Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-18 - Requirements for Application Forms and Replacement Coverage

Current through 2024-29, July 17, 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, or 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 producer, 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 medical benefits from
				Medicaid OTHER THAN payments toward your Medicare Part B premium? If yes,
				please describe.
Yes____ No____
(3)
a. If
				you had coverage from any Medicare plan other than original Medicare within the
				past 90 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. If your previous coverage before this Medicare
				plan was a different Medicare plan of the same type, your "START" date is the
				day you began your
first
plan of this type.
START __/__/__ END __/__/__
b. If you have been covered by more than one
				Medicare plan of this type, have you been covered continuously by these plans,
				with no break in coverage and no period of original Medicare (Part A or B)
				between the first plan and your current plan?
Yes____ No____
c. 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____
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 90 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.)