Mauldin Insurance Group | Insurance in Lexington, SC

Medicare Scope of Appointment

Medicare requires agents to document which types of plans you'd like to talk about before we meet. Check the topics you want to cover, sign at the bottom, and we'll reach out to set up a time. Each person should fill out their own form, so if you and your spouse both want help, please submit one for each of you.

What would you like to discuss?

Check all that apply. * We'll only discuss the products you check.

Medicare Advantage Plans (Part C) and Cost Plans Plans offered by private companies that cover everything Original Medicare covers, often with extra benefits and drug coverage. Includes HMO, PPO, PFFS, Special Needs Plans (SNP), Medical Savings Account (MSA) plans, and Medicare Cost Plans.

Stand-alone Medicare Prescription Drug Plans (Part D) Plans that add prescription drug coverage to Original Medicare, some Cost Plans, some PFFS plans, and MSA plans.

Medicare Supplement (Medigap) Insurance Plans that help pay some of the costs Original Medicare doesn't, such as deductibles and coinsurance.

Dental, Vision, and Hearing Products Stand-alone plans that help pay for dental, vision, or hearing care.

Hospital Indemnity Products Plans that pay a set cash benefit when you're admitted to the hospital.

What do these plan types mean?

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO): A Medicare Advantage Plan that provides all Original Medicare Part A and Part B coverage and sometimes Part D drug coverage. In most HMOs, you can only get care from doctors and hospitals in the plan's network, except in emergencies.

Medicare HMO Point-of-Service (HMO-POS): An HMO that may let you get some services out of network for a higher copay or coinsurance.

Medicare Preferred Provider Organization (PPO): A Medicare Advantage Plan that provides all Part A and Part B coverage and sometimes Part D drug coverage. PPOs have network providers, and you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-for-Service (PFFS): A Medicare Advantage Plan where you can see any Medicare-approved provider that accepts the plan's payment terms and agrees to treat you. Not all providers will. If the plan has a network, you'll usually pay more out of network.

Medicare Special Needs Plan (SNP): A Medicare Advantage Plan designed for people with specific needs, such as people with both Medicare and Medicaid, people living in nursing homes, or people with certain chronic conditions.

Medicare Medical Savings Account (MSA): A high-deductible health plan paired with a bank account. Medicare deposits money into the account, which you can use for medical expenses until you meet the deductible.

Medicare Cost Plan: A plan where you can use providers in and out of network. Out-of-network services are paid under Original Medicare, and you pay Medicare's coinsurance and deductibles.

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP): A stand-alone plan that adds drug coverage to Original Medicare, some Cost Plans, some PFFS plans, and MSA plans.

Other Related Products

Medicare Supplement (Medigap): Insurance that helps pay out-of-pocket costs Original Medicare doesn't cover, such as deductibles and coinsurance for Medicare-approved services.

Dental, Vision, and Hearing: Plans that help cover dental, vision, or hearing needs. These plans are not affiliated with or connected to Medicare.

Hospital Indemnity: Plans that pay benefits based on hospital stays or medical use, sometimes used to help with copays and coinsurance. These plans are not affiliated with or connected to Medicare.

Your Information

First name *

Last name *

Phone *

Street address *

City *

State *

ZIP *

Who is filling out this form? *

I am the Medicare beneficiary I am an authorized representative

Representative's full name *

Relationship to beneficiary *

Representative's phone

Your Appointment

How would you like to meet? *

Agent you'd like to meet with

Preferred appointment date *

Preferred time of day

Please Read and Sign

By checking the boxes above and signing below, you agree to a meeting with a licensed sales agent to discuss the types of products you checked.

The person who will discuss these products with you is either employed 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, does not affect your current or future Medicare enrollment, and does not enroll you in a Medicare plan.

This form will be kept on file for at least 10 years, as required by Medicare.

Signature * Sign with your finger or mouse. Beneficiary, or authorized representative if applicable.

Printed name of signer *

Date signed

I agree that my signature above is my electronic signature and has the same effect as a handwritten signature. * I agree to be contacted by Mauldin Insurance Group by phone, email, and text message about my appointment and the products I checked. *

We do not offer every plan available in your area. Currently we represent 6 organizations which offer 52 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.

Mauldin Insurance Group is not connected with or endorsed by the U.S. government or the federal Medicare program.