Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Exhibit C - Requirements for Application Form

Current through June, 2024
(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?_____________________