1. (a) Application forms shall include the following information, statements and questions designed to elicit information as to whether, as of the date of the application, the applicant has another Medicare supplement or other 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, except where the coverage is sold without an agent, containing such questions may be used.

   1. (1) The information shall be provided to prospective covered persons in statement form conforming to subparagraphs (A)-(E) of this paragraph.

      1. (A) You do not need more than one Medicare supplement policy.
      2. (B) If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need more than one type of coverage in addition to your Medicare benefits.
      3. (C) You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.
      4. (D) 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 policy will be reinstituted if requested within 90 days of losing Medicaid eligibility.
      5. (E) 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).

   2. (2) Information shall be elicited from prospective covered persons by asking the questions as provided in subparagraphs (A)-(C) of this paragraph.

      1. (A) Do you have another Medicare supplement insurance policy, certificate, or coverage in force?

         1. (i) If so, with which company?
         2. (ii) If so, do you intend to replace your current Medicare supplement policy with this policy, certificate or coverage?

      2. (B) Do you have any other health insurance policies or coverages that provide benefits similar to this Medicare supplement policy?

         1. (i) If so, with which company?
         2. (ii) What kind of policy?

      3. (C) Are you covered for medical assistance through the state Medicaid program?

         1. (i) If so, as a Specified Low Income Medicare Beneficiary (SLMB)?
         2. (ii) If so, as a Qualified Medicare Beneficiary (QMB)?
         3. (iii) If so, for other Medicaid medical benefits?

2. (b) Agents shall list the following:

   1. (1) any other health insurance policies or coverages sold to the applicant which are still in force; and
   2. (2) any other health insurance policies or coverages sold to the applicant in the past five years which are no longer in force.
3. (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 issuer, shall be returned to the applicant by the issuer upon delivery of the policy.
4. (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 such 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.
5. (e) The notice required by subsection (d) of this section shall be provided in substantially the following form and shall be in a typeface no smaller than 12-point type.
6. (f) Subsection (e)(1) and (2) of this section (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation.

Source Note:The provisions of this §3.3309 adopted to be effective June 1, 1982, 7 TexReg 1303; amended to be effective February 14, 1990, 15 TexReg 540; amended to be effective December 1, 1990, 15 TexReg 6594; amended to be effective April 15, 1992, 17 TexReg 2238; amended to be effective January 1, 1997, 21 TexReg 10753.