In the interest of full and fair disclosure, and to ensure the availability of necessary consumer information to potential subscribers or enrollees not possessing a special knowledge of Medicare, health care service plans, or Medicare supplement contracts, an issuer shall comply with the following provisions:
(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, Medi-Cal coverage, or another health insurance policy or certificate or plan contract in force or whether a Medicare supplement contract is intended to replace any other disability policy or certificate, or plan contract, presently in force. A supplementary application or
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In the interest of full and fair disclosure, and to ensure the availability of necessary consumer information to potential subscribers or enrollees not possessing a special knowledge of Medicare, health care service plans, or Medicare supplement contracts, an issuer shall comply with the following provisions:
(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, Medi-Cal coverage, or another health insurance policy or certificate or plan contract in force or whether a Medicare supplement contract is intended to replace any other disability policy or certificate, or plan contract, presently in force. A supplementary application or
other form to be signed by the applicant and solicitor containing those questions and statements may be used.
“(Statements)
(1)
You do not need more than one Medicare supplement policy or contract.
(2)
If you purchase this contract, you may want to evaluate your existing health coverage and decide if you need multiple coverages.
(3)
You may be eligible for benefits under Medi-Cal or Medicaid and may not need a Medicare supplement contract.
(4)
If, after purchasing this contract, you become eligible for Medi-Cal, the benefits and premiums under your Medicare supplement contract can be suspended, if requested, during your entitlement to benefits under Medi-Cal or Medicaid for 24 months. You must request
this suspension within 90 days of becoming eligible for Medi-Cal or Medicaid. If you are no longer entitled to Medi-Cal or Medicaid, your suspended Medicare supplement contract or, if that is no longer available, a substantially equivalent contract, will be reinstituted if requested within 90 days of losing Medi-Cal or Medicaid eligibility. If the Medicare supplement contract provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your contract was suspended, the reinstituted contract 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 contract 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 contract can be suspended, if
requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement contract under these circumstances and later lose your employer or union-based group health plan, your suspended Medicare supplement contract or, if that is no longer available, a substantially equivalent contract, will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement contract provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your contract was suspended, the reinstituted contract 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 are available in this state to provide advice concerning your purchase of Medicare supplement coverage and concerning medical assistance through the
Medi-Cal or Medicaid Program, including benefits as a qualified Medicare beneficiary (QMB) and a specified low-income Medicare beneficiary (SLMB). Information regarding counseling services may be obtained from the California Department of Aging.
(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 contract or that you had certain rights to buy such a contract, 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 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 California’s Medi-Cal program?
NOTE TO APPLICANT: If you have a share of cost under the Medi-Cal program, please answer NO to this question.
Yes____ No____
If yes,
(a)
Will Medi-Cal pay your premiums for this Medicare supplement
contract?
Yes____ No____
(b)
Do you receive benefits from Medi-Cal 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 contract?
Yes____ No____
(c)
Was this your first time in this type of Medicare plan?
Yes____ No____
(d)
Did you drop a Medicare supplement contract to enroll in the Medicare plan?
Yes____ No____
(4)
(a)
Do you have another Medicare supplement policy or certificate or contract in force?
Yes____ No____
(b)
If so, with what company, and what plan do you have? [optional for Direct Mailers]
Yes____ No____
(c)
If so, do you intend to replace your current Medicare supplement policy or certificate or contract with this contract?
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 companies 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).”
(b)
Solicitors shall list any other health insurance policies or plan contracts they have sold to the applicant as follows:
(1)
List policies and contracts sold that are still in force.
(2)
List policies and contracts sold in the past five years that are no longer in force.
(c)
An issuer issuing Medicare supplement contracts without a solicitor or solicitor firm (a direct response issuer) shall return to the applicant, upon delivery of the contract, a copy of the application or supplemental forms, signed by the applicant and acknowledged by the issuer.
(d)
Upon determining that a sale will involve replacement of Medicare supplement coverage, an issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance for delivery of the Medicare supplement contract, 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 contract the notice regarding replacement of Medicare supplement coverage.
(e)
The notice required by subdivision (d) 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
COVERAGE OR MEDICARE ADVANTAGE
(Company 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 lapse or otherwise terminate an existing Medicare supplement policy or contract or Medicare Advantage plan and replace it with a contract to be issued by [Plan Name]. Your contract to be issued by [Plan Name] will provide 30 days within which you may decide without cost whether you desire to keep the contract. You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. Terminate your present policy or contract only if, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision.
STATEMENT TO APPLICANT BY PLAN, SOLICITOR, SOLICITOR FIRM, OR OTHER REPRESENTATIVE:
(1)
I have reviewed your current medical or health coverage. To the best of my knowledge, the replacement of coverage involved in this transaction does not duplicate coverage or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement contract is being purchased for the following reason (check one):
__
Additional benefits.
__
No change in benefits, but lower premiums or charges.
__
Fewer benefits and lower premiums or charges.
__
Plan has
outpatient prescription drug coverage and applicant is enrolled in Medicare Part D.
__
Disenrollment from a Medicare Advantage plan. Reasons for disenrollment:
__
Other. (please specify) ________.
(2)
If the issuer of the Medicare supplement contract being applied for does not impose, or is otherwise prohibited from imposing, preexisting condition limitations, please skip to statement 3 below. Health conditions that you may presently have (preexisting conditions) may not be immediately or fully covered under the new contract. This could result in denial or delay of a claim for benefits under the new contract, whereas a similar claim might have been payable under your present contract.
(3)
State law provides that your replacement Medicare supplement
contract may not contain new preexisting conditions, waiting periods, elimination periods, or probationary periods. The plan will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new coverage for similar benefits to the extent that time was spent (depleted) under the original contract.
(4)
If you still wish to terminate your present policy or contract and replace it with new coverage, be certain to truthfully and completely answer any and all questions on the application concerning your medical and health history. Failure to include all material medical information on an application requesting that information may provide a basis for the plan to deny any future claims and to refund your prepaid or periodic payment as though your contract 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.
(5)
Do not cancel your present Medicare supplement coverage until you have received your new contract and are sure you want to keep it.
(Signature of Solicitor, Solicitor Firm, or Other Representative)
[Typed Name and Address of Plan, Solicitor, or Solicitor Firm]
(Applicant’s Signature)
(Date)
(f)
The application form or other consumer information for persons eligible for Medicare and used by an issuer shall contain, as an attachment, a Medicare supplement buyer’s guide in the form approved by the director. The application or other consumer information, containing, as an attachment, the buyer’s guide, shall be mailed or delivered to each applicant applying for that coverage at or before the time of application and, to establish compliance with this subdivision, the issuer shall obtain an acknowledgment of receipt of the attached buyer’s guide from each applicant. An issuer shall not make use of or otherwise disseminate any buyer’s guide that does not accurately outline current Medicare supplement benefits. An issuer shall not be required to provide more than one copy of the buyer’s guide to any applicant.
(g)
An
issuer may comply with the requirement of this section in the case of group contracts by causing the subscriber (1) to disseminate copies of the disclosure form containing as an attachment the buyer’s guide to all persons eligible under the group contract at the time those persons are offered the Medicare supplement plan, and (2) collecting and forwarding to the issuer an acknowledgment of receipt of the disclosure form containing, as an attachment, the buyer’s guide from each enrollee.
(h)
An issuer shall not require, request, or obtain health information as part of the application process for an applicant who is eligible for guaranteed issuance of, or open enrollment for, any Medicare supplement coverage pursuant to Section 1358.11 or 1358.12, except for purposes of paragraph (1) or (2) of subdivision (a) of Section 1358.11 when the applicant is first enrolled in Medicare Part B. The application form shall include a clear and conspicuous
statement that the applicant is not required to provide health information during a period where guaranteed issue or open enrollment applies, as specified in Section 1358.11 or 1358.12, except for purposes of paragraph (1) or (2) of subdivision (a) of Section 1358.11 when the applicant is first enrolled in Medicare Part B, and shall inform the applicant of those periods of guaranteed issuance of Medicare supplement coverage. This subdivision does not prohibit an issuer from requiring proof of eligibility for a guaranteed issuance of Medicare supplement coverage.