(a) Application forms must include the following statements and questions designed to obtain information as to whether, as of the date of the application, the applicant currently has a medicare supplement policy, medicare advantage plan, 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 in force at the time of application. A supplementary application or other form to be signed by the applicant and agent containing the questions and statements may be used by the issuer. [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 you become eligible for medicaid after purchasing this policy, 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 policy is no longer available, a substantially equivalent medicare supplement policy will be reinstituted if requested within 90 days of losing medicaid eligibility. If your 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 provide substantially similar benefits to the benefits in the policy before the date of suspension but will not include outpatient prescription drug coverage.
- (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 while you are covered under the employer or union-based group health plan upon your request. If your medicare supplement policy is suspended under these circumstances, and you later lose your employer or union-based group health plan, your suspended medicare supplement policy or, if that policy is no longer available, a substantially equivalent medicare supplement policy will be reinstituted if requested within 90 days of losing your employer or union-based health plan. If your 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 provide substantially similar benefits to the benefits in the policy before the date of suspension but will not include outpatient prescription drug coverage.
- (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) or a specified low-income medicare beneficiary (SLMB).
- (1) (a) Did you turn age 65 in the last 6 months?
- (b) Did you enroll in medicare Part B in the last 6 months?
- (c) If you answered yes to (1)(a) and (1)(b), what is the effect-
- (2) (a) Do you receive medical assistance through the state medicaid program? (Mark "No" if you are participating in a "spend- down program" and have not met your "share of cost.")
- (b) If you answered yes to (2)(a), will medicaid pay your premiums for this medicare supplement policy?
- (c) If you answered yes to (2)(b), do you receive any benefits from medicaid other than payment toward your medicare Part B premium?
- (3) (a) If you had coverage from any medicare plan other than original medicare (for example, medicare advantage or a medicare health maintenance organization (HMO) or preferred provider organization (PPO) within the past 63 days, fill in your start and end dates below. If you are still covered under this plan, leave the "END" date blank. If you did not have such coverage, skip to question (4).
- (b) If you are still covered under the medicare plan, do you intend to replace your current coverage with this new medicare supplement policy?
- (c) Was this your first time in this type of medicare plan?
- (d) Did you drop a medicare supplement policy to enroll in the medicare plan?
- (4) Do you have another medicare supplement policy in force?
- (a) If yes, with what company and what plan do you have? [optional for direct mail business]
- (b) If yes, do you intend to replace your current medicare supplement policy with this policy?
- (5) Have you had any other health insurance coverage within the past 63 days? (For example, employer, union, or individual plan)
- (a) If yes, with what company and what kind of policy?
- (b) If yes, what are the start and end dates of the coverage? If you are still covered under this policy, leave the "END" date blank.
[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. Mark "yes" or "no" below with an "X."
To the best of your knowledge,
Yes _______________ No _______________
Yes _______________ No _______________
ive date of your medicare Part B coverage? _______________
Yes _______________ No _______________
Yes _______________ No _______________
Yes _______________ No _______________
START ___/___/______ END ___/___/______
Yes _______________ No _______________
Yes _______________ No _______________
Yes _______________ No _______________
Yes _______________ No _______________
Company _______________
Plan _______________
Yes _______________ No _______________
Yes _______________ No _______________
Company _______________
Plan description _________
_________
_________
START ___/___/______ END ___/___/______