(1) Application forms shall include the
following questions and statements in precisely the following form designed to
elicit information as to whether, as of the date of the application, the
Applicant has another Medicare Supplement, Medicare Advantage, Medicaid
coverage, or other health insurance policy in force or whether a Medicare
Supplement Insurance Policy is intended to replace any other accident and
sickness policy presently in force. A supplementary application or other form
to be signed by the
Applicant and agent containing such questions and
statements may be used.
[Statements]
(a) You
do not need more than one Medicare Supplement Insurance Policy.
(b) If you newly enroll in a Medicare
Supplement 1 plan, you are not permitted to switch within the same company into
a Medicare Supplement 1A plan until you have been covered by the company's
Medicare Supplement 1 plan for at least 12 months.
(c) If you purchase this Policy, you may want
to evaluate your existing health coverage and decide if you need multiple
coverages.
(d) You may be eligible
for Medicaid benefits and may not need a Medicare Supplement Insurance
Policy.
(e) The benefits and
premiums under your
Medicare Supplement Insurance 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 Policy will be
reinstituted if requested within 90 days of losing Medicaid eligibility.
If the Medicare Supplement Insurance 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, as you will be enrolled in the most comparable plan
without outpatient prescription drug coverage.
[Issuers that permit a period of suspension for longer than 24
months should delete "for 24 months" and insert the appropriate
limitation.]
(f) If you are
eligible for, and have enrolled in a
Medicare Supplement Insurance 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
Insurance 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 Insurance Policy under these circumstances, and later lose your
employer or union-based
group health plan, your suspended Medicare Supplement
Insurance 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 Insurance 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, as you will be enrolled in the most comparable plan
without outpatient prescription drug coverage.
(g) Counseling services are available in
Massachusetts 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). You may call the Massachusetts
Executive Office of Elder Affairs insurance counseling program at [insert the
toll-free number of the Massachusetts Executive Office of Elder Affairs] or
write to that office at the following address for more information: [insert the
address of the Massachusetts Executive Office of Elder Affairs].
[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 65 years of age in the last six months?
Yes____ No____
(b) Did you enroll in
Medicare Part B in the
last six 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 Insurance 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 Insurance Policy?
Yes____ No____
(c) Was this your first time in this type of
Medicare plan?
Yes____ No____
(d) Did you drop a
Medicare Supplement
Insurance Policy to enroll in the
Medicare plan?
Yes____ No____
(4)
(a) Do
you have another
Medicare Supplement Insurance 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 Insurance 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.)
(2) Agents shall list any other health
insurance policies they have sold to the
Applicant.
(a) List policies sold which are still in
force.
(b) List policies sold in
the past five years which are no longer in force.
(3) 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.
(4)
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, prior to issuance or delivery of the Medicare Supplement
Insurance Policy, a notice regarding replacement of Medicare Supplement
coverage. One 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 a 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.
(5) The notice required
by 211 CMR
71.14(4) for an
Issuer shall be provided in precisely the following
form in no less than 12-point type:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE
SUPPLEMENT INSURANCE
[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 Insurance and replace it with a Policy
to be issued by [Company Name] Insurance Company. Your new Policy will provide
30 days within which you may decide without cost whether you desire to keep the
Policy. You have 30 days to review your policy and decide whether to keep it,
EXCEPT that if you are newly enrolling in a Medicare Supplement 1 plan, then
you are not permitted to switch within the same company into a Medicare
Supplement 1A plan until you have been covered by the company's Medicare
Supplement 1 plan for a period of at least 12 months. You should review your
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 coverage. You should evaluate the need for other accident
and sickness coverage you have that may duplicate this Policy.
STATEMENT TO APPLICANT BY ISSUER, INSURANCE PRODUCER, OR OTHER
REPRESENTATIVE:
I have reviewed your current medical or health insurance
coverage. To the best of my knowledge, this Medicare Supplement Insurance
Policy will not duplicate your existing Medicare Supplement coverage because
you intend to terminate your existing Medicare supplement 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.
_________ Other. (please specify)
________________________________________________________________________
________________________________________________________________________
(1) State law provides that your replacement
Policy may not contain any preexisting conditions, waiting periods, elimination
periods or probationary periods.
(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. Failure to include all
material 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.
Do not cancel your present Policy until you have received your
new Policy and are sure that you want to keep it. If you cancel your present
Policy and then decide that you do not want to keep your new Policy, it may not
be possible to get back the coverage of the present Policy.
_________________________________________________
(Signature of Insurance Producer or Other
Representative)*
[Typed Name and Address of Issuer or Insurance Producer]
_________________________________________________
(Applicant's signature)
_________________________________________________
(Date)
[*Signature not required for direct response
sales.]
