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?
________________________________________________
________________________________________________