Nevada Administrative Code › Chapter 687B - Contracts of Insurance › POLICIES SUPPLEMENTARY TO MEDICARE › General Provisions › Section 687B.255 - Elicitation and dissemination of information regarding existing coverage and its replacement; inclusion of certain statements and questions in application

Current through June 11, 2024
1. An application
				for a policy to supplement Medicare must include questions designed to elicit
				information about whether, as of the date of the application, the applicant
				currently has another policy to supplement Medicare, Medicare Advantage,
				Medicaid coverage, or another health insurance policy or certificate in force
				or whether the policy to supplement Medicare or the certificate is intended to
				replace any other policy or certificate presently in force. A supplementary
				application or other form containing such questions and statements may be used
				if it is signed by the applicant and the issuer or its agent.
2. An application must contain the following
				statements and questions:
(a) You do not need
				more than one policy to supplement Medicare.
(b) If you purchase this policy, you may want
				to evaluate your existing health coverage and decide if you need multiple
				coverages.
(c) You may be eligible
				for benefits under Medicaid and may not need a policy to supplement
				Medicare.
(d) If, after purchasing
				this policy, you become eligible for Medicaid, the benefits and premiums under
				your policy to supplement Medicare may, if requested, be suspended during your
				entitlement to benefits under Medicaid for 24 months. You must request this
				suspension within 90 days after becoming eligible for Medicaid. If you are no
				longer entitled to Medicaid, your suspended policy to supplement Medicare or,
				if that is no longer available, a substantially equivalent policy will be
				reinstituted if requested within 90 days after loss of eligibility. If the
				policy to supplement Medicare 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.
(e) If you are
				eligible for, and have enrolled in a policy to supplement Medicare by reason of
				disability and you later become covered by an employer or union-based group
				health plan, the benefits and premiums under your policy to supplement Medicare
				can be suspended, if requested, while you are covered under the employer or
				union-based group health plan. If you suspend your policy to supplement
				Medicare under these circumstances, and later lose your employer or union-based
				group health plan, your suspended policy to supplement Medicare 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 policy to supplement Medicare 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.
(f) Counseling services may be available in
				your state to provide advice concerning your purchase of a policy to supplement
				Medicare and concerning medical assistance available through the state Medicaid
				program, including benefits available to qualified Medicare beneficiaries, as
				that term is defined in
				42 U.S.C. §
											1396 d(p)(1), and to specified low-income
				Medicare beneficiaries, as described in
				42 U.S.C. §
											1396 a(a)(10)(E)(iii).
(g) If you lost or are losing your health
				insurance coverage and received a notice from your prior insurer saying that
				you were eligible for guaranteed issue of a policy to supplement Medicare, or
				that you had certain rights to buy such a policy, you may be guaranteed
				acceptance in one or more of our policies to supplement Medicare. Please
				include a copy of the notice from your prior insurer with your application.
				PLEASE ANSWER ALL QUESTIONS.
(h)
				[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 policy to supplement Medicare?
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 the 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
				policy to supplement Medicare?
Yes _____ No _____
(c) Was this your first time in this type of
				Medicare plan?
Yes _____ No _____
(d) Did you drop a policy to supplement
				Medicare to enroll in the Medicare plan?
Yes _____ No _____
(4)
(a) Do
				you have another policy to supplement Medicare 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 policy to supplement Medicare 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 policy?
Start ___/___/___ End ___/___/___
(If you are still covered under the other policy, leave "End"
				  blank.)