Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 71.00 - Medicare Supplement Insurance To Facilitate The Implementation Of M.G.L. c. 176k And Section 1882 Of The Federal Social Security Act › Section 71.14 - Requirements for Application or Replacement

Current through Register 1525, July 5, 2024
(1)
			 Application forms shall include the following questions and statements in
			 precisely the following form designed to elicit information as to whether, as
			 of the date of the application, the Applicant has another Medicare Supplement,
			 Medicare Advantage, Medicaid coverage, or other health insurance policy in
			 force or whether a Medicare Supplement Insurance Policy is intended to replace
			 any other accident and sickness policy 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]
(a) You
			 do not need more than one Medicare Supplement Insurance Policy.
(b) If you newly enroll in a Medicare
			 Supplement 1 plan, you are not permitted to switch within the same company into
			 a Medicare Supplement 1A plan until you have been covered by the company's
			 Medicare Supplement 1 plan for at least 12 months.
(c) If you purchase this Policy, you may want
			 to evaluate your existing health coverage and decide if you need multiple
			 coverages.
(d) You may be eligible
			 for Medicaid benefits and may not need a Medicare Supplement Insurance
			 Policy.
(e) The benefits and
			 premiums under your Medicare Supplement Insurance 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 Policy will be
			 reinstituted if requested within 90 days of losing Medicaid eligibility.
If the Medicare Supplement Insurance 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, as you will be enrolled in the most comparable plan
				without outpatient prescription drug coverage.
[Issuers that permit a period of suspension for longer than 24
				months should delete "for 24 months" and insert the appropriate
				limitation.]
(f) If you are
			 eligible for, and have enrolled in a Medicare Supplement Insurance 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
			 Insurance 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 Insurance Policy under these circumstances, and later lose your
			 employer or union-based group health plan, your suspended Medicare Supplement
			 Insurance 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 Insurance 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, as you will be enrolled in the most comparable plan
				without outpatient prescription drug coverage.
(g) Counseling services are available in
			 Massachusetts 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). You may call the Massachusetts
			 Executive Office of Elder Affairs insurance counseling program at [insert the
			 toll-free number of the Massachusetts Executive Office of Elder Affairs] or
			 write to that office at the following address for more information: [insert the
			 address of the Massachusetts Executive Office of Elder Affairs].
[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 65 years of age in the last six months?
Yes____ No____
(b) Did you enroll in Medicare Part B in the
			 last six 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 Insurance 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.
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 Insurance Policy?
Yes____ No____
(c) Was this your first time in this type of
			 Medicare plan?
Yes____ No____
(d) Did you drop a Medicare Supplement
			 Insurance Policy to enroll in the Medicare plan?
Yes____ No____
(4)
(a) Do
			 you have another Medicare Supplement Insurance 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 Insurance 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?
START __/__/__ END __/__/__
(If you are still covered under the other policy, leave "END"
				blank.)