Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 10 - Regulation to Implement the Medicare Supplement Insurance Minimum Standards Model Act, as amended › Rule 19-3-10.18 - Requirements for Application Forms And Replacement Coverage

Current through June 25, 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.
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(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?
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(If you are still covered under the other policy, leave "END"
				  blank.)