836-052-0165 Requirements for Application Forms, Replacement Coverage (1) Application forms shall include the statements and questions set forth in this section 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 another health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other health insurance policy or certificate currently in force. A supplementary application or other form to be signed by the applicant and agent containing such statements and questions may be used. The statements and questions are as follows: (a) 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). (b) 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 ore 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 age 65 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 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 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__________ (4)(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__________ (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) An agent shall list any other health insurance policies that the agent has sold to the applicant, and: (a) List such policies sold that are still in force; (b) List such policies sold in the past five years that 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 policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice signed by the applicant and the agent, except when 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. (5) The notice required by section (4) of this rule for an issuer, shall be provided in substantially the form shown in Exhibit 1 to this rule in no less than 12 point type. (6) 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. [ED. NOTE: Exhibits referenced are available from the agency.] Statutory/Other Authority: ORS 743.010 & 743.685 Statutes/Other Implemented: ORS 743.010, 743.683 & 743.685 History: ID 10-2005, f. & cert. ef. 7-26-05 ID 8-2005, f. 5-18-05, cert. ef. 8-1-05 ID 11-2001, f. & cert. ef. 9-24-01 ID 8-2001(Temp), f. 6-15-01, cert. ef. 6-18-01 thru 12-10-01 ID 9-1997, f. & cert. ef. 7-10-97 ID 5-1996, f. & cert. ef. 4-26-96 ID 7-1992, f. & cert. ef. 5-8-92 ID 11-1990, f. 5-11-90, cert. ef. 9-1-90 ID 1-1990, f. 1-10-90, cert. ef. 4-1-90 ID 5-1989, f. 6-30-89, cert. ef. 7-3-89 ID 1-1989(Temp), f. & cert. ef. 1-3-89