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]
(i) You do not need more than one Medicare
supplement policy.
(ii) If you
purchase this policy, you may want to evaluate your existing health coverage
and decide if you need multiple coverages.
(iii) You may be eligible for benefits under
Medicaid and may not need a Medicare supplement policy.
(iv) 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.
(v) 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.
(vi) 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 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 ___/___/ __
(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 sixty-three (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 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 [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.
