OF LABOR AND REGULATION
TO APPLICANT REGARDING REPLACEMENT
MEDICARE SUPPLEMENT INSURANCE
Source: 18 SDR 225, effective July 17, 1992; 22 SDR 107, effective February 18, 1996; 31 SDR 214, effective July 6, 2005;
39 SDR 10, effective August 1, 2012.
TO APPLICANT REGARDING REPLACEMENT
MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
company's name and address]
THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE
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 (30) days within which you may decide without cost whether
you desire to keep the policy.
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.
TO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]
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 (check one):
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. 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) for similar benefits to the extent such 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 guaranteed issue, this paragraph
need not appear.]
not cancel your present policy until you have received your new policy and are
sure that you want to keep it.
of Agent, Broker, or Other Representative)*
[Typed Name and Address of
Issuer, Agent, or Broker]
* Signature not required for
direct response sales.