ORTH CAROLIA SEIOR CITIZES ASSOCIATIO A QUICK GUIDE TO MEDICARE What ou Don t Know Could Cost ou. Building a Better Quality of Life for Senior Adults in orth Carolina Since 1977. The orth Carolina Senior Citizens Association (CSCA) is a nonprofit organization chartered by the state of orth Carolina in 1977. The information contained herein is to be used for general information purposes only. othing contained herein constitutes an application for insurance with any specific insurance company. Insurance company names and logos and any rates shown are provided as a public service and not intended as an endorsement for any particular company. Final rates quoted can only be confirmed by a licensed agent and approved by the appropriate insurance company. There is no cost to C seniors for our services. Royalty fees are paid to CSCA for the use of its intellectual property from various companies. These fees are used for the general purposes of CSCA. CSCA Medicare Advisors are licensed agents and can provide information on Medicare and Medicare Prescription Drug Plans. CSG Actuarial provided the premium rate comparison chart information. ot connected with or endorsed by the United States government or the federal Medicare program. Medicare Helpline 1-800-290-7535 www.medicaresupplementsforless.com MG412016
ORTH CAROLIA SEIOR CITIZES ASSOCIATIO PLA F AD PLA G ARE THE MOST POPULAR MEDICARE SUPPLEMET PLAS By federal law, Medicare Supplement Plan G has identical benefits to Plan F, with the exception of the $166 Medicare Part B calendar-year deductible. That is the OL difference. However, the PREMIUM rates vary widely from company to company for Plan F and Plan G for the SAME coverage. The Freedom ou Want With Original Medicare and Plan F or Plan G, you have the right to choose: Any hospital, doctor or specialist that accepts Medicare patients in the USA o networks to worry about o doctor referral needed to see a specialist o prior approval required The Savings ou eed With Original Medicare and Plan F or Plan G, 100% of all Medicareeligible charges are covered. ou pay $0 for Medicare Part A deductible and copayments ou pay $0 when you go to a primary care physician or to a specialist ou pay $0 for all Medicareeligible hospital inpatient and outpatient services ou pay $0 for preventive care services ou pay $0 when you go to a skilled nursing facility ou pay $0 for any Medicare- eligible excess charges ou pay $0 for any additional Medicare-eligible medical services IMPORTAT: Plan F will no longer be available to newly eligible Medicare beneficiaries after January 1, 2020. What does this mean for you? If you already have Plan F or are considering getting Plan F, you should be aware of the new law. The federal government will no longer allow newly eligible beneficiaries to obtain a Medicare Supplement that covers the Medicare Part B deductible after January 1, 2020. The good news: If you already have Plan F, you can keep it and will not be forced to move to another plan since this law only affects newly eligible Medicare beneficiaries. The bad news: In the future, the Plan F premium rates will increase at a higher rate than the other plans. Why is this? Each plan is individually rated based on the costs (e.g. claims processed). After 2020, when Plan F is no longer accepting new applicants, the pool of Plan F members will begin to age more than other plans, which will result in higher proportionate claims costs and thus drive up the premiums for Plan F. So what should you do? Most experts recommend Plan G now, which: has lower premium rates than Plan F and not impacted by the new law, provides the same coverage as Plan F, except for the $166 Medicare Part B deductible. Act now: If you are healthy and over age 65, it is important that you act now since you will have to go through medical underwriting in order to switch your Medicare Supplement Plan. If you wait until a later time, you risk potential health issues that could prevent you from changing your Supplement Plan. Don t Be Fooled: A Medicare Advantage plan is completely different from Original Medicare and a Medicare Supplement plan. If you join a Medicare Advantage plan instead of Original Medicare, you will continue to pay the Medicare Part B premium. It is important to realize that once you have enrolled in a Medicare Advantage plan, the coverage of services provided under Medicare Parts A and B are filed through the selected Medicare Advantage plan instead of Original Medicare. If you enroll in a Medicare Advantage plan, you will OT be enrolled in Original Medicare and you will OT be able to use your red, white and blue Medicare card when you go to the hospital, doctor or specialist. This means you no longer are under the Original Medicare plan and that you must follow the rules of the Medicare Advantage plan you have joined. MG412016 OVER Medicare Helpline 1-800-290-7535 www.medicaresupplementsforless.com
PLA F AD PLA G PREMIUM RATE COMPARISO CHART By Federal Law, Medicare Supplement Plan G has identical benefits to Plan F, with the exception of the $166 Medicare Part B calendar-year deductible. That is the OL difference. However, the PREMIUM rates vary widely from company to company for Plan F and Plan G for the SAME coverage. Best Value Company #1 AM Best Rating: A+ S&P Rating: A+ Company #2 AM Best Rating: A S&P Rating: AA- PLA G PREMIUM RATE COMPARISO CHART* Company #3 AM Best Rating: A+ S&P Rating: AA Company #4 AM Best Rating: A- S&P Rating: /A Company #5 AM Best Rating: A- S&P Rating: /A Company #6 AM Best Rating: /A S&P Rating: /A HH Discount Applied: 12% Effective Date: 4-1-16 HH Discount: 7% Effective Date: 3-1-16 HH Discount: o Effective Date: 2-1-16 HH Discount Applied: 7% Effective Date: 7/1/15 HH Discount: 7% Effective Date: 12-1-15 HH Discount: o Effective Date: 6-1-16 Age Female Male Female Male Female Male Female Male Female Male Female Male 65 $90.34 $102.07 $93.46 $107.54 $98.08 $112.75 $107.00 $116.83 $109.71 $126.17 $135.25 $135.25 66 $90.34 $102.07 $96.71 $111.29 $98.08 $112.75 $107.00 $116.83 $109.71 $126.17 $162.00 $162.00 67 $90.34 $102.07 $99.96 $114.95 $98.08 $112.75 $107.00 $116.83 $115.05 $132.31 $162.00 $162.00 68 $93.10 $105.20 $103.13 $118.54 $102.00 $117.33 $107.00 $116.83 $120.15 $138.17 $162.00 $162.00 69 $96.14 $108.64 $106.12 $112.03 $106.08 $122.00 $107.00 $116.83 $125.37 $144.17 $162.00 $162.00 70 $99.19 $112.07 $109.21 $125.62 $110.25 $126.92 $110.53 $123.65 $130.21 $149.75 $205.25 $205.25 71 $102.50 $115.81 $112.29 $129.20 $114.75 $131.92 $114.02 $129.72 $134.90 $155.33 $205.25 $205.25 72 $105.82 $119.57 $115.29 $132.61 $119.25 $137.17 $117.44 $135.10 $139.58 $160.52 $205.25 $205.25 73 $109.41 $123.63 $118.62 $136.36 $123.92 $142.42 $120.77 $139.89 $144.26 $165.90 $205.25 $205.25 74 $113.00 $127.70 $121.78 $140.03 $128.00 $147.25 $124.01 $144.15 $148.94 $171.29 $205.25 $205.25 75 $116.89 $132.06 $124.87 $143.61 $132.00 $151.83 $128.46 $149.78 $153.78 $176.85 $264.00 $264.00 Company #7 AM Best Rating: A- S&P Rating: /A PLA F PREMIUM RATE COMPARISO CHART* Company #8 AM Best Rating: A S&P Rating: A- Company #9 AM Best Rating: A+ S&P Rating: A+ Company #10 AM Best Rating: A- S&P Rating: /A Company #11 AM Best Rating: A S&P Rating: AA- Company #12 AM Best Rating: /A S&P Rating: /A HH Discount Applied: 7% Effective Date: 7-1-15 HH Discount: 7% Effective Date: 3-1-16 HH Discount Applied: 12% Effective Date: 4-1-16 HH Discount: 7% Effective Date: 12-1-15 HH Discount: 5% Effective Date: 1-1-16 HH Discount: o Effective Date: 6-1-16 Age Female Male Female Male Female Male Female Male Female Male Female Male 65 $115.65 $125.53 $117.62 $135.28 $128.23 $144.88 $131.99 $151.79 $146.05 $146.05 $148.00 $148.00 66 $115.65 $125.53 $121.62 $139.86 $128.23 $144.88 $131.99 $151.79 $152.39 $152.39 $173.50 $173.50 67 $115.65 $125.53 $125.45 $144.19 $128.23 $144.88 $137.74 $158.40 $158.74 $158.74 $173.50 $173.50 68 $115.65 $125.53 $129.36 $148.77 $132.14 $149.32 $143.23 $164.72 $165.08 $165.08 $173.50 $173.50 69 $115.65 $125.53 $133.20 $153.19 $136.47 $154.20 $148.85 $171.18 $171.08 $171.08 $173.50 $173.50 70 $119.13 $132.34 $136.95 $157.52 $140.79 $159.08 $154.08 $177.19 $177.77 $177.77 $215.50 $215.50 71 $122.58 $138.37 $140.69 $161.85 $145.49 $164.39 $159.12 $182.99 $184.12 $184.12 $215.50 $215.50 72 $125.96 $143.71 $144.44 $166.10 $150.20 $169.73 $164.17 $188.79 $190.46 $190.46 $215.50 $215.50 73 $129.24 $148.47 $148.36 $170.60 $155.30 $175.50 $169.21 $194.59 $196.81 $196.81 $215.50 $215.50 74 $132.43 $152.66 $152.19 $175.01 $160.41 $181.25 $174.25 $200.39 $203.15 $203.15 $215.50 $215.50 75 $136.91 $158.34 $155.94 $179.34 $165.92 $187.48 $179.48 $206.40 $209.50 $209.50 $271.50 $271.50 *Disclaimer: The information contained herein is to be used for general information purposes only. Premium rates shown are provided as a public service and data was obtained from public sources. Final rates can only be confirmed by a licensed agent and approved by the appropriate insurance company. Monthly rates may reflect household and EFT discounts, if applicable. Insurance company names and logos are presented to represent a broad overview of some of the Medicare Supplement companies and are not an endorsement of any company. Market Data Source: 2015 AIC Medicare Supplement Experience Exhibits and data filed with the ational Association of Insurance Commissioners in annual financial statements. This does not guarantee or warrant the accuracy of the above premium rates. Carriers may have made rate or underwriting adjustments that have not yet been reflected in the database. ot connected with or endorsed by the United States government or the federal Medicare Program. OVER
ORTH CAROLIA SEIOR CITIZES ASSOCIATIO Do you know the difference between Original Medicare, a Medicare Advantage Plan and a Medicare Supplement Plan? What Is Original Medicare? For more than 50 years, Original Medicare has been a stable program for millions of Americans. Original Medicare is coverage managed by the federal government that helps with many of your healthcare services. If you haven t signed up for Original Medicare yet, do it OW. If you wait too long, Medicare could impose a penalty. Original Medicare covers many medical expenses, but it won t cover everything. Consequently, Medicare Supplement insurance plans have played a significant role alongside Original Medicare. Medicare Supplement Plans pay for all Medicare-eligible expenses not covered by Original Medicare. That s why many Medicare beneficiaries purchase a Medicare Supplement to pay for the eligible medical expenses not covered by Original Medicare. What Is a Medicare Supplement Plan? A Medicare Supplement Plan works hand-in-hand with Original Medicare to cover the Medicare-eligible charges not covered by Medicare. They are simple to understand, affordable, offer nationwide coverage and allow policyholders to keep their healthcare providers. In most cases, you can go to any doctor, specialist or hospital that s enrolled in Medicare in the USA. There are no doctor networks to worry about, no prior approvals required, and no doctor referrals needed to see a specialist. Plan F and Plan G are the two most popular Medicare Supplement Plans. Insurance companies are required by law to offer the exact same coverage for Medicare Supplement Plan F and Plan G. MG412016 What Is a Medicare Advantage Plan? A Medicare Advantage Plan is COMPLETEL different from Original Medicare. If you enroll in a Medicare Advantage Plan, you WILL OT be enrolled in Original Medicare. Medicare Advantage Plans are OT managed by the federal government. They are a type of Medicare health plan managed by private insurance companies that contract with Medicare to provide you with Part A and Part B benefits. Medicare Advantage Plans include health maintenance organizations, preferred provider organizations and private fee-for-services plans. Medicare Advantage Plans can charge different out-of-pocket costs and have different If you enroll in a Medicare Advantage Plan, you will OT be enrolled in Original Medicare and will not be able to use your Medicare card. rules for providing services. ou may need a referral to see a specialist, or be referred to a doctor or hospital only in their network. These rules can change each year. Things to know About Medicare Advantage Plans If you enroll in a Medicare Advantage Plan, you will OT be enrolled in Original Medicare and you must use providers who accept the carrier s Medicare Advantage Plan. If you go to a doctor, hospital or specialist that doesn t belong to the Medicare Advantage Plan s network, your services may not be covered or your costs may be higher. There are numerous doctors and hospitals that will OT accept Medicare Advantage Plans. Doctors and hospitals can join or leave a plan s network anytime during the year. ou will not be able to use your red, white and blue Medicare card when you go to the doctor, specialist or hospital. OVER Medicare Helpline 1-800-290-7535 www.medicaresupplementsforless.com
ORTH CAROLIA SEIOR CITIZES ASSOCIATIO The orth Carolina Department of Insurance, SHIIP Division EXPLAIS MEDICARE ADVATAGE PLAS The SHIIP Division of the Department of Insurance has received an increased number of calls from seniors across the state who have enrolled in a Medicare Advantage plan without fully understanding the impact of their decision. These plans are available in all 100 counties in the state; however, Medicare Advantage plans are not the best fit for some beneficiaries because not every plan is accepted everywhere, though that is how they are often presented by agents. Medicare Advantage plans are federally approved plans offered to seniors and other Medicare beneficiaries by private companies. Often they offer additional coverage options that are not typically included in Original Medicare (i.e. vision, hearing, prescription drug coverage). These plans offer healthcare coverage and allow seniors to seek care from any Medicare-approved doctor and/or hospital that is willing to give them care, and that accepts the terms of the plan. While they are a good choice for some Medicare beneficiaries, they may not be the right choice for you. It is important that you call all of your health care providers (doctors, hospitals, therapists, etc.) to see if they accept the Medicare Advantage plan you are thinking about joining. To enroll in a Medicare Advantage plan you must live in the county where it is offered, and while Medicare plans do allow you to receive services outside your service area, these services may come at a higher cost to you. Medicare Advantage plans can charge a monthly premium amount above the Medicare Part B premium, and they can charge deductible and coinsurance amounts that differ from those under the Original Medicare plan. These amounts are paid out of your pocket. SHIIP has received numerous complaints from seniors saying they were misled about joining a Medicare Advantage plan. If you find that you have mistakenly enrolled in a Medicare Advantage plan, you may be able to disenroll from the plan. However, there may be limitations on when you can disenroll. ou can contact SHIIP directly to help you navigate the disenrollment process, write the company and request to be disenrolled, or call the Centers for Medicare and Medicaid Service at 1-800-633-4227 and disenroll by phone. Regardless of which option you choose, keep a record of the case number, when you called or wrote, whom you spoke to, and what you found out. If you decide to join a Medicare Advantage plan instead of Original Medicare, you will continue to pay the Medicare Part B premium. It is important to realize that once you have enrolled in a Medicare Advantage option, the coverage of services provided under Medicare Parts A and B are filed through the selected Medicare Advantage plan instead of Original Medicare. This means you no longer are under the Original Medicare plan and that you must follow the rules of the Medicare Advantage plan you have joined. MG412016 IMPORTAT HOW TO PROTECT OURSELF Insurance agents cannot come to your home without permission. If they call you to schedule an appointment, make sure you get the agent s name, the company name and a phone number. Call back to verify the person is who he says he is. If you have any doubts, the Seniors Health Insurance Information Program can tell you if that person is a licensed agent. Do not be pressured into making quick decisions. SHIIP counselors are trained to help with health insurance questions. They can be reached at:1-800-443-9354. OVER Medicare Helpline 1-800-290-7535 www.medicaresupplementsforless.com
COFUSED and OVERWHELMED By the Medicare Maze? OU ARE OT ALOE. Many seniors in orth Carolina receive a lot of information about Medicare, Medicare Advantage Plans and Medicare Supplement Plans. Understanding the differences between these plans is the first step in getting the lowest premium and the coverage that is right for you. Covering the gaps left by Medicare. Plan F and Plan G are the most popular Medicare Supplement Plans. By federal law, Plan G offers identical benefits to Plan F, with the exception of the $166 Medicare Part B calendar-year deductible. That is the OL difference. Most experts agree Plan G is a better value than Plan F. Don t be fooled. If you enroll in a Medicare Advantage Plan, you will OT be enrolled in Original Medicare and you will OT be able to use your red, white and blue Medicare card when you go to the hospital, doctor or specialist. This means you no longer are under the Original Medicare plan and that you must follow the rules of the Medicare Advantage Plan you have joined. The freedom you want. With Original Medicare and Plan F or Plan G, you have: The right to choose any hospital, doctor or specialist that accepts Medicare patients o networks to worry about o doctor referral needed to see a specialist o prior approval required ORTH CAROLIA SEIOR CITIZES ASSOCIATIO Medicare Supplement Helpline: 1.800.290.7535 www.turning65c.com The savings you need. With Original Medicare and Plan F or Plan G, 100% of all Medicare-eligible charges are covered. ou pay $0 for Medicare Part A deductible and copayments ou pay $0 when you go to a primary care physician or to a specialist ou pay $0 for all Medicare-eligible hospital inpatient and outpatient services ou pay $0 for preventive care services ou pay $0 when you go to an approved skilled nursing facility ou pay $0 for any Medicare-eligible excess charges ou pay $0 for any additional Medicare-eligible medical services COMPARE RATES PLA G Rates* Better Value Company #1 AM Best: A+ Age Female Male 65 $90.34 $102.07 66 $90.34 $102.07 67 $90.34 $102.07 68 $93.10 $105.20 69 $96.14 $108.64 70 $99.19 $112.07 71 $102.50 $115.81 72 $105.82 $119.57 73 $109.41 $123.63 74 $113.00 $127.70 75 $116.89 $132.06 PLA F Rates* Company #2 AM Best: A+ Age Female Male 65 $115.65 $125.53 66 $115.65 $125.53 67 $115.65 $125.53 68 $115.65 $125.53 69 $115.65 $125.53 70 $119.13 $132.34 71 $122.58 $138.37 72 $125.96 $143.71 73 $129.24 $148.74 74 $132.43 $152.66 75 $136.91 $158.34 *A+ A.M. Best Rated CSG Actuarial; HHD Rates Included
Are ou PAIG Too Much For our Medicare Supplement Policy? Get the Identical Coverage For LESS Many seniors in orth Carolina receive a lot of information about Original Medicare, Medicare Advantage Plans and Medicare Supplement Plans. Understanding the difference between these plans is the first step in getting the coverage and cost that is right for you. Don t be fooled by a Medicare Advantage Plan. A Medicare Advantage Plan is completely different from Original Medicare. If you join a Medicare Advantage Plan instead of Original Medicare, you will OT be enrolled in Original Medicare and will not be able to use your red, white and blue Medicare card. It is important to realize that once you have enrolled in a Medicare Advantage Plan, the coverage of service provided under Original Medicare Parts A and B are filed through the selected Medicare Advantage Plan s insurance company instead of Original Medicare and you MUST follow all the rules of the Medicare Advantage Plan you have joined. Original Medicare offers you the freedom you want. Original Medicare is managed by the federal government and helps with many of your healthcare services. Original Medicare is the federal program you paid into during your working career. With Original Medicare, you have: The right to choose any hospital, doctor or specialist that accepts Medicare patients o networks to worry about o doctor referral needed to see a specialist o prior approval required A Medicare Supplement Plan covers the gaps left by Original Medicare. Plan F and Plan G are the most popular Medicare Supplement Plans. By federal law, Plan G offers identical benefits to Plan F, with the exception of the $166 Medicare Part B calendar-year deductible. That is the OL difference. Many Medicare experts agree that Plan G is a better value than Plan F. If you currently have a Medicare Supplement policy, you can switch your plan at any time during the year. Compare rates. Why pay more when you can get the identical coverage for less? A Medicare Supplement Plan provides the savings and protection you need. With Medicare Supplement Plan F or Plan G, 100% of all Medicare-eligible charges are covered when you go the hospital, doctor, specialist or skilled nursing facility. ou pay $0 for Medicare Part A deductible and copayments ou pay $0 when you go to a primary care physician or to a specialist ou pay $0 for all Medicare-eligible hospital inpatient and outpatient services ou pay $0 for preventive care services ou pay $0 when you go to a skilled nursing facility ou pay $0 for any Medicare-eligible excess charges ou pay $0 for any additional Medicare-eligible medical services ORTH CAROLIA SEIOR CITIZES ASSOCIATIO Call the Medicare Supplement Helpline at 1.800.290.7535, or visit www.turning65c.com for more information. COMPARE RATES PLA G Rates* Better Value Company #1 AM Best: A+ Age Female Male 65 $90.34 $102.07 66 $90.34 $102.07 67 $90.34 $102.07 68 $93.10 $105.20 69 $96.14 $108.64 70 $99.19 $112.07 71 $102.50 $115.81 72 $105.82 $119.57 73 $109.41 $123.63 74 $113.00 $127.70 75 $116.89 $132.06 PLA F Rates* Company #2 AM Best: A+ Age Female Male 65 $115.65 $125.53 66 $115.65 $125.53 67 $115.65 $125.53 68 $115.65 $125.53 69 $115.65 $125.53 70 $119.13 $132.34 71 $122.58 $138.37 72 $125.96 $143.71 73 $129.24 $148.74 74 $132.43 $152.66 75 $136.91 $158.34 *A+ A.M. Best Rated CSG Actuarial; HHD Rates Included
ORTH CAROLIA SEIOR CITIZES ASSOCIATIO 2016 Medicare Part D Prescription Drug Plan Finder Tool The orth Carolina Senior Citizens Association will help you find the lowest cost Medicare Prescription Drug Plan that will meet your needs. The following questionnaire will provide the CSCA staff with the necessary information to prepare a report for your consideration. IMPORTAT Complete this form along with your Official Medicare Supplement Application and return in the enclosed postage-paid envelope to: CSCA, PO Box 34, Fayetteville, C 28302 A. Please provide us with your contact information: ame: Date of Birth: Address: City: State: Zip: County: Home Phone: ( ) Cell Phone: ( ) Email: B. Do you currently have insurance coverage for prescriptions? es o If the answer is yes, please check the type of coverage below. Federal Employee Health Benefit Plan C State Employee Health Plan TriCare Coverage VA Coverage Other C. Please provide us with your Medicare card information: 1) ame of Beneficiary on card 2) What is OUR Medicare claim number? 3) What is OUR effective date for Medicare Part A? 4) What is OUR effective date for Medicare Part B? MG412016 OVER Prescription Drug Helpline: 1-800-323-6525 ext. 23
ORTH CAROLIA SEIOR CITIZES ASSOCIATIO Medicare Part D Prescription Drug Plan Finder Tool ame of Drug Strength Daily Dosage Example: Lipitor Example: 10 mg. Example: Twice Daily I prefer to have my prescriptions filled at the following pharmacies: First Choice Pharmacy ame: Address: City: State: Zip: Second Choice Pharmacy ame: Address: City: State: Zip: Do you prefer a mail order pharmacy? es o For Office Use OL Drug List ID #: Password: MG412016 OVER Prescription Drug Helpline: 1-800-323-6525 ext. 23
ORTH CAROLIA SEIOR CITIZES ASSOCIATIO Medicare Supplement Pre-Application Form Medicare Supplements for Less Send o Money Save $600, $800, $1,000, or More Compare Rates and Save A. PLA IFORMATIO Applicant A Plan (select one): Tobacco User: Plan A Plan F Plan G es o FREE Quote or Apply Online www.turning65c.com Or Call: 1-800-290-7535 Applicant B Enter Zip Code GET QUOTE OR APPL Plan (select one): Tobacco User: Plan A Plan F Plan G es o Company (select one): AARP Aetna BCBS Cigna Mutual of Omaha Other Company (select one): AARP Aetna BCBS Cigna Mutual of Omaha Other Requested Effective Date: B. APPLICAT IFORMATIO Applicant A ame (First/Middle Initial/Last): Residence Address: City: // Requested Effective Date: Applicant B ame (First/Middle Initial/Last): Residence Address: City: // State: ZIP: State: ZIP: Mailing Address (if different from residence address): City: Mailing Address (if different from residence address): City: State: ZIP: State: ZIP: Home Phone: Email Address: (area code) Home Phone: Email Address: (area code) Current Age: Current Age: Date of Birth: (month) / / (day) (year) Date of Birth: (month) / / (day) (year) Male Female Male Female Social Security # Social Security # Height: Weight: Ft. In. Lbs. Height: Weight: Ft. In. Lbs. Over 1
B. APPLICAT IFORMATIO (continued) Applicant A Does Applicant A currently have a Medicare Supplement Policy? es o If es, ame of Insurance Company: Does Applicant A currently have coverage under a group, individual, union, or COBRA policy? es o If es, ame of Insurance Company: Applicant B Does Applicant B currently have a Medicare Supplement Policy? es o If es, ame of Insurance Company: Does Applicant B currently have coverage under a group, individual, union, or COBRA policy? es o If es, ame of Insurance Company: Type of Policy: Group Individual Union COBRA Are you applying during your Open Enrollment? es o ot Sure Are you applying during your Guaranteed Issue Period? es o ot Sure Type of Policy: Group Individual Union COBRA Are you applying during your Open Enrollment? es o ot Sure Are you applying during your Guaranteed Issue Period? es o ot Sure C. MEDICARE IFORMATIO Please reference your red, white and blue Medicare card to complete this section. If you have not yet received your Medicare card, indicate the date of your eligibility to enroll in Medicare Part A and Part B. Applicant A Medicare Claim umber: Medicare Part A Effective Date: If you are not covered under Medicare Part A, what is your If you are not covered under Medicare Part A, what is your eligibility date?: / / eligibility date?: / / Medicare Part B Effective Date: Applicant B Medicare Claim umber: / / Medicare Part A Effective Date: / / / / Medicare Part B Effective Date: / / If you are not covered under Medicare Part B, indicate the If you are not covered under Medicare Part B, indicate the date you plan to enroll: / / date you plan to enroll: / / D. HOUSEHOLD PREMIUM DISCOUT IFORMATIO ou may be eligible for a policy with a lower premium rate based on your answers to the questions in this section. 1. Do you currently have a household resident: (a) with whom you have continuously resided for the last 12 months and who is age 60 or older; OR (b) with whom you reside and to whom you are either married or in a civil union partnership? Applicant A Applicant B 2. If you answered ES to question #1 above, please fill out the following information about the household resident, unless both applicants are applying for coverage on this pre-application enrollment form. ame (First/Middle/Last): Date of Birth: Street Address: City: State: ZIP: 2
Please note: If applicant is 64 ½ years to 65 ½ years of age, applicant IS OT required to answer the following health questions or provide medication information. If applicant is 65 ½ years of age or older, applicant IS REQUIRED to answer the health information questions and medication information in Section E and F. E. HEALTH IFORMATIO If you answer ES to any of the following questions 10-19, you may OT be eligible for coverage. Call 1-800-290-7535 to verify eligibility for coverage. To the Best of our Knowledge and Belief: 10. Are you currently confined to a wheelchair or any motorized mobility device?... 11. Are you currently hospitalized, confined to a bed, in a nursing home or assisted living facility?... 12. Are you currently receiving any occupational, speech or physical therapy?... 13. Have you been advised by a medical professional to have treatment, further diagnostic evaluation, diagnostic testing, follow-up visits or any surgery that has OT been performed?... 14. At any time have you been medically diagnosed with, treated for or had surgery for any of the following: A. Chronic kidney disease, kidney failure or kidney disease requiring dialysis?... B. Emphysema, chronic obstructive pulmonary disease (COPD), any other chronic pulmonary disorder or any cardio-pulmonary disorder requiring oxygen?... C. Alzheimer s disease, dementia or any other cognitive disorder?... D. Parkinson s disease, multiple sclerosis or amyotrophic lateral sclerosis (Lou Gehrig s disease)? E. Systemic lupus, scleroderma or myasthenia gravis?... F. Acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC)?... G. An organ transplant or been advised to have an organ transplant (excluding cornea transplants)?... H. Chronic hepatitis or cirrhosis?... I. Osteoporosis with fractures?... 15. Do you have diabetes? If you do OT have diabetes, please answer o and go to question 16. If you have diabetes, please circle any of the following conditions that apply: retinopathy, neuropathy, peripheral artery disease, peripheral venous thrombotic disease, any heart disorder (including hypertension/high blood pressure), stroke (TIA) or kidney disease... 16. Do you have an implanted cardiac defibrillator?... 17. Within the past two years, have you been treated for, or been advised by a physician to have treatment for: A. Coronary artery disease, angina, heart attack, cardiac angioplasty, bypass surgery or stent placement?... B. Cardiomyopathy, congestive heart failure, aortic or cardiac aneurysm, peripheral artery disease, peripheral venous thrombotic disease, vascular angioplasty, endarterectomy, carotid artery disease, any heart or heart valve disorder, atrial fibrillation, other heart rhythm disorder or implantation of a pacemaker?... C. Alcoholism or drug abuse?... D. Any mental or nervous disorder requiring treatment (including hospital confinement) by a psychiatrist, psychologist, counselor or therapist?... E. Internal cancer, lymphoma or melanoma?... F. A stroke or transient ischemic attack (TIA)?... G. Degenerative bone disease, spinal stenosis, rheumatoid arthritis, psoriatic arthritis, arthritis that restricts mobility or have you been advised to have a joint replacement?... 18. Have you been advised by a medical professional that surgery may be required within the next 12 months for cataracts?... 19. Have you been confined to a hospital three or more times in the past two years for the same or similar medical condition?... 20. Have you taken any over-the-counter OR prescription drugs in the past 24 months?... 21. Have you used tobacco in any form in the past 12 months?... Applicant A Applicant B Over 3
Please note: If applicant is 64 ½ years to 65 ½ years of age, applicant IS OT required to answer the following health questions or provide medication information. If applicant is 65 ½ years of age or older, applicant IS REQUIRED to answer the health information questions and medication information in Section E and F. F. MEDICATIO IFORMATIO Please list all over-the-counter or prescription medications you have taken in the past 24 months in the table below. Applicant A Medication ame (copy from pharmacy label) Dosage Frequency Have you taken this medication for more than 2 years? Prescribed by primary physician? Diagnosis/Condition Applicant B Medication ame (copy from pharmacy label) Dosage Frequency Have you taken this medication for more than 2 years? Prescribed by primary physician? Diagnosis/Condition PreApp112015 4
G. OPE EROLLMET AD GUARATEED ISSUE WORKSHEET If any of the following situations apply, applicant is in an open enrollment or guaranteed issue period: ELIGIBILIT FOR OPE EROLLMET Applicant is: at least 64 ½ years of age (in most states) and within six months before or after his/her effective date for Medicare Part B, or covered under Medicare Part B prior to age 65 (eligible for a six-month open enrollment period upon reaching age 65) ote: Coverage cannot be effective until your Medicare coverage is effective. ELIGIBILIT FOR GUARATEED ISSUE Evidence of eligibility is required for the following situations. Applicant: is in the original Medicare plan, has an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays, and that coverage is ending is in the original Medicare plan, has a Medicare Select policy, and moves out of the Select plan s service area loses coverage due to their Medicare supplement insurance company s insolvency or at no fault of the applicant the leaves his/her Medicare supplement plan because the company has not followed rules, or has misled the applicant Applicant has the right to buy Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant s state by any insurance company. Applicant was enrolled in a Medicare Advantage (MA) plan, and: the plan is leaving the Medicare program or stops service in the applicant s area, or the applicant moves out of the plan s service area (applicant must switch back to original Medicare) the applicant leaves the plan because the company has not followed rules, or has misled the applicant Applicant has the right to buy Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant s state by any insurance company. the applicant decided to switch to original Medicare within the first year of joining an MA plan when first eligible for Medicare Part A at age 65 Applicant has the right to buy any Medicare supplement plan that is sold in the applicant s state by any insurance company. the applicant, after dropping his/her Medicare supplement policy to join an MA plan for the first time, has been on the MA plan less than one year and wants to switch back Applicant has the right to obtain his/her Medicare supplement policy back if that carrier still sells it or, if not available, to buy any Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant s state by any insurance company. Acceptable Evidence of Eligibility: a. Copy of the applicant s MA plan termination notice b. Copy of the letter the applicant sent to his/her MA plan requesting disenrollment c. Signed statement that the applicant has requested to be disenrolled from his/her MA plan d. Certification of group coverage e. Copy of the termination letter from employer or group carrier f. Image of insurance ID card (OL allowed if your MA plan is being terminated) PreApp112015 5
H. HEIGHT AD WEIGHT CHART Height and Weight Chart Eligibility Eligibility Find your height in the left-hand column and look across the row to find your weight. If your weight is in the Decline column, we re Find your height in the left-hand column and look across the row to find your weight. If your weight is in the Decline column, sorry, you re we re not sorry, eligible you re for coverage not eligible at this for time. coverage at this time. Rate Adjustment The column column heading heading above above your your weight weight will will indicate indicate your your appropriate appropriate rate rate adjustment, adjustment, if any if (risk any class). (risk class). PreApp112015 Decline Class I (10%) Standard Class I (10%) Class II (20%) Decline Height Weight Weight Weight Weight Weight Weight 4' 2'' < 54 54 60 61 110 111 128 129 145 146 + 4' 3'' < 56 56 62 63 114 115 133 134 151 152 + 4' 4'' < 58 58 65 66 119 120 138 139 157 158 + 4' 5'' < 60 60 67 68 123 124 143 144 163 164 + 4' 6'' < 63 63 70 71 128 129 149 150 170 171 + 4' 7'' < 65 65 73 74 133 134 154 155 176 177 + 4' 8'' < 67 67 75 76 138 139 160 161 182 183 + 4' 9'' < 70 70 78 79 143 144 166 167 189 190 + 4' 10'' < 72 72 81 82 148 149 172 173 196 197 + 4' 11'' < 75 75 84 85 153 154 178 179 202 203 + 5' 0'' < 77 77 87 88 158 159 184 185 209 210 + 5' 1'' < 80 80 89 90 164 165 190 191 216 217 + 5' 2'' < 83 83 92 93 169 170 196 197 224 225 + 5' 3'' < 85 85 95 96 175 176 203 204 231 232 + 5' 4'' < 88 88 99 100 180 181 209 210 238 239 + 5' 5'' < 91 91 102 103 186 187 216 217 246 247 + 5' 6'' < 93 93 105 106 192 193 223 224 254 255 + 5' 7'' < 96 96 108 109 197 198 229 230 261 262 + 5' 8'' < 99 99 111 112 203 204 236 237 269 270 + 5' 9'' < 102 102 115 116 209 210 243 244 277 278 + 5' 10'' < 105 105 118 119 216 217 250 251 285 286 + 5' 11'' < 108 108 121 122 222 223 258 259 293 294 + 6' 0'' < 111 111 125 126 228 229 265 266 302 303 + 6' 1'' < 114 114 128 129 234 235 272 273 310 311 + 6' 2'' < 117 117 132 133 241 242 280 281 319 320 + 6' 3'' < 121 121 136 137 248 249 288 289 328 329 + 6' 4'' < 124 124 139 140 254 255 295 296 336 337 + 6' 5'' < 127 127 143 144 261 262 303 304 345 346 + 6' 6'' < 130 130 147 148 268 269 311 312 354 355 + 6' 7'' < 134 134 150 151 275 276 319 320 363 364 + 6' 8'' < 137 137 154 155 282 283 327 328 373 374 + 6' 9'' < 140 140 158 159 289 290 335 336 382 383 + 6' 10'' < 144 144 162 163 296 297 344 345 392 393 + 6' 11'' < 147 147 166 167 303 304 352 353 401 402 + 7' 0'' < 151 151 170 171 311 312 361 362 411 412 + 7' 1'' < 155 155 174 175 318 319 369 370 421 422 + 7' 2'' < 158 158 178 179 326 327 378 379 431 432 + 7' 3'' < 162 162 183 184 333 334 387 388 441 442 + 7' 4'' < 166 166 187 188 341 342 396 397 451 452 + Medicare supplement insurance is underwritten by Mutual of Omaha Insurance Company Mutual of Omaha Plaza Omaha, ebraska 68175 6 M28785