Alabama Administrative Code › Title 482 - ALABAMA DEPARTMENT OF INSURANCE › Chapter 482-1-071 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS REGULATION › Section 482-1-071-.18 - Requirements For Application Forms And Replacement Coverage

Current through Register Vol. 42, No. 9, June 28, 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, 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 agent containing such questions and
			 statements may be used.
[Statements]
(1) You
			 do not need more than one Medicare supplement policy.
(2) If you purchase this policy, you may want
			 to evaluate your existing health coverage and decide if you need multiple
			 coverages.
(3) You may be eligible
			 for benefits under Medicaid and may not need a Medicare supplement
			 policy.
(4) 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.
(5) 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.
(6) 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).
[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 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?______________
(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.)