Thank you for your interest in the KPS Health Plans Medicare Supplement plan!

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1 KPS Application Thank you for your interest in the KPS Health Plans Medicare Supplement plan! Attached is a copy of the policy Enrollment Form and we have supplied you with a link to a printable copy of the Outline of Coverage. Should you decide to apply by mail/fax/ , the printable application needs to be reviewed and signed by an Agent before it can be submitted to KPS Health Plans. You may , fax or mail it in to CDA Insurance: Fax: Secure File Upload: Click here Mail: CDA Insurance LLC PO Box Eugene, Oregon Other Important Information Download Medicare s Choosing a Medigap Policy Guide (.pdf) Download Policy Outline (.pdf) Download Application (.pdf) Our website: If you should have any questions on the application, please call us at or

2 health plans Enrollment Application for Medicare Supplement Page 1 of 6 PO Box Seattle, WA SECTION 1 PLAN CHOICE rplan A (2010 STANDARDIZED) rplan F (2010 STANDARDIZED) rplan K rplan N PLEASE PRINT Answer all questions completely and accurately to ensure timely processing Name (Last, First, Middle): Birth Date: Address (Street, City, State, Zip): Telephone: Social Security Number (required): rmale rsingle rfemale rmarried Medicare Claim Number: MEDICARE CLAIM NUMBER Please, copy the numbers shown as MEDICARE CLAIM NUMBER on the Medicare Health Insurance card issued to you by the Social Security Administration. Enter effective date of Hospital (Part A) coverage shown on your Medicare Health Insurance card. Month: Day: Year: Enter effective date of Medical (Part B) coverage shown on your Medicare Health Insurance card. Month: Day: Year: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS FORM You must be enrolled in the KPS Medicare Supplement If you become eligible for Medicaid after purchasing this Plan you have chosen for a period of three (3) consecutive contract, the benefits and premiums under your Medicare months before KPS will provide benefits for any condition supplement contract can be suspended, if requested, for which you received medical advice, treatment, medicine, during your entitlement to benefits under Medicaid for 24 or diagnostic testing during the three (3) month period months. You must request this suspension within 90 days of immediately preceding your KPS Medicare Supplement becoming eligible for Medicaid. If you are no longer entitled contract effective date. This waiting period will be waived to Medicaid, your suspended Medicare supplement contract if KPS receives your application within six (6) months of (or, if that is no longer available, a substantially equivalent you turning age 65 or your enrollment in Medicare Part B; contract) will be reinstated if requested within 90 days of or it will be reduced to the extent you had prior coverage losing Medicaid eligibility. under another Medicare supplement plan or other more If the Medicare supplement contract provided coverage for comprehensive coverage, and you did not have a break in outpatient prescription drugs and you enrolled in Medicare coverage of more than 63 days. Please provide proof of prior Part D while your contract was suspended, the reinstated coverage with this application. contract will not have outpatient prescription drug coverage, If you intend to terminate existing Medicare but will otherwise be substantially equivalent to your supplement or Medicare Advantage insurance and replace coverage before the date of the suspension. it with a contract to be issued by KPS Health Plans, please If you are eligible for, and have enrolled in a Medicare complete the enclosed Notice To Applicant Regarding supplement contract by reason of disability and you later Replacement of Medicare Supplement Insurance or become covered by an employer or union-based group Medicare Advantage. Retain one copy for your records and health plan, the benefits and premiums under your Medicare return a completed/signed copy to KPS. supplement contract can be suspended, if requested, You do not need more than one Medicare supplement while you are covered under the employer or union-based contract. group health benefit plan. If you suspend your Medicare If you purchase this contract, you may want to evaluate your supplement contract under these circumstances, and later existing health coverage and decide if you need multiple lose your employer or union-based group health plan, your coverages. suspended Medicare supplement contract (or, if that is no longer available, a substantially equivalent contract) will If you are 65 or older, you may be eligible for benefits be reinstated if requested within 90 days of losing your under Medicaid and may not need a Medicare supplement employer or union-based group health plan. If the Medicare contract. supplement contract provided coverage for outpatient 143KPS

3 health plans prescription drugs and you enrolled in Medicare Part D while your contract was suspended, the reinstated contract will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. Enrollment Application for Medicare Supplement Page 2 of 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). SECTION 2 PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. (MARK YES OR NO WITH AN X ) 1. (a) Did you turn age 65 in the last six (6) months? r YES r NO (b) Did you enroll in Medicare Part B in the last six (6) months? r YES r NO If yes, what is the effective date? 2. Are you covered for medical assistance through the state Medicaid program? (NOTE 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.) r YES r NO (If no, proceed to next question) (a) Will Medicaid pay your premiums for this Medicare supplement contract? r YES r NO (b) Do you receive any benefits from Medicaid other than payments toward your r YES r NO Medicare Part B premium? 3. (a) Have 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) If yes, what are your start and end dates? If you are still covered under this plan, please leave END blank. (b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement contract? Start: r YES r YES r NO (If no, proceed to next question) End: r NO (c) Was this your first time in this type of Medicare plan? r YES r NO (d) Did you drop a Medicare supplement contract to enroll in the Medicare plan? r YES r NO 4. (a) Do you have another Medicare supplement contract in force? r YES r NO (If no, proceed to next question) If yes, with what company and what plan do you have? Company: Plan: (b) If yes, do you intend to replace your current Medicare supplement contract with this contract? r YES r NO 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 contract?: b) What are your dates of coverage under the other contract? If you are still covered under this plan, please leave END blank. Start: r YES r NO (If no, proceed to next section) End: 143KPS

4 SECTION 3 HEALTH STATEMENT REQUIREMENTS If you are 65 years of age or older, and you are applying for a Medicare supplement plan for the first time more than six (6) months since you first enrolled in Medicare Part B you must complete the health statement. In compliance with Washington State law, the health statement must be completed either by you or on your behalf by a relative, legal guardian, or physician. Completion of a health statement is not required if: 1. You are 65 years of age or older and applying within six (6) months of your first enrollment under Medicare Part B; or 2. You are transferring from another Medicare Supplement Plan A to the KPS Medicare Supplement Plan A (2010 Standardized); or 3. You are transferring from a Medicare Supplement plan other than Plan A to a KPS Medicare Supplement Plan; or 4. You are transferring from more comprehensive coverage to a KPS Medicare Supplement Plan. If any of these circumstances (1-4) apply to you, please skip the health statement on the next page and continue to page 5 to complete the rest of this application. If none of these circumstances (1-4) apply to you, please complete the health statement that follows. HEALTH STATEMENT Please indicate whether or not you have been diagnosed with any of the following conditions within the last five (5) years. Each condition must be checked Yes or No. Condition Please provide details of any conditions marked Yes. Year Diagnosed Name of Disease or Injury Surgery Name & Address of Hospital or Physician 1. Aids or HIV Positive ryes rno 2. Arthritis ryes rno 3. Alcoholism/Chemical Dependency ryes rno 4. Dementia (e.g., Alzheimer s) ryes rno 5. Back Conditions ryes rno 6. Cancer, Leukemia ryes rno 7. Cataracts ryes rno 8. Vein or Artery Disease ryes rno 9. Heart Disease ryes rno 10. High Blood Pressure ryes rno 11. Intestinal Conditions (e.g., stomach bowel) ryes rno Continued on next page 143KPS

5 Continued from page 3 HEALTH STATEMENT Please indicate whether or not you have been diagnosed with any of the following conditions within the last five (5) years. Each condition must be checked Yes or No. Condition Please provide details of any conditions marked Yes. Year Diagnosed Name of Disease or Injury Surgery Name & Address of Hospital or Physician 12. Kidney/Bladder Conditions ryes rno 13. Liver Conditions ryes rno 14. Parkinson s Disease ryes rno 15. Diabetes ryes rno 16. Emphysema/Lung Disorders ryes rno 17. Gall Bladder Conditions ryes rno 18. Glaucoma ryes rno 19. Prostate Disorders ryes rno 20. Mental Health Conditions (e.g., depression) ryes rno 21. Stroke ryes rno 22. Conditions Requiring Hospitalization or Surgery ryes rno PLEASE LIST ANY PRESCRIPTION DRUGS YOU ARE TAKING Name of Drug Reason Taken 143KPS

6 health plans Enrollment Application for Medicare Supplement Page 5 of 6 If you have 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 contract, or that you had certain rights to buy such a contract, 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. SECTION 4 ACKNOWLEDGEMENTS: Please read and initial each of the following statements: I am applying for enrollment with KPS Health Plans. I represent that all statements and answers on this application and health questionnaire (if applicable) are complete and true to the best of my ability and knowledge. I understand it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company; penalties include imprisonment, fines, and denial of insurance benefits. I understand coverage is available to me based on the following: My residence in Washington State My enrollment in Medicare Parts A and B My eligibility for Medicare due to age (65 or over) I understand that a true copy of this application will be attached to my contract when it is issued. I have received a copy of the following (all are required): Guide to Health Insurance for People with Medicare Notice to Applicant Regarding Replacement of Medicare Supplement Insurance Outline of Coverage I understand and agree that coverage does not begin until KPS notifies me of my coverage effective date. I authorize any physician, hospital, or other provider of service to disclose to KPS any medical information that may be requested and understand that such information will be kept confidential, except as may be necessary to administer the provisions of my contract. I authorize the Centers for Medicare and Medicaid Services (CMS) to release to KPS any information from Title XVIII (Medicare) that is required to process my claims in conjunction with Medicare, if applicable. This authorization is ongoing for as long as I am or will be eligible for Medicare and remain enrolled in this plan. I understand that KPS will not pay benefits during the first three (3) months after my effective date for any condition for which medical advice was given or treatment was recommended by or received from a physician within three months before the effective date of coverage. I understand that this waiting period will be waived if KPS receives my application within six (6) months of my turning age 65 or enrolling in Medicare Part B; or it will be reduced to the extent I had prior coverage under another Medicare supplement plan or other more comprehensive coverage with no break in coverage of more than 63 days, and I provide proof of that coverage with this application. I have read and personally completed all of the requested information on this form. (If not, please attach a letter of explanation.) Signature of Applicant Signature Date: 143KPS

7 health plans Enrollment Application for Medicare Supplement Page 6 of 6 Please mail your completed application to: KPS HEALTH PLANS PO Box Seattle, WA Upon approval of this application your coverage will begin either the first of the following month OR the first of (month). (You may request a later effective date up to 90 days from the date of this application.) SECTION 5 FOR INSURANCE PRODUCER USE ONLY: The following must be completed by an insurance producer. All information must be completed, including the notice of replacement coverage (if applicable) included with this application, or the application will be returned. 1. List any other medical or health insurance contracts sold to the applicant: 2. List contracts that are still in force: 3. List contracts sold in the past five years that are no longer in force: FOR INSURANCE PRODUCER VERIFICATION, FOR INSURANCE PRODUCER ONLY. The following MUST be completed AFTER the applicant has completed the application. To the best of my knowledge, the answers on this application are complete and accurate. Insurance Producer Name - as licensed: Agency Name: Ins. Producer No.: Mailing Address: City: State: Zip: Telephone No.: Insurance Producer Signature: The following KPS in-house insurance producer has reviewed and accepted this application: In-house Insurance Producer Name - as licensed: Ins. Producer No.: Date: In-house Insurance Producer Signature: Date: PO Box Seattle, WA Toll-free TTY KPS

8 Statement to applicant by issuer or insurance Producer: Notice to applicant regarding replacement of Medicare Supplement Insurance or Medicare Advantage Save this notice! It may be important to you in the future According to information you have furnished, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a contract to be issued by KPS Health Plans. Your new contract will provide thirty days within which you may decide without cost whether you desire to keep the contract. 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 disability coverage you have that may duplicate this contract. I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement contract 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 contract is being purchased for the following reason(s) (check one): Additional benefits No 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 If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. If you have had your current Medicare supplement policy less than three months, health conditions which you may presently have (preexisting 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) to the extent such time was spent (depleted) under 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 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. GMA-JAN /03/13

9 Do not cancel your present contract until you have received your new contract and are sure that you want to keep it. Applicant s name (please print) Applicant s signature Date Agency name Complete and sign pages 1 and 2, and then return to KPS Health Plans. Please keep the copy for your records. Main Office: 400 Warren Avenue Bremerton, WA Mailing Address: PO Box Seattle, WA Phone Number: GMA-JAN /03/13 256KPS

10 Medicare Supplement Plan Change Request Form PERSONAL INFORMATION Name (as it appears on Medicare card) PLEASE PRINT CLEARLY USING BLACK OR BLUE INK ONLY First name Middle Initial Last name Mr. Mrs. Birth date Male Ms. Female Permanent residential street address (do not use a P.O. box or a mail delivery service) Street address City County State Zip Mailing address (if different than above) Address In care of City County State Zip Premium billing address (if different than above) we will send your monthly bill here. Address In care of City County State Zip Contact information Telephone (primary) Telephone (secondary) KPS Health Plans Member ID Please make a copy of this form for your records. 14-KPS KPS Health Plans PO Box 34803, Seattle, WA Toll-free: TTY:

11 MEDICARE INFORMATION Please complete this section with the information on your red, white, and blue Medicare card. You must have Medicare Parts A and B to remain enrolled in a Medicare Supplement plan. Medicare Claim Number Part A (hospital) effective date Part B (medical) effective date Medicare Supplement Plan Change Request Form PLAN INFORMATION Plan A (2010 Standardized): $135 Plan K: $87 Plan F (2010 Standardized): $251 Plan N: $141 ACKNOWLEDGEMENTS & SIGNATURE I acknowledge that: I am requesting enrollment with KPS Health Plans. I am eligible for a KPS Health Plans Medicare Supplement based on my residence in Washington State, my enrollment in Medicare Parts A and B, and my eligibility for Medicare is due to age. A true copy of this request will be attached to my contract when it is issued. Coverage on this new plan does not begin until KPS notifies me of my coverage effective date. I authorize any physician, hospital, or other provider of service to disclose to KPS Health Plans any medical information that may be requested and understand that such information will be kept confidential, except as may be necessary to administer the provisions of my contract. I authorize the Centers for Medicare and Medicaid Services (CMS) to release to KPS Health Plans any information from Title XVIII (Medicare) that is required to process my claims in conjunction with Medicare, if applicable. This authorization is ongoing for as long as I am or will be eligible for Medicare and remain enrolled in this plan. I declare that all statements and answers on this application are complete and true to the best of my ability and knowledge. I understand it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company; penalties include imprisonment, fines, and denial of insurance benefits. Your signature Date If you are the authorized representative, you must sign above and provide the following information. Proof of your authority (e.g. Durable Power of Attorney) must be presented upon request. Name Phone Relationship to applicant

12 Authorization Agreement for Automatic Premium Payment SUBSCRIBER NAME KPS ID# (If not issued yet, leave blank) Please complete this form if you wish to have your monthly premium payment automatically withdrawn, changed, or cancelled from your bank account. This is an optional free service for your convenience. KPS arranges with your bank a transfer on or about the 10th of each month for the next month s coverage. The funds transfer will appear on your monthly bank statement. KPS will notify you in advance if there is to be any change in the amount of your premium. PLEASE NOTE: After your application is approved, it may take approximately one month to complete the arrangement with your bank. If you receive any premium bills, it means the funds transfer process has not been completed and you should remit payment before the 10th of the month of coverage. The automatic payment system will take effect for the following months, and you will no longer receive bills. Automatic premium payment account Please fill out below to start your automatic monthly premium payment. NAME ON ACCOUNT (print as shown on your bank statement) BANK NAME BRANCH NAME BRANCH ADDRESS (exactly as shown on your bank statement) CITY STATE/ZIP CODE CHECKING ACCOUNT# ROUTING NUMBER (1st 9 digits on the bottom of check) SIGNATURE OF ACCOUNT HOLDER(S) SIGNATURE OF SUBSCRIBER (If different than name on account) DATE To change premium payment account Please fill out your new bank information on the left-hand side and your old bank information below. NAME ON ACCOUNT PREVIOUS BANK NAME PREVIOUS ACCOUNT# SIGNATURE OF PAYEE/DATE SIGNATURE OF SUBSCRIBER/DATE To cancel premium payment account I no longer wish to participate in the KPS Health Plans automatic premium payment process. Please discontinue deducting premium payments from my bank account, effective. I understand KPS will continue to provide health care coverage for me (and my family) and I will be billed on a monthly basis. SIGNATURE DATE * As used herein, the term bank includes all types of financial institutions, including commercial banks, savings banks, savings and loans and credit unions. The signature(s) above gives KPS Health Plans permission to disclose the financial information for the above account to the Name on the bank account. Only billing and payment information will be given to above payee, nothing will be given regarding claims or claims payment. I have the right to revoke this permission at any time, by signing the cancellation section of my copy of this form and returning it to KPS Health Plans at the below address. APP1212 PO Box 339 Bremerton, Washington kpshealthplans.com 144KPS

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