North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-01.1 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 45-06-01.1-15 - Requirements for application forms and replacement coverage

Current through Supplement No. 393, July, 2024
1. Application forms must 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 other 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 medical
				assistance program, including benefits as a qualified medicare beneficiary
				(QMB) and a special 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.