HEALTHPARTNERS MEDICARE SUPPLEMENT PLAN ENROLLMENT FORM

Transcription

1 HEALTHPARTNERS MEDICARE SUPPLEMENT PLAN ENROLLMENT FORM Follow the steps outlined below to apply for a HealthPartners Medicare Supplement plan. You can also apply over the phone. See back page for more information. 1. You must be enrolled in Medicare Part A and Part B to qualify for this coverage. 2. Each person enrolling must complete a separate form. Please print and use a ballpoint pen in black or blue ink. 3. Answer the questions completely (as required) and to the best of your ability. 4. Sign and date the completed enrollment form. Retain the color copy of this form for your records and return the white copy to HealthPartners in the enclosed self-addressed envelope to: HealthPartners Riverview Membership Accounting OR Fax to: MS21103R P.O. Box 9463 Minneapolis, MN You will receive your member identification card after your enrollment form has been processed and approved. 6. QUESTIONS? Contact HealthPartners Medicare Sales at or , TTY 711. From Oct. 1 through March 31, we take calls from 8 a.m. to 8 p.m. CT, seven days a week. From April 1 to Sept. 30, call us 8 a.m. to 8 p.m. CT, Monday through Friday to speak with a representative. On Saturdays, Sundays and Federal holidays, you can leave a message and we ll get back to you within one business day. Please read the following information before completing this enrollment form. Be certain that all the information asked for is answered as completely as possible. You may not need to complete Section 7: Health History. Please refer to SPECIAL NOTES section and Guaranteed Issue. Missing information or forms that are not signed may delay processing of your enrollment form. Incomplete or false information which may materially affect either the acceptance of risk or hazard assumed by HealthPartners may result in denial of claims or rescission of coverage. You can pay your monthly plan premium by mail. Payment of the first month s premium is not required at the time of application. HealthPartners will send you a paper bill every month to the address provided on this enrollment form. Once you become a member of our plan you can sign up to automatically receive and pay your bills online. These plans provide an anticipated loss ratio of 77.3%. This means that on the average, a contract holder may expect that at least $77.30 of every $100 in premium payments will be returned as benefits to the contract holder over the life of the contract. Supp_ IR 9/14/ (1/19)

2 HealthPartners Medicare Supplement Plan Enrollment Form SECTION 1: Personal Information LAST NAME FIRST NAME M.I. BIRTH DATE / / SEX: F M ADDRESS* (optional) TELEPHONE Home ( ) - ALTERNATE ( ) - Is this a cell phone? YES NO Is this a cell phone? YES NO PERMANENT HOME ADDRESS (P.O. Box is not allowed) APT # CITY STATE ZIP COUNTY MAILING ADDRESS (If different from permanent home address) APT # CITY STATE ZIP COUNTY *By providing your address, you agree that HealthPartners may send you s. SECTION 2: Medicare Information 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. Name (as it appears on your Medicare card): Medicare Number: OR Is Entitled To: Effective Date (mm/dd/yyyy) Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. HOSPITAL (Part A) MEDICAL (Part B) You must have Medicare Part A and Part B to join a Medicare Supplement plan. SECTION 3: Plan Selection Choose ONE plan below. Please refer to the Outline of Coverage for plan premium rates. Basic Medicare Supplement Plan If enrolling in Basic, please indicate which optional rider(s), if any, you wish to add: Rider 1 Part A Inpatient Hospital Deductible Rider 2 Part B Deductible Rider 3 Part B Excess Charges Rider 4 Preventive Care Extended Basic Medicare Supplement Plan Supp_ IR 9/14/ (1/19)

3 SECTION 4: Tobacco Use Designation Yes No Have you used tobacco and/or smokeless tobacco* within the last 24 months? * Tobacco use is defined as use of any tobacco product on average of four or more times per week within the past 24 months, excluding religious or ceremonial use. Tobacco use doesn t apply to applicants under the age of 18. (Please note that your premiums may be modified if you indicate that you do not use tobacco as of the effective date of this application and evidence to the contrary is later discovered. If you are tobacco free for a 24 consecutive month period after your effective date, you should notify HealthPartners in writing, so that your premium can be decreased.) SECTION 5: Other Coverage Information Please answer the following questions to the best of your knowledge. Yes No 5a. Are you involuntarily losing coverage from a Medicare Supplement, Medicare Advantage, Medicare Cost, Employer Retiree Plan, or Health Care Prepayment Plan? If YES, you may be eligible for guaranteed issuance of a Medicare Supplement policy. (READ THE SPECIAL NOTES SECTION.) Please include a copy of your current plan s termination letter and provide us with the following information about your current plan: Company (Carrier) Name: Company Phone Number: Type of Policy: Policy Number: Policy Effective Date: / / Policy Termination Date: / / Yes No 5b. Are you enrolled in any other Medicare Supplement, Medicare Cost, or any other health insurance policy that provides benefits that this policy would duplicate? If YES, do you intend to replace your current health insurance coverage with this Medicare Supplement policy? Yes No Please provide the following information about your current health insurance policy: Company (Carrier) Name: Type of Policy: Policy Number: Start Date: / / End Date (leave blank if still covered by plan): / / Yes No 5c. Are you covered by Medical Assistance through the state Medicaid program? If YES, which of the following programs provides coverage for you: Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Full Medicaid Beneficiary SECTION 6: Guaranteed Issue 6a. Will your HealthPartners Medicare Supplement Plan start date be within 6 months after you turn age 65 or enroll in Medicare Part B? No. (Answer question 6b.) Yes. Your acceptance is guaranteed. SKIP SECTION 7 AND GO TO SECTION 8. 6b. Do you have guaranteed issue rights, as noted in the SPECIAL NOTES section? If so, include a copy of the termination form from your prior insurer or employer. No. (Continue to Section 7) Yes. Your acceptance is guaranteed. SKIP SECTION 7 AND GO TO SECTION 8. Supp_ IR 9/14/ (1/19)

4 SECTION 7: Health History DO NOT COMPLETE THIS SECTION IF YOU ARE ELIGIBLE FOR GUARANTEED ISSUE (including the six (6)-month open-enrollment window following your Part B effective date). Refer to SPECIAL NOTES section for further information. Please answer the following to the best of your ability: Yes No 7a. Do any of the following situations currently pertain to you or have any of these been recommended by a medical professional: Reside in a nursing home or assisted living facility, receive care in a hospital including surgery, or confined to a bed Confined to a wheelchair or other mobility device Receive dialysis Amputation caused by poor circulation, disease or trauma Organ or bone marrow transplant Pacemaker Note: For questions 7b and 7c you do not have to disclose treatment, diagnosis, or a test used to detect the presence of hepatitis B virus (HBV), hepatitis C virus (HCV), human immuno-deficiency virus (HIV), or other blood borne pathogens that was administered to you at the time you were: A criminal offender or crime victim as a result of a crime that was reported to the police; An emergency medical personnel who was tested as a result of performing emergency medical services; A corrections employee; or A patient or employee of a secured facility. Yes No 7b. Within the past 2 years, did a medical professional diagnose, treat, provide advice or prescribe medication or medication refills for any of the conditions in the chart below? Blood Disorder Hemophilia Other disorder requiring transfusions Cancer Leukemia Melanoma Multiple Myeloma Non-Hodgkin s Lymphoma Cancer of any internal organ Diabetes Type I or Type II Heart or Circulatory Poor circulation/ulcers TIA (mini-stroke) or Stroke Carotid Artery Disease Cardiomyopathy Congestive Heart Failure Heart Attack Atrial Fibrillation or Flutter Ventricular Tachycardia Enlarged Heart Kidney Chronic insufficiency Renal Failure End Stage Renal Disease (ESRD) Polycystic Kidney Disease (PKD) Liver Auto-Immune Hepatitis Chronic Hepatitis or other liver disease Cirrhosis Hepatitis C Continued on next page Supp_ IR 9/14/ (1/19)

5 Immune System Acquired Immune Deficiency Lung/Respiratory COPD (Chronic Obstructive Pulmonary Disease) Emphysema Other respiratory/lung disease requiring oxygen Digestive Crohn s Disease Ulcerative Colitis Joint Musculoskeletal Osteoarthritis Degeneration of the spinal column Mental Health Bipolar Disorder Schizophrenia Nervous System ALS Parkinson s Disease Epilepsy/Seizures Substance Abuse Alcoholism Illegal Drug Use Systemic Lupus Rheumatoid Arthritis Multiple Sclerosis Myasthenia Gravis Systemic Erythematosus Note: If you answered YES to question 7a or 7b for any of the conditions indicated, you do not qualify for coverage and HealthPartners is not able to accept your application. 7c. If there is any other condition not mentioned above for which you have received a medical diagnosis or treatment, prescribed medication or advised to have physical therapy or surgery by a medical professional within the past 5 years, please provide the details below and submit your application. Condition(s) Diagnosis Date Medication(s) and Dosage Other Treatment(s): 7d. Please provide your current height and weight: Height: Weight: SECTION 8: STOP! Please read the Authorization and Acknowledgement section on page 7 before signing below. I agree that, if approved, coverage will be effective on the first day of the month following approval or on the date designated here, providing it is not prior to the date this application was received at HealthPartners and is not more than 90 days beyond the date this application is signed. Requested Effective Date: Signature (enrollee or authorized representative) Today s date If you are the authorized representative, you must sign above and provide the following information: Name: Phone number ( ) - Address Relationship to enrollee Supp_ IR 9/14/ (1/19)

6 SPECIAL NOTES GUARANTEED ISSUE Medicare Supplement issuers must guarantee issue certain Basic Medicare Supplement policies to eligible individuals. This means that the insurer cannot discriminate in the pricing of such a policy because of health status, claims experience, receipt of health care, medical condition or age. If the receipt date of this application is within six (6) months of your Medicare Part B effective date, you have a six (6)-month open-enrollment window during which time you are eligible for guaranteed issue. If you have lost or you are losing health insurance coverage such as a Medicare Supplement, Employer Retiree Plan, Medicare Advantage, Medicare Cost, or Health Care Prepayment Plan, you may be eligible for guaranteed issue. Your eligibility begins on the date you were notified of the termination and ends 63 calendar days after the date your coverage terminates. You must apply for coverage during this time period and include a copy of the plan s termination letter. COUNSELING SERVICES Counseling services may be available in Minnesota to provide advice concerning the purchase of Medicare Supplement policies and enrollment in the state Medicaid program, including benefits as Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs). Contact the Senior Linkage Line at DISABILITY If you are eligible for, and have enrolled in a Medicare Supplement policy by reason of disability, and you later become covered by an employer or union-based group health plan, you may not need this Medicare Supplement policy. The benefits and premiums under your Medicare Supplement policy may be suspended during your enrollment in the group health plan. You must request this suspension in writing by contacting HealthPartners. If you suspend your Medicare Supplement policy under these circumstances and later lose your group health plan coverage, your suspended Medicare Supplement policy will be reactivated if requested in writing within 90 days of losing your group plan coverage. MEDICAID If after purchasing this policy you become eligible for Medicaid, you may not need a Medicare Supplement policy. The benefits and premiums under this Medicare Supplement policy can be suspended, if requested, for a total of 24 months during your entitlement to benefits under Medicaid. You must request this suspension in writing within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy may be reinstated. However, you must request reinstatement in writing within 90 days of losing Medicaid eligibility. MULTIPLE COVERAGES You do not need more than one Medicare Supplement, Medicare Advantage, or Medicare Cost insurance policy. If you purchase this policy, you may want to evaluate your existing health care coverage and decide if you need multiple coverages. Supp_ IR 9/14/ (1/19)

7 Authorization and Acknowledgement PLEASE READ AND SIGN ON PAGE 5 I acknowledge that I have read the information in this application in its entirety. All information, statements and answers are true and complete to the best of my knowledge. I also understand and agree that: This application becomes a part of the insurance contract and if any information, statements, or answers are untrue or incomplete and materially affects either the acceptance of risk or hazard assumed by HealthPartners, HealthPartners may have the right to adjust premiums, deny claims, or rescind coverage. If my application is not submitted during an open enrollment or guaranteed issue period, HealthPartners has the right to reject my application and I may be contacted via phone by a member of the underwriting staff to provide additional medical information as it pertains to enrollment. I authorize HealthPartners to obtain from health plans, providers of service and hospitals, HealthPartners affiliates and Business Associates the medical, mental and chemical health records relating to me necessary for: enrollment, claims processing, including claims HealthPartners makes for reimbursement or subrogation; quality of care assessment and improvement; accreditation, credentialing, case management, care coordination and utilization management, disease management, underwriting and premium rating, the evaluation of potential or actual claims against HealthPartners, auditing and legal services, and other health care operations. I understand this authorization can be used to obtain information for purposes of post-enrollment claims reviews, if I am offered coverage. A photocopy of this authorization shall be as valid as the original and remains in effect as long as I am continually insured by HealthPartners or until revoked. HealthPartners may access and use obtained information without further authorization if permitted or required by another law. I acknowledge receipt of: 1) The Outline of Coverage for the plan in which I am applying and 2) The Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare publication. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above) this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. I understand that I must update this application to include any condition or disease that may occur between the date of this application and the effective date of coverage. Supp_ IR 9/14/ (1/19)

8 Contact us By phone For questions, call Medicare Sales at or TTY: 711 By questions to On the Web Find more information or print off additional copies of this application at healthpartners.com/medicare. Enroll Return paper applications in the enclosed postage-paid envelope to: HealthPartners Riverview Membership Accounting MS21103R P.O. Box 9463 Minneapolis, MN Or fax them to By phone To enroll over the phone, call or On the Web Apply online at healthpartners.com/medicare. Hours of operation From Oct. 1 through March 31, we take calls from 8 a.m. to 8 p.m. CT, seven days a week. You ll speak with a representative. From April 1 to Sept. 30, call us 8 a.m. to 8 p.m. CT, Monday through Friday to speak with a representative. On Saturdays, Sundays and Federal holidays, you can leave a message and we ll get back to you within one business day rd Ave. S. P.O. Box 1309 Minneapolis, MN HealthPartners MEDICARE SUPPLEMENT ENROLLMENT FORM Supp_ IR 9/14/ (1/19)

9 NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE HealthPartners P.O. Box 9463 Minneapolis, MN Please complete this if you are replacing an existing Medicare Supplement, Medicare Advantage, or Medicare Cost policy with another policy issued by HealthPartners. This includes coverage you currently have with HealthPartners as well as other carriers. You should retain the color copy of this form for your records and mail the white copy back to HealthPartners in the enclosed self-addressed envelope. FOR THE APPLICANT: SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare Supplement, Medicare Advantage, or Medicare Cost insurance and replace it with a policy to be issued by HealthPartners. Your new policy will provide 30 days within which you may decide without cost whether you desire to keep the policy. You 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, Medicare Advantage, or Medicare Cost policy. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. 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 is guaranteed issue, this paragraph does not apply.) Do not cancel your present policy until you have received your new policy and you are sure that you want to keep it. Applicant s Signature Date FOR AGENT USE ONLY: STATEMENT TO APPLICANT BY AGENT, BROKER, OR OTHER REPRESENTATIVE I 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, Medicare Advantage, or Medicare Cost policy because you intend to terminate the existing policy. The replacement policy is being purchased for the following reason(s) (check one): Additional benefits Fewer benefits and lower premiums No change in benefits, but lower premiums Other (please specify) The following is a list of all Medicare Supplemental policies I have sold to the applicant in the last 5 years, including policies sold that are still in force: Company Date Enrolled Date Disenrolled Reason Agent name (please print): Agent Signature: Agent Code: Agent Phone: Date: / / Signature not required for direct response sales. Supp_ IR 4/27/ (7/18)