Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 71.00 - Medicare Supplement Insurance To Facilitate The Implementation Of M.G.L. c. 176k And Section 1882 Of The Federal Social Security Act
Section 71.14 - Requirements for Application or Replacement

Universal Citation: 211 MA Code of Regs 211.71

Current through Register 1531, September 27, 2024

(1) Application forms shall include the following questions and statements in precisely the following form designed to elicit information as to whether, as of the date of the application, the Applicant has another Medicare Supplement, Medicare Advantage, Medicaid coverage, or other health insurance policy in force or whether a Medicare Supplement Insurance Policy is intended to replace any other accident and sickness policy 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.

[Statements]

(a) You do not need more than one Medicare Supplement Insurance Policy.

(b) If you newly enroll in a Medicare Supplement 1 plan, you are not permitted to switch within the same company into a Medicare Supplement 1A plan until you have been covered by the company's Medicare Supplement 1 plan for at least 12 months.

(c) If you purchase this Policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

(d) You may be eligible for Medicaid benefits and may not need a Medicare Supplement Insurance Policy.

(e) The benefits and premiums under your Medicare Supplement Insurance 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.

If the Medicare Supplement Insurance 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, as you will be enrolled in the most comparable plan without outpatient prescription drug coverage.

[Issuers that permit a period of suspension for longer than 24 months should delete "for 24 months" and insert the appropriate limitation.]

(f) If you are eligible for, and have enrolled in a Medicare Supplement Insurance 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 Insurance 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 Insurance Policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare Supplement Insurance 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 Insurance 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, as you will be enrolled in the most comparable plan without outpatient prescription drug coverage.

(g) Counseling services are available in Massachusetts 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). You may call the Massachusetts Executive Office of Elder Affairs insurance counseling program at [insert the toll-free number of the Massachusetts Executive Office of Elder Affairs] or write to that office at the following address for more information: [insert the address of the Massachusetts Executive Office of Elder Affairs].

[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,

(1)
(a) Did you turn 65 years of age in the last six months?

Yes____ No____

(b) Did you enroll in Medicare Part B in the last six 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____

If yes,

(a) Will Medicaid pay your premiums for this Medicare Supplement Insurance 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 Insurance Policy?

Yes____ No____

(c) Was this your first time in this type of Medicare plan?

Yes____ No____

(d) Did you drop a Medicare Supplement Insurance Policy to enroll in the Medicare plan?

Yes____ No____

(4)
(a) Do you have another Medicare Supplement Insurance 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 Insurance 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?

START __/__/__ END __/__/__

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

(2) Agents shall list any other health insurance policies they have sold to the Applicant.

(a) List policies sold which are still in force.

(b) List policies sold in the past five years which are no longer in force.

(3) 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) 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 Insurance Policy, 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 a 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) The notice required by 211 CMR 71.14(4) for an Issuer shall be provided in precisely the following form in no less than 12-point type:

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE

[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 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 have 30 days to review your policy and decide whether to keep it, EXCEPT that if you are newly enrolling in a Medicare Supplement 1 plan, then you are not permitted to switch within the same company into a Medicare Supplement 1A plan until you have been covered by the company's Medicare Supplement 1 plan for a period of at least 12 months. You should review your 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 coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this Policy.

STATEMENT TO APPLICANT BY ISSUER, INSURANCE PRODUCER, OR OTHER REPRESENTATIVE:

I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare Supplement Insurance Policy will not duplicate your existing Medicare Supplement coverage because you intend to terminate your existing Medicare supplement 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.

_________ Other. (please specify)

________________________________________________________________________

________________________________________________________________________

(1) State law provides that your replacement Policy may not contain any preexisting conditions, waiting periods, elimination periods or probationary periods.

(2) 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. Failure to include all material 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.

Do not cancel your present Policy until you have received your new Policy and are sure that you want to keep it. If you cancel your present Policy and then decide that you do not want to keep your new Policy, it may not be possible to get back the coverage of the present Policy.

_________________________________________________

(Signature of Insurance Producer or Other Representative)*

[Typed Name and Address of Issuer or Insurance Producer]

_________________________________________________

(Applicant's signature)

_________________________________________________

(Date)

[*Signature not required for direct response sales.]

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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