A. Application forms shall include the
following questions designed to elicit information as to whether, as of the
date of the application, the
applicant currently has 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 producer, containing such questions and statements may be
used.
[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 medical benefits from
Medicaid OTHER THAN payments toward your
Medicare Part B premium? If yes,
please describe.
Yes____ No____
(3)
a. If
you had coverage from any
Medicare plan other than original
Medicare within the
past 90 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. If your previous coverage before this
Medicare
plan was a different
Medicare plan of the same type, your "START" date is the
day you began your
first plan of this type.
START __/__/__ END __/__/__
b. If you have been covered by more than one
Medicare plan of this type, have you been covered continuously by these plans,
with no break in coverage and no period of original
Medicare (Part A or B)
between the first plan and your current plan?
Yes____ No____
c. 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____
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]?
__________________________________________________
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 90 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.)
B. Producers shall list any other health
insurance policies they have sold to the
applicant.
(1) List policies sold which are still in
force.
(2) List policies sold in
the past five (5) years which are no longer in force.
C. In the case of a direct response issuer, a
copy of the application or supplemental form, signed by the applicant, and
acknowledged by the issuer, shall be returned to the applicant by the issuer
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 producer
shall furnish the applicant, prior to issuance or delivery of the Medicare
supplement policy or certificate, a notice regarding replacement of Medicare
supplement coverage. One copy of such notice signed by the applicant and the
producer, except where the coverage is sold without a producer, 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 above for an
issuer shall be provided in substantially
the following form in no less than twelve (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, PRODUCER [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 or, if applicable, Medicare
Advantage coverage because you intend to terminate your existing Medicare
supplement or leave your Medicare Advantage plan coverage. The replacement
policy is being purchased for the following reason(s) (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
reason for disenrollment. [optional only for Direct Mailers.]
____________________________________________________________
____________________________________________________________
Other (please specify)
1. Note: If the issuer of the Medicare
supplement policy being applied for does not, or is otherwise prohibited from
imposing pre-existing condition limitations, please skip to statement 2 below.
Health conditions which you may presently have (preexisting conditions) may not
be immediately or fully covered under the new policy. This could result in
denial or delay of a claim for benefits under the new policy, whereas a similar
claim might have been payable under your present policy.
2. 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)
for similar benefits to the extent such time was spent (depleted) under the
original policy.
3. 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 Producer or Other Representative)*
[Typed Name and Address of Issuer or Producer]
(Applicant's Signature)
(Date)
*Signature not required for direct response sales.
F. Paragraphs 1 and 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.
