A.
Statements
and questions. 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.
Other policies sold to this
applicant. 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 years that are no longer in
force.
C.
Signed
form. 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.
Replacement
notice. 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.
Format for notice. The notice required by the preceding Subsection for
an issuer shall be provided in substantially the following form in no less than
12 point type:
NOTICE TO APPLICANT REGARDING REPLACMENT 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, you intend to terminate existing Medicare
Supplement or Medicare Advantage insurance and replace it with a policy to be
issued by Insurance Company. Your new policy will provide 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 must 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. Paragraph (2) of the
replacement notice (applicable to preexisting conditions) must be deleted by an
issuer if the replacement does not involve application of a new preexisting
condition limitation.
