Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 275 - Medicare Supplement Insurance
Section 031-275-18 - Requirements for Application Forms and Replacement Coverage
Current through 2024-13, March 27, 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, or 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.
[Statements]
[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,
Did you turn age 65 in the last 6 months?
Yes____ No____
Yes____ No____
[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,
Yes____ No____
Yes____ No____
START __/__/__ END __/__/__
Yes____ No____
Yes____ No____
Yes____ No____
Yes____ No____
__________________________________________________
Yes____ No____
Yes____ No____
________________________________________________
________________________________________________
________________________________________________
________________________________________________
START __/__/__ END __/__/__
(If you are still covered under the other policy, leave "END" blank.)
B. Producers shall list any other health insurance policies they have sold to the applicant.
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.
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 such 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 twelve (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 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, PRODUCER [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 or leave your Medicare Advantage plan coverage. 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 reason for disenrollment. [optional only for Direct Mailers.]
____________________________________________________________
____________________________________________________________
Other (please specify)
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 or Other Representative)*
[Typed Name and Address of Issuer or Producer]
(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.