Alaska Administrative Code › Title 3 - Commerce, Community, and Economic Development › Part 2 - Division of Insurance › Chapter 28 - Life, Health, Variable, and Related Insurance › Article 5 - Health Insurance Marketed as Medicare Supplements › 3 AAC 28.500 - Requirements for application forms and replacement coverage

Current through May 31, 2024
(a) Application
				  forms must include the following statements and questions designed to obtain
				  information as to whether, as of the date of the application, the applicant
				  currently has a medicare supplement policy, medicare advantage plan, 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 in force at the time of
				  application. A supplementary application or other form to be signed by the
				  applicant and agent containing the questions and statements may be used by the
				  issuer.
[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 you become eligible
				  for medicaid after purchasing this policy, 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 policy is no longer available, a substantially equivalent medicare
				  supplement policy will be reinstituted if requested within 90 days of losing
				  medicaid eligibility. If your 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 provide substantially
				  similar benefits to the benefits in the policy before the date of suspension
				  but will not include outpatient prescription drug coverage.
(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 while you are
				  covered under the employer or union-based group health plan upon your request.
				  If your medicare supplement policy is suspended under these circumstances, and
				  you later lose your employer or union-based group health plan, your suspended
				  medicare supplement policy or, if that policy is no longer available, a
				  substantially equivalent medicare supplement policy will be reinstituted if
				  requested within 90 days of losing your employer or union-based health plan. If
				  your 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 provide substantially similar benefits to the benefits
				  in the policy before the date of suspension but will not include outpatient
				  prescription drug coverage.
(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) or 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. 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 you answered yes to (1)(a) and (1)(b),
				  what is the effective date of your medicare Part B coverage?
_________
(2)
(a) Do
				  you receive medical assistance through the state medicaid program? (Mark "No"
				  if you are participating in a "spend-down program" and have not met your "share
				  of cost.")
Yes _______________ No _______________
(b) If you answered yes to (2)(a), will
				  medicaid pay your premiums for this medicare supplement policy?
Yes _______________ No _______________
(c) If you answered yes to (2)(b), do you
				  receive any benefits from medicaid other than payment toward your medicare Part
				  B premium?
Yes _______________ No
					 _______________
(3)
(a) If
				  you had coverage from any medicare plan other than original medicare (for
				  example, medicare advantage or a medicare health maintenance organization (HMO)
				  or preferred provider organization (PPO) within the past 63 days, fill in your
				  start and end dates below. If you are still covered under this plan, leave the
				  "END" date blank. If you did not have such coverage, skip to question (4).
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) Do you have another medicare supplement
				  policy in force?
Yes _______________ No _______________
(a) If yes, with what company and what plan
				  do you have? [optional for direct mail business]
Company _______________
Plan _______________
(b) If yes, do you intend to replace your
				  current medicare supplement policy with this policy?
Yes _______________ No
					 _______________
(5) Have you had any other health insurance
				  coverage within the past 63 days? (For example, employer, union, or individual
				  plan)
Yes _______________ No _______________
(a) If yes, with what company and what kind
				  of policy?
Company _______________
Policy description _________
_________
_________
(b) If yes, what are the start and end dates
				  of the coverage? If you are still covered under this policy, leave the "END"
				  date blank.
START _______________ / _______________ / _______________
					 END _______________ / _______________ / _______________