The Centers for Medicare and Medicaid Services requires sales agents to document the scope of a marketing appointment prior to any sales meeting, to ensure understanding of what will be discussed between the sales 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.

To be completed by the Beneficiary or Authorized Representative

I understand that this electronic signature on this Scope of Appointment Form (“Form”) means that I have read and understood the contents of this Form. If the Form has the printed name of an authorized representative, the printed name certifies that: 1) This person is authorized under State law to complete this Form, and 2) Documentation of this authority is available upon request.

If you are the authorized representative, please sign above and print clearly and legibly below:

By signing this form, you agree to meeting with a sales agent to discuss the types of products you initiated above. Please note, the person who will discussthe productsis either employed by 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 or future enrollment, or automatically enroll you in a Medicare Plan.

To be completed by Agent:

Standalone Medicare Prescription Drug Plans Part D
Medicare Prescription Drug Plan (PDP) - A standalone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
Medicare Advantage Plans (Parts C) and other Medicare Plans
Medicare Health Maintenance Organization (HMO) - A Medicare Advantage Plan that provides all Original Medicare Part A and Part 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 Advantage Plans (Parts C) and other Medicare Plans
Medicare Health Maintenance Organization (HMO) - A Medicare Advantage Plan that provides all Original Medicare Part A and Part 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 Preferred Provider Organization (PPO) Plan - A Medicare Advantage Plan that provides all Original Medicare Part a and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals, but you can also use out-of-network providers, usually at higher cost.
Medicare Private Fee-for-Service (PFFS) Plan - A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital or provider that accepts the plan's payment, terms and conditions and agrees to treat you - not all providers will. If youjoin 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 Point of Service (POS) Plan - A type ofMedicare Advantage Plan available in a local or regional area which combines the best features of an HMO with out-of-network benefits. Like the HMO, members are required to designate an in-network physician to be the primary health care provider. You can use doctors, hospitals and providers outside of the in-network for an additional cost.
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 - Ain a Medicare Cost 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 under Original Medicare, butyou will be responsible for Medicare coinsurance and deductibles.
Dual Eligible Special Needs Plan (DSNP) - A Medicare Advantage plan option for those who currently have Medicare, Parts A & B, and with Medicaid. Medicare is the Federal program that helps with your medical costs and Medicaid is a state program that helps people who have low income. With these plans, Medicare is your primarv coverage and Medicaid is your secondary coverage.
Medicare Supplement (Medigao) Products
Plans offering a supplemental policy to fill "gaps" in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside ofthe country. These plans are not affiliated or connected to Medicare.

Note: Scope of Appointment documentation is subject to CMS record retention requirements.

Health coverage is offered by Sander Health Plans, a MedicareAdvantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in these plans depends on Sander Health Plans contractrenewal with Medicare.

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