Medigap 65 Application Form – Fill Out and Use This PDF

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 (9-Digit if known):
Sex:							Height:		Weight:
Male	Female	Home Phone (		)			___ ft. ___ in.		________ lbs.
1B. PLAN OPTIONS
Please check the MediGap-65 Plan for which you are applying (check only one plan):
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 for-profit health service plan incorporated under the laws of the state of Maryland. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®´ Registered trademark of CareFirst of Maryland, Inc. If you reside in either Prince George’s or Montgomery county, then a Group Hospitalization and Medical Services, Inc. policy will be issued. For Baltimore City and all other counties in the state of Maryland, a CareFirst of Maryland, Inc. policy will be issued.

MDSUPPAPP (8/12)

1

CUT9342-1S (9/12)

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 MediGap-65 Policy.

Health Insurance Claim Number:

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, High-Deductible F or N, answer 3E. If you are applying for Plans G, L, or M, skip 3E and Section 4, and go directly to Section 5.

•If you answered NO to 3A, 3B, 3C AND 3D, continue to question 3E.

3E. Please answer questions 1-7 in this section.
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

CUT9342-1S (9/12)

Section 3. eliGibilitY informAtion (continued) ▼

MDSUPPAPP (8/12)

3

CUT9342-1S (9/12)

Section 3. eliGibilitY informAtion (continued) ▼

*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 All-Inclusive Care for the Elderly (PACE).

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 pre-existing condition waiting period. You must submit evidence of the date of termination or disenrollment of the other plan OR evidence of enrollment in Medicare Part D along with this application.

Skip Section 4 and go directly to Section 5.

•Pre-existing condition waiting periods only apply to Plans A, B, F, High-Deductible F and N. Pre-existing condition waiting periods do not apply to Plans G, L, or M.

•If you answered NO to ALL questions in Section 3 (3A, 3B, 3C, 3D AND 3E) continue to Section 4.

MDSUPPAPP (8/12)

4

CUT9342-1S (9/12)

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.

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.

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

CUT9342-1S (9/12)

Section 4. heAlth evAluAtion (continued) ▼

4C. HEALTH QUESTIONNAIRE

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.

4D. ADDiTioNAL HEALTH QUEsTioNs

Please answer the following questions regarding your most recent medical history, to the best of your knowledge and belief.

NOTE: ALL QUESTIONS MUST BE CHECKED “YES” OR “NO” OR YOUR APPLICATION WILL BE RETURNED.

	1. Are you currently hospitalized, bedridden, confined to a nursing facility, require the	Yes	No
	use of a wheelchair, or received home health care in the last 90 days?
	2. Have you been advised by a medical practitioner that you will need to be
	hospitalized, bedridden, confined to a nursing facility, require the use of a	Yes	No
	wheelchair, or receive home health care within the next six months?
	3. Have you been advised by a medical practitioner to have surgery within the next	Yes	No
	six months?
	4. Have you had medical tests in the last year for which you have not yet	Yes	No
	received results?
	5. Have you ever been hospitalized or had a condition that required hospitalization that	Yes	No
	occurred during the past seven years immediately before the date of this application?
	Duration Dates: From: _______ / _______ / ______ To: _______ / _______ / ______
	Condition: ___________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ __

MDSUPPAPP (8/12)

6

CUT9342-1S (9/12)

Section 4. heAlth evAluAtion (continued) ▼

4E. EXPLANATioN oF DiAGNosis AND TREATMENTs

If you have checked “Yes” to any part of SECTION 4C or 4D, for each box checked, please provide complete information regarding diagnosis or condition, treatment (including all medications, hospitalizations, surgeries and diagnostic testing results) and dates. If more space is needed, attach a separate sheet of paper.

			Explain treatment (including all	Recovery
Question	Diagnosis or Condition	Duration	medications, hospitalizations, surgery
Number		Dates	and diagnostic test results and	(check
				one box)
			physician/hospital name)
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial
		From:		Full
		To:		Partial

Section 5. pASt And current coverAGe ▼

Please review the statements below, then answer all questions to the best of your knowledge.

•You do not need more than one Medicare supplement insurance policy.

•If you purchase this policy, 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.

•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 you 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.

MDSUPPAPP (8/12)

7

CUT9342-1S (9/12)

Section 5. pASt And current coverAGe (continued) ▼

•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 policy 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 your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as through the state Medicaid program, including benefits as a Qualified Medical Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

For your protection, you are required to answer all of the questions below (5A through 5M).

You are only required to answer questions 5N and 5O if you are applying for Plans A, B, F, High-Deductible F or N. Please Note: 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 enrollment form.

5A. Did you turn age 65 in the last 6 months?			Yes	No
5B. Did you enroll in Medicare Part B in the last 6 months?			Yes	No
5C. If Yes, what is the effective date? _______ / ________ / _______
5D. Are you covered for medical assistance through the State Medicaid program?
	(Medicaid is not the same as Federal Medicare. Medicaid is a program run by the
	state to assist with medical costs for lower or limited-income people.)		Yes	No
	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 NO, skip to question 5G.
	If YES, continue to 5E.
5E. Will Medicaid pay your premiums for this Medicare supplement policy?			Yes	No
5F.	Do you receive any benefits from Medicaid OTHER THAN payments toward your
	Medicare Part B premium?		Yes	No
5G. Have you had coverage from any Medicare plan other than original Medicare
	within the past 63 days (for example, a Medicare Advantage Plan, or a Medicare
	HMO or PPO)?		Yes	No
	If NO, skip to question 5K.
	If YES, fill in your start and end dates below. If you are still covered under this
	plan, leave “END” blank.
	START ________ / ________ / _______	END ________ / ________ / _______
5H. If you are still covered under the Medicare plan, do you intend to replace your
	current coverage with this new Medicare supplement policy?		Yes	No
5I.	Was this your first time in this type of Medicare plan?		Yes	No
5J.	Did you drop a Medicare supplement policy to enroll in the Medicare plan?		Yes	No

MDSUPPAPP (8/12)

8

CUT9342-1S (9/12)

Section 5. pASt And current coverAGe (continued) ▼

Please ONLY answer Questions 5N and 5o if you are applying for Plans A, B, F, High-Deductible F or N. If you are applying for Plans G, L or M, skip ahead to Section 6.

5N. At the time of this application, have you had continuous creditable coverage* of at
least 6 months, without a break in this coverage of more than 63 consecutive days?....	Yes	No
If NO, please continue to question 50.
If you answered YES and are applying for Plans A, B, F, High-Deductible F or N, you must
submit evidence of Creditable Coverage along with this application. However, you will NOT
have to meet the pre-existing condition waiting period. Please skip ahead to Section 6.
50. At the time of this application, have you had continuous creditable coverage* of less
than 6 months, without a break in this coverage of more than 63 consecutive days? ...	Yes	No
If you answered YES and applied for Plans A, B, F, High-Deductible F or N, you
MUsT submit evidence of Creditable Coverage along with this application and
the 90-day pre-existing condition waiting period will be reduced by the number
of days you had creditable coverage. However, there is one exception. If you
answered YES to any question in Section 3E, you will NOT have to meet the pre-
existing condition waiting period.

*Creditable coverage means coverage under any of the following plans: 1) a group health plan; 2) health insurance coverage;

3)Medicare Part A or Part B; 4) Medicaid 5) CHAMPUS; 6) a medical care program of the Indian Health Service or of a tribal organization; 7) a State health benefit risk pool; 8) the Federal Employees Health Benefit Plan; 9) a public health plan as defined in federal regulations; or 10) a health benefit plan defined under the Peace Corp Act.

Documents that may be used as evidence of “creditable coverage,” include:

• a certificate of “creditable coverage;”	• third-party statements verifying periods of coverage;
• paystubs showing a payroll deduction for health coverage;	• and any other relevant documents that evidence periods
• a health insurance identification card;	of health coverage.

MDSUPPAPP (8/12)

9

CUT9342-1S (9/12)

Section 6. premium pAYment ▼

CareFirst BlueCross BlueShield wants to help you save time! Our standard method of payment is automated payment via bank withdrawal.

Please check this box if you do not wish to set up an automated payment account and intend to pay by submitting paper checks or by credit card.

Otherwise, to take advantage of this time saving option, please fill out the information below. Choose either:

Checking Account

Savings Account

Bank Name:

Bank Routing Number:

Bank Account Number:

Name that appears on the Account:

Bank Routing	Bank Account	Check
Number	Number	Number

I hereby authorize CareFirst BlueCross BlueShield to charge my account for the payment of premiums due for an unpaid invoice. If any check draft is dishonored for any reason, or drawn after the depositor’s authorization has been withdrawn, CareFirst agrees that the financial institution will not be held liable. I understand that non-payment of premiums due to dishonored auto-draft payment attempts may result in termination of coverage. I also understand that if the Policyholder elects to pay premium through an electronic payment, CareFirst BlueCross BlueShield may not debit or charge the amount of the premium due prior to the premium due date, except as authorized by the Policyholder. My recurring payments will be processed on the 6th of each month (including holidays). Members registered for recurring payment will not receive a paper bill in the mail. However, you may view and print your invoice during the recurring payment period from the invoice history online at www.carefirst.com/myaccount.

Signature of Account Holder: X_______________________________________ Date:________ / ________ / _______

MDSUPPAPP (8/12)

10

CUT9342-1S (9/12)

Section 7. electronic communicAtion conSent ▼

CareFirst BlueCross BlueShield (CareFirst) wants to help you manage your health care information and protect the environment by offering you the option of electronic communication.

Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or text messaging by providing your email address and/or cell phone number and consent below.

Electronic notices regarding your CareFirst health care coverage include, but are not limited to:

nExplanation of Benefits alerts

nReminders

nNotice of HIPAA Privacy Practices

nCertification of Creditable Coverage

You may also receive information on programs related to your existing products and services along with new products and services that may be of interest to you.

Please Note: you may change your email and consent information anytime by logging into www.carefirst.com/ myaccount or by calling the customer service phone number on your ID card. You can also request a paper copy of electronic notices at any time by calling the customer service phone number on your ID card.

I understand that to access the information provided electronically through email, I must have the following:

nInternet access;

nAn email account that allows me to send and receive emails; and

nMicrosoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher), and Adobe Acrobat Reader 4 (or higher).

I understand that to receive notices through text messaging:

nA text messaging plan with my cell phone provider is required; and

nStandard text messaging rates will apply.

By checking below, I hereby agree to electronic delivery of notices, instead of paper delivery by:

Email only

Cell phone text messaging only Email and cell phone text messaging

CareFirst BlueCross BlueShield will not sell your email or phone number to any third party and we do not share it with third parties except for CareFirst business associates that perform functions on our behalf or to comply with the law.

MDSUPPAPP (8/12)

11

CUT9342-1S (9/12)

Section 8. conditionS of enrollment (pleASe reAd thiS Section cArefullY) ▼

IT IS UNDERSTOOD AND AGREED THAT:

A copy of this application is available to the Policyholder (or to a person authorized to act on his/her behalf), from CareFirst BlueCross BlueShield (CareFirst).

This information is subject to verification. To do so I authorize any physician, hospital, pharmacy, pharmacy benefit manager or pharmacy related service organizations or any other medical or medically- related person or company including MIB, Inc. to release my “Medical Information” to CareFirst’s business associates or representatives. I further authorize any business associate who receives “Medical Information” from any physician, hospital pharmacy, pharmacy benefit manager or pharmacy related service organizations or any other medical or medically-related person or company including MIB, Inc. to release my “Medical Information” to CareFirst. I understand that my Medical Information consists of any diagnoses, treatment, prescriptions from a pharmacy, or any other medically related information about me. I authorize CareFirst to use my Medical Information for underwriting and to determine my eligibility for insurance benefits. I authorize CareFirst to make a brief report of my protected health information to MIB.

This authorization shall include and apply to any and all protected health information related to treatments where I have requested a restriction to a health care provider to release information and/or for any health care item or service for which I have paid the health care provider in full. I understand this authorization will remain in effect for 30 months from the date signed.

I understand that I have the right to cancel this authorization at any time, in writing, except to the extent that CareFirst has already taken action in reliance on this authorization. I also understand that CareFirst’s Notice of Privacy Practices includes information pertaining to authorizations and to requirements of revocation. A copy of the Notice may be obtained by contacting the CareFirst’s Privacy Office. CareFirst will not use or disclose the Medical Information for any purposes other than those listed above except as may be required by law. CareFirst is required to tell you by law that information disclosed pursuant to this authorization may be subject to re-disclosure and that under some limited circumstances will no longer be protected by federal privacy regulations.

If CareFirst determines that additional information is needed, I will receive an authorization to release that information. Failure to execute an authorization may result in the denial of my application for coverage. Additionally I understand that failure to complete any section of this application, including signing below, may delay the processing of my application.

To the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded. They are representations that are made to induce the issuance of, and form part of the consideration for a CareFirst policy. I understand that a medically underwritten policy is only issued under the conditions that the health of the applicant named on the application remains as stated above. Applicants who are permitted to skip Section 4 of this application are not issued a medically underwritten policy. I also understand that failure to enter accurate, complete and updated medical information may result in the denial of all benefits or cancellation of my policy. (This statement does not apply to applicants who are permitted to skip Section 4 of this application and are issued a policy under the Guaranteed Issue provisions.) CareFirst may rescind or void my coverage only if (1) I have performed an act, practice, or omission that constitutes fraud; or (2) I have made an intentional misrepresentation of material

fact. CareFirst will provide 30-days advance written notice of any rescission of coverage and refund any premiums to the Policyholder. The Member is responsible for repayment of any claim payment made by CareFirst on the Member’s behalf.

I will update CareFirst if there have been any changes in health concerning the applicant listed in this application that occur prior to acceptance of this application by CareFirst. (This statement does not apply to applicants who are permitted to skip Section 4 of this application and are issued a policy under the Guaranteed Issue provisions.)

If you have any questions concerning the benefits and services that are provided by or excluded under this Policy, please contact a membership services representative before signing this application.

An applicant whose application is denied by CareFirst due to medical underwriting may not submit a new application for enrollment within ninety (90) days of the denial.

MDSUPPAPP (8/12)

12

CUT9342-1S (9/12)

Section 8. conditionS of enrollment (continued) ▼

WARNING: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

Information regarding your insurability will be treated as confidential. CareFirst or its reinsurers may, however, make a brief report thereon to the MIB, Inc., a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such

a company, MIB, upon request, will supply such company with the information about you in its file. Regarding MIB: Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901. If you question the accuracy of the information in the MIB file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. CareFirst or its reinsurers may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.

X___________________________________________________________________ Date ________ / ________ / _______

Applicant’s Signature (PLEASE DO NOT PRINT)

FOR OFFICE USE ONLY:

Re-sign and re-date below only if box is checked.

Signature of Applicant: X_____________________________________________ Date ________ / ________ / _______

FoR BRoKER UsE oNLY:	Name:	SSN/Tax ID #:	CareFirst-Assigned ID#:
Contracted Broker:
Sub-Agent/Sub-Agency:
Writing Agent:

MDSUPPAPP (8/12)

13

CUT9342-1S (9/12)