N.J. Admin. Code § 11:4-23.16
Current through Register Vol. 56, No. 24, December 18, 2024
Section 11:4-23.16 - Requirements for application forms and replacement coverage(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has a Medicare supplement or Medicare Advantage, Medicaid coverage or another health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other accident and sickness policies or certificates in force. A supplementary application or other form to be signed by the applicant and agent may be used. The application form or supplementary application form shall contain the questions and statements set forth below. 1. Statements shall be as follows: i. You do not need more than one Medicare supplement policy.ii. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.iii. You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.iv. If after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your 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 were 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.v. 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 health plan. If the Medicare supplement policy provided 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 be substantially equivalent to your coverage before the date of suspension.vi. Counseling services may be available in your State to provide advice concerning your purchase of Medicare supplement coverage 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).2. 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 insurance 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.3. Questions, which shall be numbered 1, 2, 3, 4 and 5, shall be as follows and shall be prefaced by the statement "To the best of your knowledge" and, unless noted differently, should be answered yes or no: Click here to view form.
(b) Agents shall list any other health policies which they have sold to the applicant that are currently in force, and any such policies sold to the applicant within the previous five years that are no longer in force, clearly indicating which policies are in force and which are not.(c) Upon determination that a sale will involve replacement of Medicare supplement coverage, a carrier or its agent shall furnish to the applicant, prior to the issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of such notice signed by the applicant and agent, except where coverage is sold without an agent, shall be provided to the applicant, and an additional signed copy shall be retained by the carrier. A direct response carrier shall deliver to the applicant at the time of the issuance of the policy (certificate) the notice regarding replacement of Medicare supplement coverage.(d) Carriers shall include a waiver of all preexisting condition exclusion clauses, waiting periods, elimination periods or probationary periods in a replacement policy for at least that same period of duration of the conditional clause(s) in the applicant's existing policy which has expired at the time of issuance of the replacement policy, to the extent of the benefits of the existing policy.(e) The notice required by (c) above shall be provided in substantially the form set forth in Exhibit E of the Appendix to Subchapters 16 and 23 of this chapter, incorporated herein by reference, in no less than 12 point type. Item (1) of the notice set forth in Exhibit E may be omitted or modified if preexisting conditions are covered under the new coverage. If the policy or certificate is guaranteed issue, item (3) of the notice of Exhibit E may be omitted.N.J. Admin. Code § 11:4-23.16
Amended by R.1991 d.345, effective 7/1/1991.
See: 23 N.J.R. 1264(a), 23 N.J.R. 2014(a).
Section 23.9 "Requirements for replacement" recodified and reworded- "Requirements for application forms and replacement coverage".
Added "or certificate", "or Medicare supplement", "or is intended to be additional to any such policies or certificates", "and agent, except where coverage is not sold through an agent,", "the questions shall be substantially as follows:" in (a). Added (a)1 through 4. Added (b), (d). Recodified existing (b) and (c) and (e) as (c), (e) and (f).
Deleted "or service corporation", "signed by the applicant", "certificate"; added "or certificate", "signed by the applicant and the agent, except where coverage is sold without an agent" in recodified (c).
Substantial revision of "Notice to applicant regarding Replacement of Accident and Sickness or Medicare Supplement Coverage" in recodified (e).
Deleted old (d).
Deleted "N.J.A.C. 11:4-23.9(c) and (d)"; added "(e)" and "or modified" in recodified (f).
Amended by R.1993 d.26, effective 1/4/1993.
See: 24 N.J.R. 12(a), 25 N.J.R. 141(a).
Rule on appropriateness of recommended purchase and excessive coverage recodified to 23.18; rule on requirements for application forms and replacement coverage recodified from 23.12; "Notice to Applicant ..." deleted, with reference to Appendix E added; duplication of coverage and value to applicant to be included in application form.
Amended by R.1996 d.295, effective 7/1/1996.
See: 28 N.J.R. 1647(a), 28 N.J.R. 3462(a).
Recodified from N.J.A.C. 11:4-23.15 by R.1999 d.38, effective 12/28/1998 (to expire February 26, 1999).
See: 31 N.J.R. 181(a).
Former N.J.A.C. 11:4-23.16, Filing requirements for advertising, recodified to N.J.A.C. 11:4-23.17.
Adopted concurrent proposal, R.1999 d.100, effective 2/26/1999.
See: 31 N.J.R. 181(a), 31 N.J.R. 876(a).
Amended by R.2005 d.291, effective 9/6/2005.
See: 37 N.J.R. 1428(a), 37 N.J.R. 3376(a). Rewrote (a).