Scope of Appointment Form

Scope of Appointment Form

Scope of Appointment Form

The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of marketing appointment at least 48 hours prior to any meeting to ensure understanding of what is to be communicated between the agent and the Medicare beneficiary (or authorized representative). A Scope of Appointment is required for each individual, and a new form is required if the beneficiary or representative requests information not indicated in the prior form.


 

Medicare Advantage Plans (Part C) and cost plans

Medicare Health Maintenance Organization (HMO) Plan - A Medicare Advantage plan that provides all Original Medicare Parts A and 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 Health Maintenance Organization (HMO-POS) plan - A Medicare Advantage plan that provides all Original Medicare Parts A and B health coverage and sometimes covers Part D prescription drug coverage. HMO-POS plans may allow you to get some services out-of-network for a higher copay or coinsurance.


Medicare Preferred Provider Organization (PPO) plan - A Medicare Advantage plan that provides all Original Medicare Parts A and B health coverage and sometimes covers Part D prescription drug coverage. PPO plans have network doctors, providers 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 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 cot 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.


Stand-alone Medicare Prescription Drug (Part D) plan

Medicare Prescription Drug plan (Part D) - A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost plans, some Medicare Private Fee-For-Service plans, and Medicare Cost Savings Account plans.


Other related products

Medicare Supplement (Medigap) Products - Insurance policies that help pay some of the gaps in Original Medicare Parts A and B, such as deductibles and coinsurance amounts of Medicare-approved services.


Dental/Vision/Hearing products - Plans offering additional benefits for consumers who are looking to cover dental, vision or hearing needs. 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 copays/coinsurance. These plans are not affiliated or connected to Medicare.


Complete the sections below.

Check the plan types to discuss in detail. *

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

Beneficiary name
Beneficiary name
First
Last
Address
Address
Electronic signature agreement and attestation

(Meeting date MUST be 48 hours after signature date.)

(Only complete this section if an authorized representative.)

Agent Name/Writing ID: Jean Enyeart/18046908

Agent Phone: 704-897-7899

Agent Signature: Jean Enyeart