APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE APPLICATION INSTRUCTIONS This application may be used by Medicare-eligible persons to apply for Medicare supplement coverage from Empire HealthChoice Assurance, Inc. Medicare supplement coverage is available only to persons enrolled in both Part A and Part B of Medicare. If both husband and wife are requesting Medicare supplement coverage, each must submit a separate application. Complete the application in its entirety. An incomplete application may result in a delay in coverage. PART 1 TELL US ABOUT YOURSELF Complete this section with the applicant s: Name, Street address (no post office boxes) and Telephone number Gender and Date of birth Mailing address if different from the Street address Information from the red, white and blue Medicare card: Medicare claim number, Hospital (Part A) Insurance effective date and Medical (Part B) Insurance effective date. If the applicant is currently enrolled with Empire the next three (3) questions must be answered. PART 2 SELECT YOUR COVERAGE Place an x in the Medicare supplement plan of choice. PART 3 TO THE BEST OF YOUR KNOWLEDGE AND BELIEF COMPLETE THE FOLLOWING These questions are to determine if the applicant is enrolled in another policy or certificate that supplements Medicare. Each question must be answered either YES or NO. PART 4 SIGN AND DATE BELOW BEFORE MAILING The signature of the person who is applying for coverage is required for the application to be considered complete. If the applicant is unable to sign, legal documentation must be provided that designates another person as the applicant s representative. For assistance in completing your application, please contact us at 1-800-809-7328, Monday Friday, 8:00 a.m. 5:00 p.m. Mail the completed application and any required documentation in the enclosed self addressed envelope to: Enrollment Processing Center P.O. Box 5007 Middletown, NY 10940-9007 Please do not send payment at this time. You will receive a bill for your first premium once your application is approved and processed. EHA-APP-09 LGL 9719E 3/09 Services are provided by Empire HealthChoice Assurance, Inc., independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. DS SNYFR0671DS r03/09
APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE PART 1- TELL US ABOUT YOURSELF PART 1 TELL US ABOUT YOURSELF Social Security Number Area Code Daytime Telephone Number Last Name First Name Middle Initial Street Address Apartment Number City State Zip Code _ Male _ Female Date of Birth Mailing address if different from street address: Mailing address Apartment Number City State Zip Code Taking information from your red, white and blue Medicare Card, enter information requested below: Health Insurance S O C I A L S E C U R I T Y A C T NAME OF BENEFICIARY JOHN DOE CLAIM NUMBER Claim Number -- -- -- 000-00-0000- A MALE IS ENTITLED TO EFFECTIVE DATE Hospital Insurance Effective Date l l l l ------------------------------------_ HOSPITAL (PARTA) 00-00-00 SEX Medical Insurance Effective Date l l l l ------------------------------------_ MEDICAL (PART B) 00-00-00 SIGN HERE Are you currently enrolled with Empire HealthChoice Assurance, Inc? _Yes _ No If Yes, what is the Identification Number on your Identification Card? If your present Empire HealthChoice Assurance, Inc. coverage provides benefits for a spouse and/or one or more dependent children who are not eligible for Medicare, complete the following. This will enable us to offer continuous coverage to your spouse and/or dependent(s) in a direct payment program that is comparable to your current coverage. Name Relationship Date of Birth Social Security Number
Please read the Outline of Medicare Supplement Coverage accompanying this application for full details about benefits and rates. Then select the coverage you are applying for. Check Only One Box: PLAN A PLAN B PLAN C PLAN F PLAN H PLAN K PLAN L PART 2 SELECT YOUR COVERAGE Optional Rider: SilverSneakers Fitness Program EMPIRE HEALTHCHOICE ASSURANCE, INC. IS PROHIBITED FROM SELLING MEDICARE SUPPLEMENT INSURANCE TO AN INDIVIDUAL COVERED UNDER A MEDICARE SUPPLEMENT POLICY OR CERTIFICATE WHO DOES NOT DESIRE TO REPLACE THE POLICY OR CERTIFICATE, OR WHERE THE MEDICARE SUPPLEMENT POLICY OR CERTIFICATE WOULD DUPLICATE BENEFITS TO WHICH THE INDIVIDUAL IS ENTITLED UNDER A MEDICARE ADVANTAGE PLAN. PART 3 TO THE BEST OF YOUR KNOWLEDGE AND BELIEF COMPLETE THE FOLLOWING PART 3 SELECT A THIRD-PARTY DESIGNEE (Optional) PART 4 FOR YOUR PROTECTION, YOU MUST COMPLETE THE FOLLOWING Questions. To the best of your knowledge and belief: (Please mark Yes or No below with an X ) (a) (1) Did you turn age 65 in the last 6 months? (2) Did you enroll in Medicare Part B in the last 6 months? If yes, what is the effective date? (b) 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.) If yes, (1) Will Medicaid pay your premiums for this Medicare supplement policy? (2) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
(c) (1) If you had coverage from any Medicare Advantage plan other than original Medicare within the past 63 days (for example, a Medicare HMO, PPO or PFFS), fill in your start and end dates below. If you are still covered under the Medicare Advantage plan, leave END DATE blank. START DATE END DATE (2) If you are still covered under the Medicare Advantage plan, do you intend to replace your current coverage with this new Medicare supplement policy? (3) Was this your first time in this type of Medicare Advantage plan? (4) Did you drop a Medicare supplement policy to enroll in the Medicare Advantage plan? (d) (1) Do you have another Medicare supplement or Medicare Select policy or certificate in force? (2) If so, with what company and what plan do you have? (3) If so, do you intend to replace your current Medicare supplement or Medicare Select policy or certificate with this policy or certificate? (e) Have you had coverage under any other health insurance policy or certificate within the past 63 days? (For example, an employer, union or individual plan) (1) If so, with what company and what kind of policy? (2) What are your dates of coverage under the other policy? START DATE END DATE (If you are still covered under the other policy, leave END DATE blank.)
PART 4 - SIGN AND DATE BELOW BEFORE MAILING All information furnished is true and complete to the best of my knowledge. I understand that there will be a six-month waiting period for coverage of any condition for which I received medical treatment or advice within six months prior to the effective date of the new Contract. I understand that the time I was covered under any other health insurance or employer-provided health benefit arrangement before I become covered under this Contract will be counted toward this six-month waiting period, if there was no break in coverage greater than 63 days between the termination of the other coverage and the effective date of the new Contract. Signature Date PART 5- SELECT A THIRD PARTY DESIGNEE (OPTIONAL) Under New York State law, customers with Medicare Supplement insurance may designate another person (a third party) to receive a notice of nonpayment of insurance premiums. In the event the premium is not received by the due date a THIRD PARTY BILLING STATEMENT will be sent to the designated person. If you wish to authorize a person to receive this notice of payment due, provide the information requested below. The person you select MUST sign. Last Name First Name Middle Initial Home Address Apartment Number City State Zip Code Desiginated Third Party Signature Date I authorize Empire HealthChoice Assurance, Inc. to send, to the Third Party Designee, a THIRD PARTY BILLING STATEMENT for the person named on this application. This Authorization is valid for the duration of my coverage with Empire unless a different expiration date is indicated here: (specify month, day, year) I understand that this Designation does not include the ability to make decisions concerning my health care. I also understand that I may revoke this designation at any time, except to the extent that action has been taken in reliance upon it, by submitting a request in writing to Empire. I understand that the person/entity I have named to receive information may not be subject to privacy laws. They may be able to release the information and privacy laws may no longer protect the information. I do hereby affirm that I am the member or the person with the legal authority (appropriate legal documentation must be provided) to act on behalf of the applicant. Applicant/Legally Authorized Person Signature Date Authority of person signing form (e.g. Power of Attorney)
IMPORTANT INFORMATION YOU SHOULD KNOW Notice: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. _ You do not need more than one Medicare Supplement contract or certificate. _ If you purchase this contract, 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 or certificate. _ If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy may 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 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 New York State to provide advice concerning your purchase of Medicare Supplement insurance and concerning medical assistance through the New York State Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a specified low-income Medicare beneficiary (SLMB). You may call 1-800-333-4114 for information. S ADDITIONAL INFORMATION YOU SHOULD KNOW With all new applications, you must provide one Proof of Residence document indicating that you are a New York State resident living within Empire s 28-county operating area. These counties are: Albany, Bronx, Clinton, Columbia, Delaware, Dutchess, Essex, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington or Westchester. Acceptable documents for Proof of Residence include (all items must be current and not expired): Voter Registration Card Driver s License Motor Vehicle Non-driver s License Motor Vehicle Registration New York State Insurance ID Card Utility Bill* Telephone Bill* (cellular phone bills are acceptable) Cable Television Bill* New York State Department of Motor Vehicle Certificate of Title Computerized Statement of School or Property Taxes Unemployment Check* Computerized W-2 Form Copy of Current Lease Agreement (signed by tenant and landlord) Certificate of Residency* Letter from Nursing Home (on company letterhead)* 1099R (must be from the Social Security Administration) *These items must be dated within the past 90 days.
Please note: The street address on your Proof of Residence document must match the street address listed on your application. A post office (PO) box address is not acceptable for Proof of Residence. However, it may be listed as an additional mailing address. If you do not have acceptable Proof of Residence, in your own name, you may submit an acceptable document (from list above) in your spouse s name as long as you both reside at the same address. When Empire receives your application, you will receive an acknowledgement letter from us confirming receipt. This is not an acceptance letter. Once your application is approved & processed, you will receive a contract booklet and identification (ID) card indicating the effective date of coverage. Please allow two (2) to three (3) week for processing. Effective date of coverage Once your application is accepted, your coverage will become effective on the date we received the completed application. For example, if Empire receives your application on July 10 and it is considered complete, even if it takes several days for us to review it, your coverage will be effective on July 10. However, if your application is received within 30 days after the date your Medicare coverage first becomes effective, Empire s Medicare Supplement coverage will become effective retroactive to that date. For example, if Empire receives your application on July 10 and your Medicare coverage became effective July 1, your Empire Medicare Supplement coverage will be effective on July 1. If you would like to have your coverage start at a later date, please specify the exact date by writing it in next to your coverage selection in Part 2 of the application. Changing your Coverage If you are currently enrolled in one of Empire s Medicare Supplement programs and you are submitting this application to either only upgrade or downgrade your coverage to a different Medicare supplement program, please note the following: Proof of Residence is not required with your application. You will not have a new six (6) month waiting period for pre-existing conditions. All sections of the application must be completed. To increase (upgrade) your benefits: Medicare Supplement coverage upgrades can only be made on your enrollment anniversary date. For example, if your enrollment began on 01/01/01, you can only upgrade on 01/01 of any following year, as long as your application is received within 90 days prior to your anniversary date. To reduce (downgrade) your benefits: Medicare Supplemental coverage downgrades can be made at any time.