New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 25 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 13.10.25.24 - REQUIREMENTS FOR APPLICATION FORMS AND REPLACEMENT COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Statements
				and questions.
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.
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.)