Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix R - Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage

Current through Register Vol. 48, No. 28, July 12, 2024
Insurance company's name and address
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU
				  IN THE FUTURE
According to (your application) (information you have
				  furnished) you intend to terminate existing Medicare supplement or Medicare
				  Advantage insurance and replace it with a policy to be issued by (Company Name)
				  Insurance Company. Your new policy will provide 30 days within which you may
				  decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it
				  with all accident and sickness coverage you now have. If, after due
				  consideration, you find that purchase of this Medicare supplement coverage is a
				  wise decision, you should terminate your present Medicare supplement or
				  Medicare Advantage coverage. You should evaluate the need for other accident
				  and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY INSURANCE PRODUCER:
I have reviewed your current medical or health insurance
				  coverage. To the best of my knowledge, this Medicare supplement or, if
				  applicable, policy will not duplicate your existing Medicare supplement
				  coverage because you intend to terminate your existing Medicare supplement or
				  leave your Medicare Advantage Plan. The replacement policy is being purchased
				  for the following reason (Check one):
Additional benefits.
No change in benefits, but lower
				  premiums.
Fewer benefits and lower premiums.
My plan has outpatient prescription drug
				  coverage and I am enrolling in Part D for disenrollment. (Optional only for
				  Direct Mailers)
Disenrollment from a Medicare Advantage plan.
				  Please explain reason.
Other. (Please specify)
Note:
If the issuer of the Medicare
				  supplement policy being applied for does not, or is otherwise prohibited from
				  imposing, pre-existing condition limitations, please skip to statement 2
				  below.
1) Health conditions which you may presently have
				  (preexisting conditions) may not be immediately or fully covered under the new
				  policy. This could result in denial or delay of a claim for benefits under the
				  new policy, whereas a similar claim might have been payable under your present
				  policy.
2) Section 363(7)(b) of the Illinois Insurance
				  Code [215 ILCS 5/363(7)(b) ] provides that your replacement policy or
				  certificate may not contain new preexisting conditions, waiting periods,
				  elimination periods or probationary periods. The issuer will waive any time
				  periods applicable to preexisting conditions, waiting periods, elimination
				  periods, or probationary periods in the new policy (or coverage) for similar
				  benefits to the extent such time was spent (depleted) under the original
				  policy.
3) If you still wish to terminate your present
				  policy and replace it with new coverage, be certain to truthfully and
				  completely answer all questions on the application concerning your medical and
				  health history. Failure to include all material medical information on an
				  application may provide a basis for the company to deny any future claims and
				  to refund your premium as though your policy had never been in force. After the
				  application has been completed and before you sign it, review it carefully to
				  be certain that all information has been properly recorded. [If the policy or
				  certificate is guaranteed issue, this paragraph need not appear.]
Do not cancel your present policy until you have
				  received your new policy and are sure that you want to keep it.
____________________________________________________________________
(Signature of Insurance Producer or Other
				  Representative)
Typed Name and Address of Issuer or Insurance
				  Producer
____________________________________________________________________
(Applicant's Signature)
____________________________________________________________________
Date
* Signature not required for direct response
				  sales.