Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.015 - Requirements for Application Forms and Replacement Coverage

Current through Reg. 50, No. 138; July 16, 2024
(1) Application forms shall include the
				following statements and the following questions designed to elicit information
				as to whether, as of the date of the application, the applicant currently has
				Medicare supplement, or 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 applicant and agent containing such questions and
				statements may be used.
[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).
[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 our 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?
Yes__ No__.
[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.]
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 plan
				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.)