2) 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:
A) Did you turn age 65 in the last 6 months? B) Did you enroll in Medicare Part B in the last 6 months? C) If yes, what is the effective date? _______________________D) 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.
If yes:
i) Will Medicaid pay your premiums for this Medicare supplement policy? ii) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? E) 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. i) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy? ii) Was this your first time in this type of Medicare plan? iii) Did you drop a Medicare supplement policy to enroll in the Medicare plan? F) Do you have another Medicare supplement policy in force? i) If so, with what company, and what plan do you have (optional for Direct Mailers)?ii) If so, do you intend to replace your current Medicare supplement policy with this policy? G) Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan) i) If so, with what company, and what kind of policy? __________________________________________
__________________________________________
__________________________________________
__________________________________________
ii) What are your dates of coverage under the other policy? (If you are still covered under the other policy, leave "END" blank.)