Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-66 - Washington medicare supplement insurance regulation › Section 284-66-142 - Form of replacement notice

Current through Register Vol. 24-14, July 15, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE
				SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
[Insurance company's name and address]
SAVE THIS NOTICE!
IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to [your application] [information you have
							 furnished], you intend to terminate existing medicare supplement or medicare
							 advantage insurance and replace it with a policy to be issued by [Company name]
							 Insurance Company. Your new policy will provide thirty days within which you
							 may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully.
							 Compare it with all accident and sickness coverage you now have. If, after due
							 consideration, you find that purchase of this medicare supplement coverage is a
							 wise decision, you should terminate your present medicare supplement or
							 medicare advantage coverage. You should evaluate the need for other disability
							 coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY ISSUER, [INSURANCE PRODUCER
							 OR OTHER REPRESENTATIVE]:
I have reviewed your current medical or health
							 insurance coverage. To the best of my knowledge, this medicare supplement
							 policy will not duplicate your existing medicare supplement or, if applicable,
							 medicare advantage coverage because you intend to terminate your existing
							 medicare supplement coverage or leave your medicare advantage plan. The
							 replacement policy is being purchased for the following reason(s) (check
							 one):
. . ..
Additional benefits.
. . ..
No change in benefits, but lower premiums.
. . ..
Fewer benefits and lower premiums.
. . ..
My plan has outpatient prescription drug coverage and
							 I am enrolling in Part D.
. . ..
Disenrollment from a medicare advantage plan.
Please explain reason for disenrollment. [optional
							 only for direct mailers]
. . ..
Other. (please specify)
1.
NOTE: If the issuer of the medicare supplement policy
							 being applied for does not, or is otherwise prohibited from imposing
							 preexisting condition limitations, please skip to statement 2 below. If you
							 have had your current medicare supplement policy less than three months, health
							 conditions which you may presently have (preexisting conditions) may not be
							 immediately or fully covered under the new policy. This could result in denial
							 or delay of a claim for benefits under the new policy, whereas a similar claim
							 might have been payable under your present policy.
2.
State law provides that your replacement policy or
							 certificate may not contain new preexisting conditions, waiting periods,
							 elimination periods or probationary periods. The insurer will waive any time
							 periods applicable to preexisting conditions, waiting periods, elimination
							 periods, or probationary periods in the new policy (or coverage) to the extent
							 such time was spent (depleted) under original policy.
3.
If you still wish to terminate your present policy
							 and replace it with new coverage, be certain to truthfully and completely
							 answer all questions on the application concerning your medical and health
							 history. Failure to include all material medical information on an application
							 may provide a basis for the company to deny any future claims and to refund
							 your premium as though your policy had never been in force. After the
							 application has been completed and before you sign it, review it carefully to
							 be certain that all information has been properly recorded. [If the policy or
							 certificate is guaranteed issue, this paragraph need not appear.]
Do not cancel your present policy until you have
							 received your new policy and are sure that you want to keep it.
. . . . . . . . . . ..
(Signature of Insurance producer, or Other
							 Representative)*
[Typed Name and Address of Issuer, or Insurance
							 producer]
. . . . . . . . . . . . . . . . . . . . . . . . . . .
							 . . . . . . ..
(Applicant's Signature)
. . . . . . . . . . . . . . . . . . ..
(Date)
*Signature not required for direct response
							 sales.
Statutory Authority:
				  RCW
				  48.02.060(3)(a) and
				  48.17.010(5).
				  11-01-159 (Matter No. R 2010-09), §
										284-66-142, filed 12/22/10,
				  effective 1/22/11. Statutory Authority:
				  RCW
				   48.06.060 and
				  48.66.165. 07-06-014 (Matter No. R
				  2006-13), §
										284-66-142, filed 2/26/07,
				  effective 3/29/07. Statutory Authority:
				  RCW
				   48.02.060 and
				  48.66.165. 05-17-019 (Matter No. R
				  2004-08), §
										284-66-142, filed 8/4/05,
				  effective 9/4/05. Statutory Authority:
				  RCW
				   48.02.060,
				  48.66.041 and
				  48.66.165. 96-09-047 (Matter No. R
				  96-2), §
										284-66-142, filed 4/11/96,
				  effective 5/12/96. Statutory Authority:
				  RCW
				   48.02.060,
				  48.20.450,
				  48.20.460,
				  48.20.470,
				  48.30.010,
				  48.44.020,
				  48.44.050,
				  48.44.070,
				  48.46.030,
				  48.46.130 and
				  48.46.200. 92-06-021 (Order R
				  92-1), §
										284-66-142, filed 2/25/92,
				  effective 3/27/92.
Reviser's note: The brackets and enclosed material in the
				  text of the above section occurred in the copy filed by the
				  agency.