In the interest of full and fair disclosure, and to ensure the availability of necessary consumer information to potential subscribers or enrollees not possessing a special knowledge of Medicare, health care service plans, or Medicare supplement contracts, an issuer shall comply with the following provisions:
"(Statements)
(Questions)
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 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. PLEASE ANSWER ALL QUESTIONS.
[Please mark Yes or No below with an "X."]
To the best of your knowledge,
Yes____ No____
Yes____ No____
NOTE TO APPLICANT: If you have a share of cost under the Medi-Cal program, please answer NO to this question.
Yes____ No____
If yes,
Yes____ No____
Yes____ No____
START __/__/__ END __/__/__
Yes____ No____
Yes____ No____
Yes____ No____
Yes____ No____
Yes____ No____
Yes____ No____
Yes____ No____
________________________________________________
________________________________________________
________________________________________________
________________________________________________
START __/__/__ END __/__/__
(If you are still covered under the other policy, leave "END" blank)."
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT COVERAGE OR MEDICARE ADVANTAGE
(Company name and address)
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE
According to [your application] [information you have furnished], you intend to lapse or otherwise terminate an existing Medicare supplement policy or contract or Medicare Advantage plan and replace it with a contract to be issued by [Plan Name]. Your contract to be issued by [Plan Name] will provide 30 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. Terminate your present policy or contract only if, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision.
STATEMENT TO APPLICANT BY PLAN, SOLICITOR, SOLICITOR FIRM, OR OTHER REPRESENTATIVE:
__ Additional benefits.
__ No change in benefits, but lower premiums or charges.
__ Fewer benefits and lower premiums or charges.
__ Plan has outpatient prescription drug coverage and applicant is enrolled in Medicare Part D.
__ Disenrollment from a Medicare Advantage plan. Reasons for disenrollment:
__ Other. (please specify) ________.
(Signature of Solicitor, Solicitor Firm, or Other Representative) [Typed Name and Address of Plan, Solicitor, or Solicitor Firm] | |
(Applicant's Signature) | |
(Date) |
Ca. Health and Saf. Code § 1358.18