Title 3 . Commerce, Community, and Economic Development

Chapter 28 . Miscellaneous

Section 500. Requirements for application forms and replacement coverage

3 AAC 28.500. Requirements for application forms and replacement coverage

(a) Application forms must include the following statements and questions designed to obtain information as to whether, as of the date of the application, the applicant currently has a medicare supplement policy, medicare advantage plan, 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 in force at the time of application. A supplementary application or other form to be signed by the applicant and agent containing the questions and statements may be used by the issuer.

[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 you become eligible for medicaid after purchasing this policy, 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 policy is no longer available, a substantially equivalent medicare supplement policy will be reinstituted if requested within 90 days of losing medicaid eligibility. If your 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 provide substantially similar benefits to the benefits in the policy before the date of suspension but will not include outpatient prescription drug coverage.

(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 while you are covered under the employer or union-based group health plan upon your request. If your medicare supplement policy is suspended under these circumstances, and you later lose your employer or union-based group health plan, your suspended medicare supplement policy or, if that policy is no longer available, a substantially equivalent medicare supplement policy will be reinstituted if requested within 90 days of losing your employer or union-based health plan. If your 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 provide substantially similar benefits to the benefits in the policy before the date of suspension but will not include outpatient prescription drug coverage.

(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) or 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. 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 you answered yes to (1)(a) and (1)(b), what is the effective date of your medicare Part B coverage? ____________________________________________ (2) (a) Do you receive medical assistance through the state medicaid program? (Mark "No" if you are participating in a "spend-down program" and have not met your "share of cost.") Yes ________ No ________ (b) If you answered yes to (2)(a), will medicaid pay your premiums for this medicare supplement policy? Yes ________ No ________ (c) If you answered yes to (2)(b), do you receive any benefits from medicaid other than payment toward your medicare Part B premium? Yes ________ No ________ (3) (a) If you had coverage from any medicare plan other than original medicare (for example, medicare advantage or a medicare health maintenance organization (HMO) or preferred provider organization (PPO) within the past 63 days, fill in your start and end dates below. If you are still covered under this plan, leave the "END" date blank. If you did not have such coverage, skip to question (4). 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) Do you have another medicare supplement policy in force? Yes ________ No ________ (a) If yes, with what company and what plan do you have? [optional for direct mail business] Company ______________________________ Plan ______________ (b) If yes, do you intend to replace your current medicare supplement policy with this policy? Yes ________ No ________ (5) Have you had any other health insurance coverage within the past 63 days? (For example, employer, union, or individual plan) Yes ________ No ________ (a) If yes, with what company and what kind of policy? Company ______________________________ Policy description _____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (b) If yes, what are the start and end dates of the coverage? If you are still covered under this policy, leave the "END" date blank. START ____/____/________ END ____/____/________

(b) Agents shall list any other health insurance policies they have sold to the applicant as follows:

(1) list policies sold that are still in force; and

(2) list policies sold in the past five years that are no longer in force.

(c) In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant and acknowledged by the insurer, shall be returned to the applicant by the insurer upon delivery of the policy.

(d) Upon determining that a sale will involve replacement of medicare supplement coverage, an issuer, other than a direct response issuer or its agent, shall furnish the applicant, before issuance or delivery of the medicare supplement policy or certificate, a notice regarding replacement of medicare supplement coverage. One copy of the notice signed by the applicant and the agent, except where the coverage is sold without an agent, must be provided to the applicant and an additional signed copy must be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of medicare supplement coverage.

(e) The notice required under (d) of this section for an issuer must be provided in substantially the following form in no less than 12-point type:

NOTICE TO APPLICANT REGARDING REPLACEMENT

OF MEDICARE SUPPLEMENT OR MEDICARE ADVANTAGE COVERAGE

[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 coverage and replace it with a policy to be issued by [company name] Insurance Company. Your new policy will provide 30 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 accident and sickness coverage you have that may duplicate this policy.

STATEMENT TO APPLICANT BY ISSUER, AGENT (BROKER 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 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 (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 the reason for disenrollment. [optional for direct mail business]

__________________ 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. Health conditions that you might 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) for similar benefits to the extent that that time was spent (depleted) under the 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 a 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 agent, broker, or other representative; signature not required for direct sales.]

___________________________________________________________________________

[Typed name and address of issuer, agent, or broker]

___________________________________________________________________________

[Applicant's signature]

___________________________________________________________________________

[Date] =forme

(f) The first two paragraphs of the replacement notice that are applicable to preexisting conditions may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation.

History: Eff. 3/26/82, Register 81; am 8/8/90, Register 115; am 7/1/92, Register 122; am 7/12/96, Register 139; am 9/4/2005, Register 175

Authority: AS 21.06.090

AS 21.42.130

AS 21.89.060