2000 Minnesota Statutes

     62A.44 Applications. 

    Subdivision 1.    Applicant copy.  No individual 
 Medicare supplement plan shall be issued or delivered in this 
 state unless a signed and completed copy of the application for 
 insurance is left with the applicant at the time application is 
 made. 

    Subd. 2.    Questions.  (a) Application forms shall 
 include the following questions designed to elicit information 
 as to whether, as of the date of the application, the applicant 
 has another Medicare supplement or other health insurance policy 
 or certificate in force or whether a Medicare supplement policy 
 or certificate is intended to replace any other accident and 
 sickness policy or certificate presently in force.  A 
 supplementary application or other form to be signed by the 
 applicant and agent containing the questions and statements may 
 be used. 

    "(1) You do not need more than one Medicare supplement 
    policy or certificate. 

    (2) If you purchase this policy, you may want to evaluate 
    your existing health coverage and decide if you need 
    multiple coverages. 

    (3) You may be eligible for benefits under Medicaid and may 
    not need a Medicare supplement policy or certificate.  

    (4) The benefits and premiums under your Medicare 
    supplement policy or certificate 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 policy or 
    certificate will be reinstated if requested within 90 days 
    of losing Medicaid eligibility. 

    (5) Counseling services may be available in Minnesota to 
    provide advice concerning medical assistance through state 
    Medicaid, Qualified Medicare Beneficiaries (QMBs), and 
    Specified Low-Income Medicare Beneficiaries (SLMBs). 

    To the best of your knowledge: 

    (1) Do you have another Medicare supplement policy or 
    certificate in force? 

    (a) If so, with which company? 

    (b) If so, do you intend to replace your current Medicare 
 supplement policy with this policy or certificate? 

    (2) Do you have any other health insurance policies that 
    provide benefits which this Medicare supplement policy or 
    certificate would duplicate?  

    (a) If so, please name the company. 

    (b) What kind of policy?  

    (3) Are you covered for medical assistance through the 
    state Medicaid program?  If so, which of the following 
    programs provides coverage for you?  

    (a.)  Specified Low-Income Medicare Beneficiary (SLMB), 

    (b.)  Qualified Medicare Beneficiary (QMB), or 

    (c.)  full Medicaid Beneficiary?" 

    (b) Agents shall list any other health insurance policies 
 they have sold to the applicant.  

    (1) List policies sold that are still in force.  

    (2) List policies sold in the past five years that are no 
 longer in force.  

    (c) In the case of a direct response issuer, a copy of the 
 application or supplemental form, signed by the applicant, and 
 acknowledged by the insurer, shall be returned to the applicant 
 by the insurer on delivery of the policy or certificate.  

    (d) Upon determining that a sale will involve replacement 
 of Medicare supplement coverage, any issuer, other than a direct 
 response issuer, or its agent, shall furnish the applicant, 
 before issuance or delivery of the Medicare supplement policy or 
 certificate, a notice regarding replacement of Medicare 
 supplement coverage.  One copy of the notice signed by the 
 applicant and the agent, except where the coverage is sold 
 without an agent, shall be provided to the applicant and an 
 additional signed copy shall be retained by the issuer.  A 
 direct response issuer shall deliver to the applicant at the 
 time of the issuance of the policy or certificate the notice 
 regarding replacement of Medicare supplement coverage. 

    (e) The notice required by paragraph (d) for an issuer 
 shall be provided in substantially the following form in no less 
 than 12-point type: 

            "NOTICE TO APPLICANT REGARDING REPLACEMENT 

                 OF MEDICARE SUPPLEMENT INSURANCE

              (Insurance company's name and address)

   SAVE THIS NOTICE!  IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

    According to (your application) (information you have 
 furnished), you intend to terminate existing Medicare supplement 
 insurance and replace it with a policy or certificate to be 
 issued by (Company Name) Insurance Company.  Your new policy or 
 certificate will provide 30 days within which you may decide 
 without cost whether you desire to keep the policy or 
 certificate. 

    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 policy.  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 policy because you intend to 
    terminate the existing Medicare supplement policy.  The 
    replacement policy or certificate is being purchased for 
    the following reason(s) (check one): 

    ______  Additional benefits 

    ______  No change in benefits, but lower premiums 

    ______  Fewer benefits and lower premiums 

    ______  Other (please specify)  
    ____________________________________________________________
    ____________________________________________________________
    ____________________________________________________________

    (1) Health conditions which you may presently have 
    (preexisting conditions) may not be immediately or fully 
    covered under the new policy or certificate.  This could 
    result in denial or delay of a claim for benefits under the 
    new policy or certificate, whereas a similar claim might 
    have been payable under your present policy or certificate. 

    (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 the 
    time was spent (depleted) under the original policy or 
    certificate. 

    (3) If you still wish to terminate your present policy or 
    certificate 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 or certificate 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.) 

    Do not cancel your present policy or certificate until you 
    have received your new policy or certificate and you are 
    sure that you want to keep it. 

    

    _____________________________________________________ 

    (Signature of Agent, Broker, or Other Representative)* 

    

    _____________________________________________________ 

    (Typed Name and Address of Issuer, Agent, or Broker) 

    

    _____________________ 

    (Date) 

    

    __________________________________ 

    (Applicant's Signature) 

    

    _____________________ 

    (Date) 

    

    *Signature not required for direct response sales." 

    

    (f) Paragraph (e), clauses (1) and (2), of the replacement 
 notice (applicable to preexisting conditions) may be deleted by 
 an issuer if the replacement does not involve application of a 
 new preexisting condition limitation. 

    HIST: 1983 c 263 s 14; 1992 c 554 art 1 s 13; 1993 c 13 art 1 
 s 18; 1993 c 330 s 10; 1996 c 446 art 1 s 35