Instructions for Completing the Blue Medicare Supplement SM 1. Page 1; Section 1: Complete your Personal Information. 2. Page 1; Section 2: Select your desired plan. and effective date. Application 3. Page 2; Section 3: Select how often you want to pay and if by automatic bank draft or by a bill mailed to your home. 4. Pages 2; Section 4: Please copy the information from your red, white and blue Medicare Card onto the form to the right. Applications cannot be processed and will be returned if this information is incomplete. 5. Pages 3, 4; Sections 5, 6: Complete the section concerning your current or previous insurance. 6. Page 4; Section 7: Answering these health questions are not required if you are applying for coverage within 6 months of first enrolling in Medicare Part B. 7. Page 4; Section 8: Sign and date. 8. Sign and date the Authorization form. 9. Submit your application by doing any one of the following: Fax your completed application to Beth Pesakoff at (888) 273-6713 Email me a scanned copy to beth.pesakoff@healthplansofnorthcarolina.com Mail it directly to me at the following address: Beth Pesakoff Authorized Agent PO Box 220353 Charlotte, NC 28222
Date Received Group Number PO Box 17168, Winston-Salem, NC 27199-3714 Application for Please fill in ALL information completely in blue or black ink. New Enrollment Application Change Application Section 1: Applicant Information Last Name First Name (Exactly as it appears on Original Medicare card) Questions? Call Toll Free (800) 478-0583 Middle Initial Mailing Address (street) City County State Zip Billing Address (if different - ONLY bills will be sent to this address) (If this is part of a list bill, please put Entity s billing address here and fill out Section 3.): Address (street) City County State Zip If you are a member under a Blue Cross and Blue Shield of rth Carolina Certificate, provide your subscriber #: Under 65 Sex: Male Female Age Category: 65 66-69 70-74 75+ Social Security Number 0 0 Birthdate: Month Day Year Area Code Telephone Number Section 2: Plan Information Choose the Plan you wish to select (check only one): High A B C D F Ded F G K L M N Month Day Year When would you like your coverage to begin: An independent licensee of the Blue Cross and Blue Shield Association. D157, 4/15 IMPORTANT: This application is continued on the other side.
Section 3: Billing Information Questions? Call Toll Free (800) 478-0583 and Payment Authorization You will be billed monthly. I agree that the total premium will be billed, upon this application s acceptance, but not if this application is denied. I agree that if charges are dishonored, whether with or without cause and whether intentionally or inadvertently, Blue Cross and Blue Shield of rth Carolina (BCBSNC) shall have no liability whatsoever even though dishonor results in forfeiture of insurance. If you are a part of a list bill, please fill out the following: Entity Name: Section 4: Your Medicare Coverage CORP #: M Medicare Health Insurance Please copy the information from your red, white and blue Medicare Card onto the form to the right. Applications cannot be processed and will be returned if this information is incomplete. Medicare Claim Number: Is Entitled to: Effective Date Month Day Year Hospital (Part A): Medical (Part B): Section 5: Consumer Information for Your Protection You do not need more than one Medicare supplement 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 policy. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy will be suspended 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 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 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 the suspension. 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, the benefits and premiums under your Medicare supplement 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 policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement 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 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 the suspension. Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement 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).
Section 6: Questions (Please Mark or Below with an X ) 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?.................................. (b) Did you enroll in Medicare Part B within the last 6 months?.................... If yes, what is the effective date? 2. Are you covered for medical assistance through the state Medicaid program?....... te 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?... (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?..................... 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 HMO or PPO), fill in your effective and termination dates below. Month Day Year Month Day Year Effective Date: Termination Date: (If you are still covered under this plan, leave Termination Date blank.) (b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?.............. (c) Was this your first time in this type of Medicare plan?........................ (d) Did you drop a Medicare supplement policy to enroll in the Medicare plan?...... 4. (a) Do you have another Medicare supplement policy in force?................... (b) If yes, with what company and what plan do you have? (c) If yes, do you intend to replace your current Medicare supplement policy with this policy?....................................... (You must complete and submit the tice to Applicant [J84] form with this application.) 5. Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan)............ (a) If yes, with what company and what kind of policy? (b) What are your dates of coverage under the other policy? Month Day Year Month Day Year Effective Date: Termination Date: (If you are still covered under the other policy, leave Termination Date blank.) BCBSNC may request a HIPAA certificate for verification purposes.
Section 7: A Few Questions About Your Health Completion of the following five health questions is not required if you are applying for coverage within 6 months of first enrolling in Medicare Part B. If you meet these requirements, proceed to Section 8. 1. Are you currently hospitalized, residing in a nursing home, enrolled in a hospice program, or expecting to enter a hospital or a nursing home in the next 6 months?.......... 2. Have you been hospitalized more than one time during the past 12 months?............... 3. Have you been diagnosed or treated for any of the following diseases or conditions within the last 24 months? (a) Cancer (other than skin cancer)................................................. (b) Heart and/or lung disease..................................................... (c) Alzheimer s Disease.......................................................... (d) Parkinson s Disease.......................................................... (e) Alcohol/chemical dependency................................................. (f) Liver disorder............................................................... 4. Do you use an oxygen tank or machine or require kidney dialysis?........................ 5. Have you been diagnosed or treated for AIDS (acquired immune deficiency syndrome) or HIV (human immunodeficiency virus)?................................... Section 8: By Signing Below, I Understand and Agree to the Following: By signing this application, I hereby certify that all statements on this application are complete and true. Failure to provide complete and accurate information will allow Blue Cross and Blue Shield of rth Carolina ( BCBSNC ) to deny future claims and seek a refund for claims paid as though the certificate had never been issued. I understand and agree that the certificate applied for will be effective only if the application is approved, a membership certificate is issued by BCBSNC, and fees have been paid. I understand that any coverage provided based on this application shall be subject to the provisions of the certificate and endorsements issued to me by BCBSNC. (For information regarding waiting periods and pre-existing conditions, please refer to your Outline of Medicare Supplement Coverage booklet.) Also, by signing this application, I understand that if I am currently enrolled with BCBSNC on an individual policy (such as Blue Advantage, Blue Advantage Saver, Blue Options HSA, Blue Value, Blue Select, or Blue Local), my policy will be canceled to correspond with the effective date of your Medicare Supplement coverage. This does not apply if your policy was purchased on the Health Insurance Marketplace. You will need to contact them directly in order for your policy to be terminated if you choose. By signing this form, I, Applicant, appoint the BCBSNC appointed producer named below to act as my representative ( Representative ) and authorize such Representative to do the following: 1. To transmit/convert all personal information from this paper application ( Paper Application ) to electronic format ( Electronic Application ). The personal information submitted by Representative shall be taken from the Paper Application after I read and accurately complete the Paper Application in its entirety and sign the Paper Application. Representative shall correctly, accurately and completely transmit/convert all of the information provided by me on the Paper Application in an electronic format to BCBSNC. 2. To use my electronic signature for the Electronic Application. Representative s use of my electronic signature shall constitute my authorization and shall be considered as my legally binding signature for such Electronic Application. BCBSNC will provide me with a copy of my Electronic Application once my Application has been approved. I have ten (10) days after receipt of my Electronic Application to notify BCBSNC that information on the Electronic Application is not accurate. If notice is not received by BCBSNC within the appropriate time frame, the Electronic Application shall be considered the accurate and original Application authorized and completed by me and for which I will be responsible. The above authorization will expire 90 days after the application submitted date. Did you receive a copy of the NAIC-HHS Guide to Health Insurance for People with Medicare and the Outline of Coverage?... Signature of Applicant: Date: te: This application cannot be processed without the applicant s signature. Section 9: For Producer s Completion: 1. Was this a direct mail application? (If no, then #2 applies.) 2. By signing, I confirm that the coverage applied for does not duplicate any existing coverage (assuming replacement of existing Medicare Supplement policy) to the best of my knowledge and belief. I certify that I have truly and accurately recorded on the application form the information supplied by the applicant. Signature of Producer: Print Name: Telephone Number (including area code): Producer Number: Agency Number: Agent shall list any other health insurance policies sold which are currently in force. Also list health insurance policies sold within the past five years which are no longer in force.
APPLICANT S SOCIAL SECURITY NUMBER NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE Blue Cross and Blue Shield of rth Carolina, PO Box 17168, Winston-Salem, NC 27199-3714 SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Blue Cross and Blue Shield of rth Carolina. Your new policy will provide thirty (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 or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. STATEMENT TO APPLICANT BY ISSUER, 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 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): Additional benefits 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: Other (please specify): 1. te: If the issuer of the Medicare supplement policy being applied for does not impose, or is otherwise prohibited from imposing, pre-existing condition limitations, please skip to statement 2 below. Health conditions which you may presently have (pre-existing 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 pre-existing conditions, waiting periods, elimination periods, or probationary periods. The insurer will waive any time period applicable to pre-existing 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 Blue Cross and Blue Shield of rth Carolina 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. Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. APPLICANT S SIGNATURE DATE FOR AGENT USE ONLY SIGNATURE OF AGENT, BROKER, OR REPRESENTATIVE NAME OF ISSUER, AGENT, BROKER, OR REPRESENTATIVE PLEASE TYPE ADDRESS OF AGENT, BROKER, OR REPRESENTATIVE CITY STATE ZIP CODE An independent licensee of the Blue Cross and Blue Shield Association. J84, 1/11