Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 7 - Medicare Supplement Insurance Minimum Standards › Section 230-RICR-20-30-7.21 - Requirements for Application Forms and Replacement Coverage

Current through June 14, 2024
A. The following items shall be included in
				  the outline of coverage in the order prescribed below. All amounts in brackets
				  shall be updated to the current deductible and coinsurance levels:
1. 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.
a. You do not need more than one Medicare
				  supplement policy.
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 Medicare supplement policy.
d. 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.
e. 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.
f. 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.)