(STATEMENTS)
1. You
do not need more than one Medicare supplement policy.
2. If you purchase this policy, you may want
to evaluate your existing health coverage and decide if you need multiple
coverages.
3. You may be eligible
for benefits under Medicaid and may not need a Medicare supplement
policy.
4. If, after purchasing
this policy, you become eligible for Medicaid, the benefits and premiums under
your Medicare supplement policy can be suspended, if requested, during your
entitlement to benefits under Medicaid for 24 months. You must request this
suspension within 90 days of becoming eligible for Medicaid. If you are no
longer entitled to Medicaid, your suspended Medicare supplement policy (or, if
that is no longer available, a substantially equivalent policy) will be
reinstituted if requested within 90 days of losing Medicaid eligibility. If the
Medicare supplement policy provided coverage for outpatient prescription drugs
and you enrolled in Medicare Part D while your policy was suspended, the
reinstituted policy will not have outpatient prescription drug coverage, but
will otherwise be substantially equivalent to your coverage before the date of
the suspension.
5. If you are
eligible for, and have enrolled in a Medicare supplement policy by reason of
disability and you later become covered by an employer or union-based group
health plan, the benefits and premiums under your Medicare supplement policy
can be suspended, if requested, while you are covered under the employer or
union-based group health plan. If you suspend your Medicare supplement policy
under these circumstances, and later lose your employer or union-based group
health plan, your suspended Medicare supplement policy, (or, if that is no
longer available, a substantially equivalent policy) will be reinstituted if
requested within 90 days of losing your employer or union-based group health
plan. If the Medicare supplement policy provided coverage for outpatient
prescription drugs and you enrolled in Medicare part D while your policy was
suspended, the reinstituted policy will not have outpatient prescription drug
coverage, but will otherwise be substantially equivalent to your coverage
before the date of the suspension.
6. Counseling services may be available in
your state to provide advice concerning your purchase of Medicare supplement
insurance and concerning medical assistance through the state Medicaid program,
including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified
Low-Income Medicare Beneficiary (SLMB).
(QUESTIONS)
If you lost or are losing other health insurance coverage and
received a notice from your prior insurer saying you were eligible for
guaranteed issue of a Medicare supplement insurance policy, or that you had
certain rights to buy such a policy, you may be guaranteed acceptance in one or
more of our Medicare supplement plans. Please include a copy of the notice from
your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.
Please mark Yes or No below with an "X"
To the best of your knowledge,
1.
(a) Did
you turn age 65 in the last 6 months?
Yes__________________ No_____
(b) Did you enroll in Medicare Part B in the
last 6 months?
Yes________ No________
(c) If yes, what is the effective
date?_____________________
2. Are you covered for medical assistance
through the state Medicaid program?
NOTE TO APPLICANT: If you are participating in a "Spend-Down
Program" and have not met your "Share of Cost," please answer NO to this
question.
Yes__________________ No_____
If yes,
(a) Will
Medicaid pay your premiums for this Medicare supplement policy?
Yes________ No________
(b) Do you receive any benefits from Medicaid
OTHER THAN payments toward your Medicare Part B premium?
Yes________ No________
3.
(a) If
you had coverage from any Medicare plan other than original Medicare within the
past 63 days (for example, a Medicare Advantage plan, or a medicare HMO or
PPO), fill in your start and end dates below. If you are still covered under
this plan, leave "END" blank.
START___/___/___ END____/___/___
(b) If you are still covered under the
Medicare plan, do you intend to replace your current coverage with this new
Medicare supplement policy?
Yes___________ No_____
(c) Was this your first time in this type of
Medicare plan?
Yes________ No________
(d) Did you drop a Medicare supplement policy
to enroll in the Medicare plan?
Yes________ No________
4.
(a) Do
you have another Medicare supplement policy in force?
Yes________ No________
(b) If so, with what company, and what plan
do you have [optional for Direct Mailers]?
Yes________ No________
(c) If so, do you intend to replace your
current Medicare supplement policy with this policy?
Yes________ No________
5. Have you had coverage under any other
health insurance within the past 63 days?
(For example, an employer, union, or individual plan)
Yes________ No________
(a) If so, with what company and what kind of
policy?
________________________________________
________________________________________
________________________________________
________________________________________
(b) What are your dates of coverage under the
other policy?
START___/___/___ END____/___/___
(If you are still covered under the other policy, leave "END"
blank.)
