R590-146-18. Requirements for Application Forms and Replacement Coverage

  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 producer containing such questions and statements may be used.

TABLE I

(Statements)

(Boldface Type)

  (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

(Boldface Type)

  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 the 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

(a) If yes, 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?

If you are still covered under the other policy, leave "END" blank.

START / / END / /

  B. Producers 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, which 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 producer, 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 producer, except where the coverage is sold without a producer, 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 12-point type:

TABLE II

NOTICE TO APPLICANT REGARDING REPLACEMENT

OF MEDICARE SUPPLEMENT INSURANCE

OR MEDICARE ADVANTAGE

(Boldface Type)

(Insurance company's name and address)

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

(Boldface Type)

According to (your application) (information you have

furnished), you intend to terminate existing Medicare

supplement insurance or Medicare Advantage and replace

it with a policy to be issued by (Company Name)

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 or Medicare Advantage 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, PRODUCER (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(s) (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 Mailer.)

  ..... 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 fullycovered 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 Producer, Broker or Other Representative)

(Typed Name and Address of Issuer, Producer or Broker)

....................................................

(Applicant's Signature)

....................................................

(Date)

Signature not required for direct response sales.

  F. Subsections 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.