include certain deductibles, coinsurance, and copayments.

    • Medigap policies generally require enrollment in Medicare Part A and Part B.


    Dental, Vision, and Hearing Products

    Dental, Vision, and Hearing Products

    • Products that provide additional benefits for dental, vision, or hearing services.

    • Coverage and benefits vary depending on the specific product and plan.

    • These products may be offered separately from Medicare health coverage.


    Hospital Indemnity Products

    Hospital Indemnity 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.

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    By signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do NOT work directly for the federal government.

    Signing this form does NOT affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan, or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.

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    We do not offer every plan available in your area. Currently we represent 10 organizations which offer 232 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.