Application for Medicare Supplement Coverage

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1 Application for Medicare Supplement Coverage Complete application in full Use ballpoint pen Print legibly Plan Selection Plan A Plan D Plan N Requested Effective Plan C Plan F Date: / / Applicant Information Last Name First Name Middle Initial Gender F M Residence Address: City State Zip Mailing Address (if different from above): City State Zip Social Security number: Home telephone number: ( ) address Date of Birth (month/day/year): / / Your current age: Questions about Medicare and Other Previous or Existing Coverage 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 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 and belief: Please mark Yes or No below with an X. 1a Did you turn age 65 in the last 6 months? b Did you enroll in Medicare Part B in the last 6 months? c If yes, what is the effective date? / / (refer to your red, white and blue Medicare card) Medicare Claim Number: d Did you enroll in Medicare Part C (a Medicare Advantage plan) in the last 6 months? e If yes, what is the effective date? / / f Did you enroll in Medicare Part D (a stand-alone Medicare prescription drug plan) in the last 6 months? g If yes, what is the effective date? / / MSUP Application 2012 Page 1 of 6

2 To the best of your knowledge and belief: Please mark Yes or No below with an X. 2a b c 3a b Are you covered for medical assistance through the state Medicaid program? Note to applicant: If you are participating in a Medicaid "spend-down program" and have not met your "Share of Cost," please answer NO to this question. If you answered Yes: Will Medicaid pay your premiums for this Medicare Supplement policy? Do you receive any benefits from Medicaid other than payments toward your Medicare Part B premium? 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 start and end dates below. If you are still covered under this plan, leave the End date blank. Start / / End / / 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? 4a Do you have another Medicare Supplement policy in force? b If you answered Yes: With what company, and what plan do you have? Name of company Plan c 5a b Do you intend to replace your current Medicare Supplement policy with this policy? Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan) If you answered Yes: With what company, and what kind of policy? Name of company Type of Policy c What are your dates of coverage under the other policy? If you are still covered under the other policy, leave the End date blank. Start / / End / / MSUP Application 2012 Page 2 of 6

3 Select a payment frequency: Select a payment method: Payment Information Monthly (bank draft only) Semi-annual Annual Check. I understand that checks are accepted only for payment frequencies of Semi-annual or Annual only. Bank Draft (EFT). Please withdraw the premium electronically from my bank account for the payment frequency I have selected above. I have attached a voided check or have provided my banking information below. Account Type: Checking Savings Accountholder Name: Name of Banking Institution: Bank routing number: Account Number: Upon acceptance of my application, I authorize New West Health Services (NWHS) to withdraw funds from my account for all premiums due. NWHS's rights with each charge are the same as if personally paid by me. This authorization will remain in effect for the duration of my policy term unless I request, in writing, to terminate it. Signature Date Important Statements Please Read Carefully (1) You do not need more than one Medicare Supplement policy. (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. (4) If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy must 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. Upon receipt of timely notice, the issuer must either return to the policyholder or certificateholder that portion of the premium attributable to the period of Medicaid eligibility or provide coverage to the end of the term for which premiums were paid, at the option of the insured, subject to adjustment for paid claims. 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 reinstated 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 reinstated policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. (5) 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 reinstated 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, Page 3 of 6

4 the reinstated policy will not have prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension. (6) 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). Application Agreement and Authorization (1) I, the Applicant, understand that this is an application only. No rights to coverage are conferred to me until New West Health Services accepts my application, issues a Medicare Supplement policy to me, and receives applicable premiums. (2) I understand that I should not cancel any existing insurance coverage unless and until I am notified in writing by New West Health Services of my acceptance for coverage. I acknowledge that I may not be accepted for coverage. (3) I understand that New West Health Services relies upon the information I have provided on this application, on the New West Supplemental Health Questionnaire (if required), and on any other information I have provided to make a determination about my eligibility for coverage. (4) I understand premiums for my coverage must be paid when due. I understand that the first month's premium will be charged only if this application is accepted. Acceptance of premium by New West Health Services does not constitute a waiver of their right to cancel my coverage retroactively for fraud or for intentional misrepresentation of material facts as stated on this application. If such a retroactive cancellation occurs, New West Health Services may deduct any benefit payments from any paid premium before refunding such premiums to me. I agree to repay any benefit payments to which I was not entitled. (5) I am a resident of Montana and accept the terms and conditions of any policy issued to me by New West Health Services under the laws of this state. (6) I have received a copy of the New West Health Services Notice of Privacy Practices. (7) I understand that an agent (producer) or broker assisting me with this application does not have the authority to bind coverage or commit New West Health Services in any manner. (8) I understand that New West Health Services may need to obtain medical records to determine my eligibility for coverage or, if a policy is issued to me, to determine whether benefits for specific claims are payable under the policy. I agree to cooperate with New West Health Services to obtain any authorizations, medical records, or other information needed to review my application or claims. (9) I authorize the transfer of claims information from Medicare to New West Health Services. I certify that all of the information I have provided on this application and on other required supplemental forms (if any) is true, complete, and correct. I have read, understand and agree to the terms of this Application Agreement. I hereby apply for coverage and agree that the coverage for which I am applying is subject to eligibility requirements and that the policy effective date will be assigned by New West Health Services. Signature of Applicant Date MSUP Application 2012 Page 4 of 6

5 This Section to be Completed by New West Health Services Representative/Producer i. I have advised the applicant to read, fully complete, and sign this application to the best of the applicant's knowledge and ability. ii. iii. iv. I have advised the applicant that coverage will not commence until New West Health Services has notified him/her that the application has been received and approved. The "Guide to Health Insurance for People with Medicare" and an Outline of Medicare Supplement Coverage have been provided to the applicant. The applicant is applying for coverage during an open enrollment or guaranteed issue period. (For a guaranteed issue period: A copy of the notice from the prior insurer is enclosed.) *If No: The following Health Information is required: (1) New West Supplemental Health Questionnaire (2) Conditioned Authorization to Release Medical Information The required forms, completed and signed by the applicant, are enclosed. v. Based on the applicant's answers to Questions 3b and 4c (on page 2 of this application), this Medicare Supplement policy will replace another Medicare plan or Medicare Supplement policy. vi. *If Yes: I have provided the applicant with a fully executed copy of the attached "Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage." List any other health insurance policies sold to the applicant. Policies still in force: * Yes* No Policies sold in the last five (5) years that are no longer in force: vii. I have received from the applicant the sum of $, which is the full initial premium for month(s). I have explained to the Applicant that if, for any reason, this application is not accepted and the Medicare Supplement policy is not issued, the total payment will be refunded and no other liability is created or assumed by New West Health Services until and unless the policy applied for has been issued. I certify the following: 1. I have responded truthfully and correctly to the above statements; and 2. I am not aware of any information not disclosed in the application that might affect the applicant's eligibility. I have explained to the applicant that no policy may be issued if he/she answered 'Yes' to item 2a or 'No' to item 4c in the "Questions about Medicare and Other Previous or Existing Coverage" section. Signature of Representative: Date: Printed Name: Telephone: Page 5 of 6

6 NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE New West Health Services 130 Neill Avenue Helena MT SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare or Medicare advantage supplement insurance and replace it with a policy to be issued by New West Health Services. 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. Terminate your present policy only if, after due consideration, you find that purchase of this Medicare supplement or Medicare advantage coverage is a wise decision. STATEMENT TO APPLICANT BY ISSUER, OR PRODUCER: 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(s): Additional benefits. No change in benefits, but lower premiums. Fewer benefits and lower premiums. Other (please specify) 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: (1) Note: If the issuer of the Medicare supplement policy being applied for does not, 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 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 or supplemental forms concerning your medical/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. Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. Producer or Insurer Signature of Producer or Other Representative* Typed Name & Address of Issuer or Producer Applicant The above "Notice to Applicant" was delivered to me on (date): Applicant's Signature Date *Signature not required for direct response sales. Page 6 of 6

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