Navigating the intricacies of healthcare in the golden years of life, especially for those residing in Maryland, entails understanding and efficiently managing Medicare supplements through forms like the MediGap-65 Application. This essential document, designated specifically for Maryland residents, serves as a bridge for those seeking to augment their Medicare coverage through CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc., depending on their geographical location within the state. The application process outlined within the form is meticulous, requiring applicants to provide comprehensive personal information, select from an array of plan options tailored to different needs and circumstances, and furnish details regarding their Medicare coverage. Importantly, the process underscores the significance of timing, both in terms of eligibility criteria centered around age and Medicare Part B enrollment windows, and in its stipulation for prospective applicants to meticulously chart their health history and current medication regimen. The form embodies a structured pathway to securing supplemental health coverage, making it imperative for applicants to engage with the process thoughtfully to ensure their health needs are met without undue financial burden.
| Question | Answer |
|---|---|
| Form Name | Medigap 65 Application Form |
| Form Length | 13 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min 15 sec |
| Other names | myaccount, how to maryland medigap 65, MediGap-65, maryland 65 application |
Maryland Residents
For assistance completing this application,
CALL
CareFirst of Maryland, Inc. 10455 Mill Run Circle, Owings Mills, MD 21117 Group Hospitalization and Medical Services, Inc.
840 First Street, NE, Washington, DC 20065
inStructionS
1.Please fill out all applicable spaces on this application. Print or type all information.
2.Sign this application on page 13 and return it in the
CareFirst BlueCross BlueShield Mailroom Administrator
P.O. Box 14651 Lexington, KY 40512
3.Send no money with this application. You will be notified by mail of the amount due if this application is accepted.
Give careful attention to all questions in this application. Accurate, complete information is necessary before your application can be processed. If incomplete, the application will be returned and delay your coverage.
pleASe reAd And check the ApplicAble box
If you live in Baltimore City or any other county in the State of Maryland, besides Prince George’s or Montgomery County, please check the CareFirst of Maryland, Inc.
box above. If you live in Prince George’s or Montgomery county, please check the Group Hospitalization and Medical Services, Inc. box above. Please check only one box.
Last Name |
First Name |
Middle Initial |
Residence Address (Number and Street)
City |
State |
Zip Code |
|
|
|
|
|
|
|
|
|
Note: Please consider retaining your existing plan coverage until it is determined that you have passed Medical Underwriting.
Section 1. ApplicAnt informAtion ▼ |
|
|
|
|
|
|
|
|||
1A. PERSONAL INFORMATION |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
||
Social Security (or Railroad Retirement) Number: |
|
Date of Birth: ________ / ________ / _______ |
||||||||
________ — ________ — ____________ |
|
|
||||||||
|
|
|
|
Month |
Day |
Year |
||||
|
|
|
|
|
|
|
|
|
||
Billing Address (if different from Resident Address): |
|
|
|
|
|
|
|
|||
Number and Street: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
City: |
|
|
|
|
|
State: |
Zip Code |
|||
|
|
|
|
|
|
|
|
|
|
|
Sex: |
|
|
|
|
|
|
Height: |
|
Weight: |
|
Male |
Female |
Home Phone ( |
|
) |
|
|
___ ft. ___ in. |
________ lbs. |
||
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
1B. PLAN OPTIONS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
Please check the |
|
|
|
|||||||
PLAN A* |
PLAN B |
PLAN F |
High Deductible PLAN F |
|
|
|
|
|||
PLAN G |
PLAN L |
PLAN M |
PLAN N |
|
|
|
|
|
|
|
*If you are under age 65 and have Medicare, you may apply for PLAN A only.
A private not
MDSUPPAPP (8/12) |
1 |
Section 1. ApplicAnt informAtion (continued) ▼
1C. EFFECTIVE DATE
Your coverage becomes effective on the first day of the month following receipt and approval of this application. You will receive a Policy confirming the following effective date.
Requested Effective Date of Coverage: ________ / ________ / _______
Month Day Year
Section 2. medicAre coverAGe informAtion ▼
Please provide the following Medicare Information as printed on your red, white and blue Medicare identification card. You must have both Medicare Part A (hospital) and Medicare Part B (medical/surgical) coverage or will obtain Medicare coverage before the effective date of this
Health Insurance Claim Number:
Medicare Hospital (PART A) Effective Date:
________ / ________ / _______
Month Day Year
Medicare Medical/Surgical (PART B) Effective Date:
________ / ________ / _______
Month Day Year
Section 3. eliGibilitY informAtion ▼
Please answer the following question regarding your eligibility:
3A. Did you turn age 65 in the last 6 months? |
Yes |
No |
|
|
|
3B. Are you age 65 or older and have you enrolled in Medicare Part B within the last |
|
|
6 months? |
Yes |
No |
|
|
|
3C. Are you under age 65, eligible for Medicare due to a disability, AND did you |
|
|
enroll in Medicare Part B within the last 6 months? OR, Are you under age 65, |
|
|
eligible for Medicare due to a disability, AND have you been terminated from |
|
|
the Maryland Health Insurance Plan as a result of enrollment in Medicare Part B |
|
|
within the last 6 months? |
Yes |
No |
|
|
|
3D. At the time of this application, are you within 6 months from the first day of the |
|
|
month in which you first enrolled or will enroll in Medicare Part B? |
Yes |
No |
NOTE:
•If you answered YES to 3A, 3B, 3C or 3D, your acceptance is guaranteed. If you are applying for plans A, B, F,
•If you answered NO to 3A, 3B, 3C AND 3D, continue to question 3E.
3E. Please answer questions |
|
|
1. Were you enrolled under an employer group health plan or union coverage |
|
|
that pays after Medicare pays (Medicare Supplemental Plan) and that plan is |
|
|
ending or will no longer provide you with supplemental health benefits, and |
|
|
the applicable coverage was terminated or ceased within the past 63 days? |
|
|
OR, Did you receive a notice of termination or cessation of all supplemental |
|
|
health benefits within the past 63 days (if you did not receive the notice, |
|
|
did the date you received notice that a claim has been denied because of a |
|
|
termination or cessation of all supplemental health benefits occur within the |
|
|
past 63 days)? |
Yes |
No |
MDSUPPAPP (8/12) |
2 |
Section 3. eliGibilitY informAtion (continued) ▼
WITHIN THE PAST 63 DAY PERIOD WERE YOU ENROLLED UNDER:
2. A Medicare Health Plan* such as a Medicare Advantage Plan or you are 65 years of age or older and enrolled with a Program of
a.The Plan was terminated, no longer provides or has discontinued the Plan in the service area where you live
b.You were not able to continue coverage with the Plan because you moved out of the plan’s service area or other change in circumstances specified by the Secretary of the Department of Health and Human Services. This does not include failure to pay premiums on a timely basis
c.You are leaving because you can show that the Plan substantially violated a material provision of the policy including not providing medically necessary care on a timely basis or in accordance with medical standards
d.You are leaving because you can show that the Plan or its agent misled you in marketing the policy
e.The certification of the organization was terminated
3.A Medicare Supplemental policy and your enrollment ended and at least one of the following was met:............................................................................................
a.Through no fault of your own or because your insurance company has gone bankrupt and you lost coverage, or is going bankrupt and you will be losing your coverage
b.You are leaving because you can show that the company substantially violated a material provision of the policy
c.You are leaving because you can show that the company or its agent misled you in marketing the policy
4. A Medicare Health Plan* such as a Medicare Advantage or PACE plan that you joined when you first enrolled under Medicare Part B at age 65 or older, and within 12 months of enrolling you decided to switch back to a Medicare Supplement policy. ..................................................................................................
5. A Medicare Supplemental plan that you dropped and subsequently enrolled for the first time with a Medicare Health Plan* such as Medicare Advantage or PACE plan; and you have been in the plan less than 12 months and want to return to a Medicare Supplemental plan...................................................................................
6. A Medicare Part D plan, and ALSO were enrolled under a Medicare Supplement plan that covers outpatient prescription drugs. When you enrolled in Medicare Part D, you terminated enrollment in the Medicare Supplement Plan that covered outpatient prescription drug coverage. ...................................................................
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
MDSUPPAPP (8/12) |
3 |
Section 3. eliGibilitY informAtion (continued) ▼
7. An employer group health plan or union coverage that provides health benefits and the plan terminated, and solely because of your Medicare eligibility, you are not eligible for the tax credit for health insurance costs (under 35 of the Internal Revenue Code) and enrollment in the Maryland Health Insurance Plan (under
Yes
No
*Medicare Health Plan includes a Medicare Advantage Plan; a Medicare Cost plan (under 1876 of the federal Social Security Act); a similar organization operating under demonstration project authority effective for periods before April 1, 1999); a Health Care Prepayment Plan (under an agreement under 1833 (a)(1)(A) of the federal Social Security Act), a Medicare Select policy, HCFA certified provider sponsored organization, or a Program of
NOTE:
•If you answered YES to questions 3A, 3B, 3C or 3D, your acceptance is guaranteed. Skip Section 4 and go directly to Section 5.
•If you answered YES to any question in Section 3E you will NOT have to meet the
Skip Section 4 and go directly to Section 5.
•
•If you answered NO to ALL questions in Section 3 (3A, 3B, 3C, 3D AND 3E) continue to Section 4.
MDSUPPAPP (8/12) |
4 |
Section 4. heAlth evAluAtion ▼
Please complete Section 4A. If you answer “Yes” to any of the questions in Section 4A, you are not required to complete Sections 4B - 4E.
Have you had a physical exam within the past 5 years?
Have you used tobacco products within the last 5 years?
Yes
Yes
No
No
4A. PLEASE ANSWER THE FOLLOWING HEALTH QUESTIONS TO HELP DETERMINE WHETHER OR NOT YOU ARE ELIGIBLE.
To the best of your knowledge and belief, in the last five years, have you consulted a physician, licensed medical provider, been diagnosed, treated, OR advised by a medical practitioner to have treatment for known symptoms or known indications of the following conditions:
NOTE: ALL QUESTIONS MUST BE CHECKED “YES” OR “NO” OR YOUR APPLICATION WILL BE RETURNED.
1. Cancer (except skin or thyroid).....................................................................................
2. Melanoma, Hodgkin’s Disease, Leukemia, or Multiple Myeloma .................................
3. Kidney Disease or Disorder: Including Kidney Failure, Kidney Dialysis ........................
4. Amyotrophic Lateral Sclerosis or Anterior Horn Disease..............................................
5. Alzheimer’s, Senile Dementia, or other organic brain disorders, including
alcoholic psychosis .......................................................................................................
6. An Organ Transplant (kidney, liver, heart, lung, or bone marrow), or are on a waiting
list for a transplant .......................................................................................................
7. Have you tested positive for exposure to the HIV infection or been diagnosed as
having Acquired Immune Deficiency Syndrome (AIDS) caused by the HIV infection,
or other sickness or condition derived from such infection?........................................
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
If you answered YES to any of the questions in Section 4A, you are NOT eligible for these plans at this time. If your health status changes in the future, allowing you to answer NO to all of the questions in this section, please submit an application at that time. For information regarding plans that may be available, contact your local state department on aging.
If you answered NO to ALL the questions in Section 4A, please continue to Section 4B.
4B. MEDiCATioNs
If you are presently using or have used medication or prescription drugs in the past 12 months (1 year), please provide details below. If more space is needed, attach a separate sheet of paper.
Illness or Condition: |
Medication: |
Dosage: |
How Often Taken: |
|
|
|
|
Date of Last Treatment: |
Attending Physician Name and Address: |
|
|
________ / ________ / _______ |
|
|
|
|
|
|
|
Illness or Condition: |
Medication: |
Dosage: |
How Often Taken: |
|
|
|
|
Date of Last Treatment: |
Attending Physician Name and Address: |
|
|
________ / ________ / _______ |
|
|
|
|
|
|
|
Illness or Condition: |
Medication: |
Dosage: |
How Often Taken: |
|
|
|
|
Date of Last Treatment: |
Attending Physician Name and Address: |
|
|
________ / ________ / _______ |
|
|
|
|
|
|
|
MDSUPPAPP (8/12) |
5 |