Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.5 - Medicare Supplements › Rule 6.6.510 - REQUIREMENTS FOR APPLICATION FORMS AND REPLACEMENT COVERAGE

Current through Register Vol. 13, July 5, 2024
(1) Application forms must include the
				following questions designed to elicit information as to whether, as of the
				date of application, the applicant currently has Medicare supplement, Medicare
				advantage, Medicaid coverage, or another health 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 as the following 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 must 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. Upon receipt of
				timely notice, the issuer must either return to the policyholder or
				certificateholder that portion of the premium attributable to the period of
				Medicaid eligibility or provide coverage to the end of the term for which
				premiums were paid, at the option of the insured, subject to adjustment for
				paid claims. 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 reinstated 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 reinstated 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 reinstated 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 reinstated policy will not
				have prescription drug coverage, but will otherwise be substantially equivalent
				to your coverage before the date of 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 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 _____
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.
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)
(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?
Start / / End / /
(If you are still covered under the other policy, leave
				  "end" blank.)
[End Statements and Questions
				  Form]