Application for Medicare Supplement Insurance

Transcription

1 Page 1 of 8 FOR STAFF/AGENT/BROKER USE ONLY 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI TTY 711 Amt. pd. Check no. Staff/Agent/Broker name Agent no. Received date Seminar attendee Walk-in Phone consult Scheduled appointment Fax completed application to Application for Medicare Supplement Insurance A. Select your plan BASIC PLAN ONLY BASIC PLAN PLUS RIDERS YOU ARE REQUESTING (When adding or removing optional riders, mark all the riders you are electing to keep.) Medicare Part A Deductible Rider Medicare Part B Deductible Rider* OR Medicare Part B Excess Charges Rider Medicare Part B Copayment or Coinsurance Rider* Additional Home Health Care Rider Foreign Travel Emergency Rider *You cannot have both the Part B Deductible Rider and Part B Copayment or Coinsurance Rider Requested effective date of policy: / Month Year (NOTE: Your effective date must be the 1 st of the month. Upon approval, your effective date cannot be changed.) B. Applicant information First name MI Last name Sex: M F Date of birth / / Age Phone - - Permanent address (and P.O. box if applicable) City State ZIP County Mailing address (only if different from permanent address) Street address City State ZIP (complete address and suffix: e.g. john.doe@yahoo.com) Please provide the name of your primary care physician (PCP) or clinic PCP First name Last name Clinic Marital status: Married Single Widowed Divorced/separated Household discount: If married, is your spouse also a member of Security Health Plan? Yes No If yes, complete the information below to be eligible for a household discount. This premium discount will be applied retroactively to the first month and all months going forward. Spouse s first name Last name Date of birth / / Check one: Already enrolled in Security Health Plan Enrolling together in Security Health Plan (Please continue to page 2)

2 Payment method (choose one): Automatic premium deduction each month from bank account (please complete Automatic Premium Payment Authorization below) Credit card/debit card option: After your enrollment is processed, a Security Health Plan representative will contact you to assist in setting up your credit or debit card payments Billing by mail Page 2 of 8 Billing cycle: Monthly Quarterly Automatic Premium Payment Authorization For your convenience, you may have your monthly premium payments made automatically from your checking or savings account. This automatic payment plan provides an easy, dependable way to make premium payments. More than 21,000 members take advantage of this convenient service. You will receive a $5.00 per month discount if you sign up for automatic premium payments. Please allow up to 60 days for your authorization form to be processed and your first automatic payment to be deducted We will notify you when you can expect your payments to begin Your premium will be deducted on the 20 th of the month preceding the month of coverage If the amount of your premium changes you will be informed in advance Questions? Please call our Customer Service Department at or , between 7 a.m. and 5:30 p.m. Monday through Friday. If you are hearing or speech impaired, call TTY 711 Account holder information (* required fields) Name* Address City* State* ZIP* Financial institution of payor (see sample below for help completing #1 to #5) 1. Institution name* 2. Branch 3. Address* City* State* ZIP* 4. ABA routing number* (always 9 digits) 5. Account number* Make this deduction from: Checking (enclose voided check) Savings (account no. ) I (payor) authorize Security Health Plan of Wisconsin, Inc., and the financial institution named above to initiate entries to my checking/savings account for payment of premiums. This authority will remain in effect until I notify Security Health Plan and the financial institution in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I understand that the premium will be deducted on or after the 20 th of the month. I can stop payment of any entry by notifying Security Health Plan and my financial institution 7 days before my account is charged. I understand the amount of an erroneous charge will be credited to my account upon notification. Payor signature* Date / / MM DD YYYY Subscriber signature* (if not payor) Date / / MM DD YYYY (Please continue to page 3)

3 Page 3 of 8 Please help us meet the needs of our members more effectively. Complete the following information regarding your spoken language, written language and race/ethnicity. Your answers will not affect your enrollment. What is your preferred language: Spoken What is your race/ethnicity: Written White Black / African American Other American Indian / Alaska Native Native Hawaiian or Other Pacific Islander C. Medicare insurance information Asian Two or more races Please take out your red, white and blue Medicare card to complete this section. Fill out this information as it appears on your Medicare card. OR Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. Name (as it appears on your Medicare card): Medicare number* Is entitled to: Effective date: HOSPITAL (Part A) MEDICAL (Part B) *NOTE: Failure to include the Medicare Number will result in delays in processing the application D. Other insurance information 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. 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. a. Are you covered for medical assistance through the state Medicaid program? (NOTE: If you are participating in a Spend-Down Program and have not met your Share of Cost, please answer No to this question.) Yes No b. If yes, will Medicaid pay your premiums for this Medicare Supplement policy? Yes No c. 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), please fill in your start and end dates. If you are still covered under this plan, leave END blank: START / / END / / (Please continue to page 4)

4 Page 4 of 8 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? c. If so, do you intend to replace your current Medicare Supplement policy with this policy? Yes No 5. a. Have you had coverage under any other health insurance within the past 63 days (for example, an employer, union or individual plan)? Yes No b. If so, with what company and what kind of policy? c. What are your dates of coverage under the other policy? If you are still covered under the other policy, leave END blank: START / / END / / 6. a. Are you covered by another plan from Security Health Plan? Yes No b. If yes, what is your current subscriber number? E. Important information Please read! NOTE: If you have other Medicare Supplement insurance that you don t intend to cancel, you are not eligible for this Security Health Plan Medicare Supplement policy. You do not need more than one Medicare Supplement, Medicare Cost, Medicare Advantage or Medicare Select policy. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement, Medicare Cost, Medicare Advantage or Medicare Select policy. If after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement, Medicare Cost, Medicare Advantage or Medicare Select 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, Medicare Cost, Medicare Advantage or Medicare Select policy, or, if that is no longer available, a substantially equivalent policy, will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare Supplement, Medicare Cost, Medicare Advantage or Medicare Select policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension. (Please continue to page 5)

5 Page 5 of 8 If you are eligible for and have enrolled in a Medicare Supplement or Medicare Cost 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 or Medicare Cost policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare Supplement or Medicare Cost policy under these circumstances, and later lose your employer or unionbased group health plan, your suspended Medicare Supplement or Medicare Cost policy or, if that is no longer available, a substantially equivalent policy, will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare Supplement or Medicare Cost policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension. Counseling services may be available in your state or provide advice concerning your purchase of Medicare Supplement or Medicare Cost insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-income Medicare Beneficiary (SLMB). See the booklet, Wisconsin Guide to Health Insurance for People with Medicare, which you received at the time you were solicited to purchase this policy. F. Eligibility You are automatically accepted for coverage and no health questions are required to be answered if: You are applying 3 calendar months before you enroll in Medicare Part B. You are applying in the calendar month in which you enroll in Medicare Part B. You are applying within 6 calendar months beginning with the month you enroll in Medicare Part B. You are applying within 6 calendar months beginning with the month of your 65 th birthday. You are guaranteed issue if you enrolled in Medicare Part B under the age of 65 on any of the following grounds: health status, claims experience, receipt of health care or medical condition. You are currently insured by Security Health Plan, are losing eligibility and applying for this coverage at least 30 days prior to your coverage termination. You are eligible for guaranteed issue. Guaranteed issue applies when you lose or terminate health coverage under certain circumstances if you apply within 63 days of the termination date of your prior health plan. You must provide a copy of the termination notice you received from your prior plan along with your application. This notice must verify the circumstances of your prior plan s termination. It must also describe your right to guaranteed issue of Medicare Supplement insurance. IMPORTANT: Unless the applicant is deemed disabled, applications submitted more than 3 months before applicant turns age 65 will be denied. G. Health questions Health questions should NOT be answered if you fall under any of the circumstances through which you are automatically accepted or guaranteed issue as described in Section F above. 1. In the past 2 years, a. Have you been hospitalized (more than 24 hours) three times or more, or been recommended to have inpatient surgery that hasn t yet been performed?. Yes No b. Have you been hospitalized for the treatment of mental or nervous disorders including alcohol or drug abuse?. Yes No (Please continue to page 6)

6 Page 6 of 8 c. Have you had or been told by your physician you had a heart attack, congestive heart failure, heart valve disorder, heart rhythm disorder, enlarged heart, coronary artery disease (hardening or narrowing of the artery or arterial blockage), carotid artery disease, stroke, aneurysm or peripheral vascular disease?.. Yes No d. Have you had or been told by your physician you had diabetes that requires insulin; liver disease; or broken bones due to osteoporosis?.. Yes No e. Have you had or received treatment for end-stage renal disease (ESRD) kidney disease, or have you received kidney dialysis?.... Yes No 2. In the past 5 years, a. Have you had or received treatment or surgery for cancer (except for non-melanoma skin cancer), Hodgkin s disease, melanoma or leukemia?.. Yes No b. Have you had or been recommended to have any organ transplant other than of the cornea? Yes No 3. Have you ever been diagnosed with multiple sclerosis, muscular dystrophy, cerebral palsy, amyotrophic lateral sclerosis (Lou Gehrig s disease or ALS), Parkinson s disease, Alzheimer s disease, systemic lupus, myasthenia gravis, hemophilia, sickle cell anemia, emphysema or cystic fibrosis?.. Yes No 4. Are you currently confined to a nursing facility?.. Yes No IMPORTANT: If you answered yes to any of the questions above, please provide further details. If additional space is needed please attach a separate sheet. Item no. Specific illness, injury, surgery, hospitalization or condition Name and address of treating physician and hospital Dates of illness, injury, surgery, hospitalization or condition: begin date end date/current Please list all prescribed medications you are taking. Attach separate sheet if needed. (Please continue to page 7)

7 Page 7 of 8 H. Terms and conditions 1. All statements and answers in this application are representations made by the applicant on his/her own behalf to induce the issuance of the contract(s) applied for. The applicant on behalf of himself or herself agrees to provide information as needed to process this application. 2. Subject to the acceptance of this application by Security Health Plan of Wisconsin, Inc., the applicant hereby agrees to pay Security Health Plan the prevailing premiums for the policy. Payment is due on or before the 20th day of the month through which membership has been paid. 3. This form is an application for coverage only. Regardless of any advance payment of premiums, the policy applied for will become effective only upon the acceptance of this application by Security Health Plan of Wisconsin, Inc. This will be evidenced by the issuance of an identification card and booklet/certificate. 4. I acknowledge receipt of: Wisconsin Guide to Health Insurance for People with Medicare Security Health Plan s Medicare Supplement Outline of Coverage I agree that the answers I gave are true and complete to the best of my knowledge. They are made to induce the issuance of and as part of the policy I am applying for. I apply for enrollment subject to the Terms and Conditions listed above. Applicant s signature Date / / If you were required to fill out the health questions in section G, your application may be subject to medical underwriting. Please complete and return the form, Use and Disclose Protected Health Information for Enrollment and Related Purposes Authorization, with this application. If you are the applicant s authorized representative, you must sign above and provide the following information: Name Address Phone number: - - Relationship to applicant I. Agent/broker s acknowledgement I have read and understand the application. I certify that the applicant has both Medicare Parts A and B. The policy applied for will not duplicate any health insurance coverage. Agent/broker s name (please print) Agent/broker s signature Date / / J. Complaints The applicant may contact the Office of the Commissioner of Insurance (OCI), a state agency that enforces Wisconsin s insurance laws, and file a complaint. Contact OCI by writing to: Office of the Commissioner of Insurance Complaints Department 125 South Webster Street PO Box 7873 Madison, WI Or call OCI at or to request a complaint form. (Please continue to page 8)

8 Page 8 of 8 K. Notice of nondiscrimination Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status. Security Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at (TTY: 711). If you believe that Security Health Plan of Wisconsin, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with: Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: shp.appeals.grievance@securityhealth.org You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Security Health Plan s Member Advocate is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC Phone: or (TDD) Complaint forms are available at L. Limited English proficiency services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711).