Sales Appointment Confirmation Form printable pdf download

Sales Appointment Confirmation Form

To be completed by person with Medicare.

Please initial below in the box beside the plan type that you want the agent to discuss

with you. If you do not want the agent to discuss a plan type with you, please leave the

box empty. (Please note that an agent may also discuss a Medicare Supplement policy

with you.)

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — 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 health care. 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 and terms and conditions.

Medicare Special Needs Plan (SNP) — A special type of Medicare Advantage

Plan that provides more focused and specialized health care 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 — A type of health 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).

Moda Health is a PPO and a prescription drug plan with a Medicare contract.

Enrollment in a Moda Health plan depends on contract renewal.

H3813_401009B(02/2009)

Sales Appointment Confirmation Form