Scope of Appointment

    In the space provided below, please initial next to the type of health product(s) you want the licensed sales agent to discuss.









    By signing this form, you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing plan options with you is either employed 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 form does NOT afect your current enrollment, nor will it enroll you in a Medicare Advantage plan, prescription drug plan or other Medicare plan.

    Beneficiary or legally authorized representative signature and signature date:


    To be completed by agent: (Please print)



    If the period between form completion and the scheduled appointment was less than 48 hours, indicate which exception was met to waive the 48-hour requirement:


    Scope of appointment documentation is subject to CMS record retention requirements.

    Scope of sales appointment form

    It’s important for you to understand the type of products that you can choose to discuss before your appointment with a licensed sales agent. The Centers for Medicare & Medicaid Services (CMS) requires sales agents to document the scope of any personal marketing appointment 48 hours prior to the scheduled appointment, except for scope of sales appointment forms that are completed during the last four days of a valid election period for the beneficiary or for unscheduled, in-person meetings (walk-ins) or in-bound calls initiated by the beneficiary. All information provided on this form is confidential, and a separate form should be completed by each beneficiary who wishes to discuss plan options or their legally authorized representative. We look forward to speaking with you.

    The licensed sales agent who will discuss the products with you is either employed or contracted by a Medicare plan. They do not work for the federal government. This licensed sales agent 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 status, or automatically enroll you in a Medicare plan.

    Stand-alone Medicare prescription drug plans (Part D)

    Medicare prescription drug plan (PDP)

    This stand-alone drug plan adds prescription drug coverage to Original Medicare and some other Medicare plans.

    Medicare Advantage plans (Part C)

    A Medicare Advantage (MA) plan provides all Original Medicare Part A and Part B health coverage and sometimes offers Part D prescription drug coverage (MAPD) and other additional benefits. There are different types of MA plans, such as:

    Health maintenance organization (HMO) plan

    This type of MA plan typically requires you to see only in-network providers and get referrals from a primary care doctor.

    Preferred provider organization (PPO) plan

    In most cases, on this type of MA plan, you'll pay less if you use in-network doctors. Referrals from a primary care doctor are not required.

    Private fee-for-service (PFFS) plan

    On this type of MA plan, you may go to any Medicare-approved doctor, hospital or provider that accepts the plan’s payment, accepts the terms and conditions and agrees to treat you—but not all providers will.

    Special Needs Plan (SNP)

    This type of MA plan has a benefits package designed for people with special healthcare needs. Examples of groups served include people who have both Medicare and Medicaid, reside in nursing homes, and/or have certain chronic medical conditions.

    Other products

    Medicare Supplement

    Medicare Supplement plans are standardized plans that can be bought with varying coverage options to help supplement your Original Medicare plan. While an MA plan takes the place of Original Medicare, a Medicare Supplement plan is simply added on to Original Medicare. Medicare Supplement plans have no provider networks and help pay some of the costs that Original Medicare does not pay. Medicare supplement plans cannot be held with an MA plan.

    Dental

    Stand-alone Dental plans are available at varying levels of coverage at in- and out-of-network providers.

    Vision

    Stand-alone Vision plans are available at varying levels of coverage at in- and out-of-network providers.

    Hospital indemnity

    Hospital indemnity plans cover some of the costs associated with hospital stays that may not be covered by a primary health plan.