Current through Reg. 50, No. 13; March 28, 2025
(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 currently has
another Medicare supplement, Medicare Advantage, Medicaid coverage, 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 currently 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) The information shall be provided to
prospective covered persons in statement form conforming to subparagraphs (A) -
(F) of this paragraph.
(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 more than one
type of coverage in addition to your Medicare benefits.
(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) Information shall be elicited from
prospective covered persons by asking the questions as follows: 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.
(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?
(D) Are you covered for
medical assistance through the state Medicaid program?
(i) {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____
(ii) If yes;
(I) Will Medicaid pay your premiums for this
Medicare supplement policy? Yes____ No____
(II) Do you receive any benefits from
Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes____
No____
(E) 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 __/__/__
(i) 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____
(ii) Was this your first time in this type of
Medicare plan? Yes____ No____
(iii)
Did you drop a Medicare supplement policy to enroll in the Medicare plan?
Yes____ No____
(F) Do
you have another Medicare supplement policy in force? Yes____ No____
(i) If so, with what company, and what plan
do you have {optional for Direct Mailers}?
(ii) If so, do you intend to replace your
current Medicare supplement policy with this policy? Yes____ No____
(G) Have you had coverage under
any other health insurance within the past 63 days? (For example, an employer,
union, or individual plan) Yes____ No____
(i)
If so, with what company and what kind of policy?
(ii) What are your dates of coverage under
the other policy? START __/__/__ END __/__/__ (If you are still covered under
the other policy, leave "END" blank.)
(b) Application forms shall
include questions to elicit information as to whether the applicant is an
eligible person as defined in §
3.3312(b) of
this title (relating to Guaranteed Issue for Eligible Persons), or whether the
applicant is eligible for reduction of any applicable preexisting condition
limitation under §
3.3324(c) and (d)
of this title (relating to Open Enrollment).
(c) Agents shall list the following:
(1) any other health insurance policies or
coverages sold to the applicant which are still in force; and
(2) any other health insurance policies or
coverages sold to the applicant 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 issuer, shall be returned to
the applicant by the issuer 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 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.
(f) The notice required by subsection (e) of
this section shall be provided in substantially the following form and shall be
in a typeface no smaller than 12-point type.
Attached
Graphic
(g)
Subsection (f)(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.