Authority: IC
27-8-13-10;
IC
27-8-13-16
Affected: IC
27-8-13-1
Sec. 1.
(a)
Application forms shall include statements and questions as established in this
subsection designed to elicit information as to whether, as of the date of the
application, the applicant currently has another Medicare supplement, Medicare
Advantage, or Medicaid coverage or another health insurance policy or
certificate in force or whether a Medicare supplement policy or certificate is
intended to replace any other accident and sickness policy or certificate
presently in force. A supplementary application or other form to be signed by
the applicant and agent containing questions and statements may be used, such
as the following:
(1) The following
statements:
(A) You do not need more than one
(1) Medicare supplement policy.
(B)
If you purchase this policy, you may want to evaluate your existing health
coverage and decide if you need multiple coverages.
(C) You may be eligible for benefits under
Medicaid and may not need a Medicare supplement policy.
(D) 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 twenty-four (24) months. You must request this
suspension within ninety (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 ninety (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.
(E) 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 ninety (90) days of losing your employer or unionbased 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.
(F)
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 Qualified
Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary
(SLMB).
(2) 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 (1) 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:
To the best of your knowledge,
(A) Did you turn age sixty-five (65) in the
last six (6) months?
Yes ________ No ________
(B) Did you enroll in Medicare Part B in the
last six (6) months?
Yes ________ No ________
(C) If yes, what is the effective date?
__________
(D) 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 ________
(i) If yes, will Medicaid pay your premiums
for this Medicare supplement policy?
Yes ________ No ________
(ii) Do you receive any benefits from
Medicaid OTHER THAN payments toward your Medicare Part B premium?
Yes ________ No ________
(E) If you had coverage from any Medicare
plan other than original Medicare within the past sixty-three (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 ___/___/___
(F) 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 ________
(G) Was this your first time in this type of
Medicare plan?
Yes ________ No ________
(H) Did you drop a Medicare supplement policy
to enroll in the Medicare plan?
Yes ________ No ________
(I) Do you have another Medicare supplement
policy in force?
Yes ________ No ________
(i) If so, with what company, and what plan
do you have [optional for Direct Mailers]?
(ii) If so, do you intend to replace your
current Medicare supplement policy with this policy?
Yes ________ No ________
(J) Have you had coverage under any other
health insurance within the past sixty-three (63) days? (For example, an
employer, union, or individual plan)
Yes ________ No ________
(i) If so, with what company and what kind of
policy?
(ii) What are your dates of
coverage under the other policy?
START ___/___/___ END ___/___/___
If you are still covered under the other policy, leave "END"
blank.
(b) Agents shall list any other health
insurance policies they have sold to the applicant. List policies sold that:
(1) are still in force; and
(2) in the past five (5) years, are no longer
in force.
(c) In the
case of a direct response issuer, a copy of the application or supplemental
form:
(1) signed by the applicant;
and
(2) acknowledged by the
insurer;
shall be returned to the applicant by the insurer upon
delivery of the policy.
(d) Upon determining that a sale will involve
replacement of Medicare supplement coverage, any issuer, other than a direct
response issuer or its agent, shall furnish the applicant, before issuance or
delivery of the Medicare supplement policy or certificate, a notice regarding
replacement of Medicare supplement coverage. One (1) copy of the notice signed
by the applicant and the agent, except where the coverage is sold without an
agent, shall be provided to the applicant and an additional signed copy shall
be retained by the issuer. A direct response issuer shall deliver to the
applicant at the time of the issuance of the policy the notice regarding
replacement of Medicare supplement coverage.
(e) The notice required by subsection (d) for
an issuer shall be provided in substantially the following form in not smaller
than 12-point type:
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF MEDICARE SUPPLEMENT INSURANCE OR
MEDICARE ADVANTAGE
[Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT
TO YOU IN THE FUTURE.
According to [your application] [information you have
furnished], you intend to terminate existing Medicare supplement or Medicare
Advantage insurance and replace it with a policy to be issued by [Company Name]
Insurance Company. Your new policy will provide thirty (30) days within which
you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it
with all accident and sickness coverage you now have. If, after due
consideration, you find that purchase of this Medicare supplement coverage is a
wise decision, you should terminate your present Medicare supplement or
Medicare Advantage coverage. You should evaluate the need for other accident
and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY ISSUER, AGENT
[BROKER OR OTHER REPRESENTATIVE]:
I have reviewed your current medical or health insurance
coverage. To the best of my knowledge, this Medicare supplement policy will not
duplicate your existing Medicare supplement coverage or, if applicable,
Medicare Advantage because you intend to terminate your existing Medicare
supplemental coverage or leave your Medicare Advantage plan. The replacement
policy is being purchased for the following reasons (check one):
Additional benefits.
____ No change in benefits, but lower premiums.
____ Fewer benefits and lower premiums.
____ My plan has outpatient prescription drug coverage and I
am enrolling in Part D.
____ Disenrollment from a Medicare Advantage plan. Please
explain the reason for disenrollment [optional only for Direct Mailers]
_________________________________________________________________
____ Other (please specify).
(1) State law provides that your replacement
policy or certificate may not contain new preexisting conditions, waiting
periods, elimination periods, or probationary periods. The insurer will waive
any time periods applicable to preexisting conditions, waiting periods,
elimination periods, or probationary periods in the new policy (or coverage) to
the extent such time was spent (depleted) under the original policy.
(2) If you still wish to terminate your
present policy and replace it with new coverage, be certain to truthfully and
completely answer all questions on the application concerning your medical and
health history. Failure to include all material medical information on an
application may provide a basis for the company to deny any future claims and
to refund your premium as though your policy had never been in force. After the
application has been completed and before you sign it, review it carefully to
be certain that all information has been properly recorded. (If the policy or
certificate is guaranteed issue, this paragraph need not appear.) Do not cancel
your present policy until you have received your new policy and are sure that
you want to keep it.
(Signature of Agent, Broker or Other Representative)*
[Typed Name and Address of Issuer, Agent or Broker]
(Applicant's Signature)
(Date)
*Signature not required for direct response sales.
(f) Subsection (e)(1) and
(e)(2) of the replacement notice (applicable to preexisting conditions) may be
deleted by an issuer if the replacement does not involve application of a new
preexisting condition limitation.
