[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?
Yes ______ No _______
[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,
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 health maintenance organization or preferred provider organization), 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.)
Ins 3.39(23)(b)(b) Agents shall list, in a supplementary form signed by the agent and submitted to the issuer with each application for Medicare supplement coverage, any other health insurance policies they have sold to the applicant as follows: Ins 3.39(23)(bL)(bL) In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant, and acknowledged by the issuer, shall be returned to the applicant by the issuer upon delivery of the policy. Ins 3.39(23)(c)(c) Upon determining that a sale will involve replacement, an issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy, a notice regarding the replacement of Medicare supplement coverage in no less than 12 point type. One copy of the notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the solicitation of the policy the notice regarding replacement of Medicare supplement coverage. Ins 3.39(23)(d)(d) The notice required by par. (c) for an issuer shall be provided in substantially the form as shown in Appendix 7. Ins 3.39(23)(e)(e) If the application contains questions regarding health and tobacco usage, include a statement that health questions should not be answered if the applicant is in the open-enrollment period described in sub. (3r), or during a guaranteed issue period under sub. (34). Ins 3.39(24)(a)(a) Every issuer marketing Medicare supplement insurance coverage in this state, directly or through its producers, shall do all of the following: Ins 3.39(24)(a)1.1. Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate. Ins 3.39(24)(a)2.2. Establish marketing procedures to assure excessive insurance is not sold or issued. Ins 3.39(24)(a)3.3. Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or insured for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of any such insurance. Ins 3.39(24)(a)4.4. Display prominently by type-size, stamp or other appropriate means, on the first page of the policy the following: “Notice to buyer: This policy may not cover all of your medical expenses.” Ins 3.39(24)(b)(b) Every issuer marketing Medicare supplement insurance shall establish auditable procedures for verifying compliance with par. (a). Ins 3.39(24)(c)(c) In addition, the following acts and practices are prohibited: Ins 3.39(24)(c)1.1. ‘Twisting.’ Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or issuers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another issuer. Ins 3.39(24)(c)2.2. ‘High pressure tactics.’ Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance. Ins 3.39(24)(c)3.3. ‘Cold lead advertising.’ Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose is solicitation of the purchase of insurance and that contact will be made by an agent or issuer. Ins 3.39(24)(e)(e) In regards to any transaction involving a Medicare supplement policy, no person subject to regulation under chs. 600 to 655, Stats., may knowingly prevent or dissuade or attempt to prevent or dissuade, any person from: Ins 3.39(24)(e)1.1. Filing a complaint with the office of the commissioner of insurance; or Ins 3.39(24)(e)2.2. Cooperating with the office of the commissioner of insurance in any investigation; or Ins 3.39(24)(e)3.3. Attending or giving testimony at any proceeding authorized by law. Ins 3.39(24)(f)(f) If an insured exercises the right to return a policy during the free-look period, the issuer shall mail the entire premium refund directly to the person who paid the premium. Ins 3.39(24)(g)(g) The terms “Medicare Supplement,” “Medigap,” “Medicare Wrap Around,” and “Medicare Advantage Supplement” and words of similar import may not be used in any materials including advertisements as defined in s. Ins 3.27 (5) (a), unless the policy or certificate is issued in compliance with this section. Ins 3.39(25)(25) Appropriateness of recommended purchase and excessive insurance. Ins 3.39(25)(a)(a) In recommending the purchase or replacement of any Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. Ins 3.39(25)(b)(b) Any sale of Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy that will provide an individual more than one Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy is prohibited. Ins 3.39(25)(c)(c) An agent shall forward each application taken for a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy to the issuer within 7 calendar days after taking the application. An agent shall mail the portion of any premium collected due the issuer to the issuer within 7 days after receiving the premium. Ins 3.39(25)(d)(d) An agent may not take and an issuer may not accept an application from an insured more than 3 months prior to the insured becoming eligible. Ins 3.39(26)(a)(a) On or before March 1 of each year, every issuer providing Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy in this state shall report the following information for every individual resident of this state for which the insurer has in force more than one Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy: Ins 3.39(26)(a)4.4. Company name and national association of insurance commissioners number. Ins 3.39(26)(b)(b) The items in par. (a) must be grouped by individual policyholder or certificateholder and listed on a form made available by the commissioner. Issuers shall submit the information in the manner compliant with the commissioner’s instructions on or before March 1 of each year. Ins 3.39(27)(27) Waiting periods in replacement policies or certificates. If a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy replaces another Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy that has been in effect for at least 6 months, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare supplement, Medicare select, or new Medicare cost policy for similar benefits to the extent such periods were satisfied under the original policy or certificate. Ins 3.39(28)(28) Group certificate continuation and conversion requirements. Ins 3.39(28)(a)(a) If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in par. (c), the issuer shall offer certificateholders at least the following choices: Ins 3.39(28)(a)1.1. An individual Medicare supplement policy which provides for continuation of the benefits contained in the group policy; and Ins 3.39(28)(a)2.2. At the option of the group issued a certificate, offer the certificateholder continuations of coverage under the group certificate for the time specified in s. 632.897, Stats. Ins 3.39(28)(b)(b) If membership in a group is terminated, the issuer shall: Ins 3.39(28)(b)1.1. Offer the certificateholder such conversion opportunities as are described in par. (a); or Ins 3.39(28)(b)2.2. At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy for the time specified in s. 632.897, Stats. Ins 3.39(28)(c)(c) If a group Medicare supplement certificate is replaced by another group Medicare supplement certificate, the issuer of the replacement certificate shall offer coverage to all persons covered under the old group certificate on its date of termination. Coverage under the new group certificate shall not result in any exclusion for preexisting conditions that would have been covered under the group certificate being replaced. Ins 3.39(29)(a)(a) An issuer shall not deliver or issue for delivery a Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy to a resident of this state unless the policy form or certificate form has been filed with and approved by the commissioner in accordance with filing requirements and procedures prescribed by the commissioner.
