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, 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 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 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]?
_______________________________
(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.)
B. Agents 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 that 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 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, prior to issuance or delivery of the Medicare supplement
policy or certificate, 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 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 INSRUANCE 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 or, if applicable, Medicare
Advantage coverage because you intend to terminate your existing Medicare
supplement coverage or leave your Medicare Advantage plan. The replacement
policy is being purchased for the following reason (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 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 that
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 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. 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.
