Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-66 - Washington medicare supplement insurance regulation › Section 284-66-130 - Requirements for application forms and replacement of medicare supplement insurance coverage

Current through Register Vol. 24-14, July 15, 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 another
			 medicare supplement, medicare advantage, medicaid coverage, or another health
			 insurance or other disability policy or certificate in force or whether a
			 medicare supplement insurance policy or certificate is intended to replace any
			 other policy or certificate of a health care service contractor, health
			 maintenance organization, disability insurer, or fraternal benefit society
			 presently in force. A supplementary application or other form to be signed by
			 the applicant and insurance producer containing the questions and statements,
			 may be used: If the coverage is sold without an insurance producer, the
			 supplementary application must be signed by the applicant.
[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) If you are
			 sixty-five or older, 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 twenty-four months. You must request this
			 suspension within ninety 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 ninety 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 benefit 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 rein-stituted 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.)
____________________________________________