Current through Register Vol. 50, No. 9, September 20, 2024
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 any 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 containing such questions and
statements may be used.
B. An
application for a Medicare supplement policy shall not be combined with an
application for any other type of insurance coverage. The application may not
make reference to or include questions regarding other types of insurance
coverage except for those questions specifically required under this Section.
1. [Statements]
a. You do not need more than one Medicare
supplement policy.
b. If you
purchase this policy, you may want to evaluate your existing health coverage
and decide if you need multiple coverages.
c. You may be eligible for benefits under
Medicaid and may not need a Medicare supplement policy.
d. 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.
e. 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.
f. 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. [Questions]
a. 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"]
i. To the best of your knowledge:
(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?
_______________
ii. Are
you covered for medical assistance through the state Medicaid program? Yes____
No____ If yes:
[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.]
(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____
iii.
(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____
iv.
(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____
v. 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.)
C. 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, which are no longer in force.
D. 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.
E.
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.
F. The notice required by
Subsection E above for an issuer shall be provided in substantially the
following form in no less than 12 point type.
NOTICE TO APPLICANT REGARDING REPLACEMENT
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 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 benefit, 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 which 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) 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.
G. 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.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:1111 (re-designated from LSA-R.S. 22:224 pursuant
to Acts 2008, No. 415, effective January 1, 2009) and
42 U.S.C.
1395 et seq.
