OAR 836-052-0165
Requirements for Application Forms, Replacement Coverage


(1)

Application forms shall include the statements and questions set forth in this section designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, 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 health insurance policy or certificate currently in force. A supplementary application or other form to be signed by the applicant and agent containing such statements and questions may be used. The statements and questions are as follows:

(a)

Statements:

(A)

You do not need more than one Medicare supplement policy.

(B)

If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

(C)

You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.

(D)

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 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.

(E)

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 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.

(F)

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 a qualified Medicare beneficiary (QMB) and a specified low income Medicare beneficiary (SLMB).

(b)

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 policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in ore 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,

(1)

Intentionally left blank —Ed.

(a)

Did you turn age 65 in the last six months?
Yes______ No__________

(b)

Did you enroll in Medicare Part B in the last six months?
Yes______ No__________

(c)

If yes, what is the effective date? _______________________

(2)

Are you covered for medical assistance through the state Medicaid program?
(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.)
Yes______ No___________
If yes,

(a)

Will Medicaid pay your premiums for this Medicare supplement policy?
Yes______ No__________

(b)

Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
Yes______ No__________

(3)

Intentionally left blank —Ed.

(a)

If 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), fill in your start and end dates below. If you are still covered under this plan, leave “END” blank.
START ___/___/___ END ___/___/___

(b)

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__________

(c)

Was this your first time in this type of Medicare plan?
Yes______ No__________

(d)

Did you drop a Medicare supplement policy to enroll in the Medicare plan?
Yes______ No__________

(4)

Intentionally left blank —Ed.

(a)

Do you have another Medicare supplement policy in force?
Yes______ No__________

(b)

If so, with what company, and what plan do you have (optional for Direct Mailers)?__________________________________________

(c)

If so, do you intend to replace your current Medicare supplement policy with this policy?
Yes______ No__________

(5)

Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan)
Yes______ No__________

(a)

If so, with what company and what kind of policy?
___________________________________________
___________________________________________
___________________________________________
___________________________________________

(b)

What are your dates of coverage under the other policy?
START ___/___/___ END ___/___/___
(If you are still covered under the other policy, leave “END” blank.)

(2)

An agent shall list any other health insurance policies that the agent has sold to the applicant, and:

(a)

List such policies sold that are still in force;

(b)

List such policies sold in the past five years that are no longer in force.

(3)

In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant and acknowledged by the issuer, shall be returned to the applicant by the issuer upon delivery of the policy.

(4)

Upon determining that a sale will involve replacement of Medicare supplement coverage, any issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice signed by the applicant and the agent, except when the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage.

(5)

The notice required by section (4) of this rule for an issuer, shall be provided in substantially the form shown in Exhibit 1 to this rule in no less than 12 point type.

(6)

Paragraphs 1 and 2 of the replacement notice (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation.
[ED. NOTE: Exhibits referenced are available from the agency.]

Source: Rule 836-052-0165 — Requirements for Application Forms, Replacement Coverage, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0165.

836‑052‑0103
Purpose
836‑052‑0107
Authority
836‑052‑0114
Applicability and Scope
836‑052‑0119
Definitions
836‑052‑0124
Policy Definitions and Terms
836‑052‑0129
Policy Provisions
836‑052‑0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
836‑052‑0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836‑052‑0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992
836‑052‑0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
836‑052‑0138
Open Enrollment
836‑052‑0139
Medicare Select Policies and Certificates
836‑052‑0140
Standards for Claims Payment
836‑052‑0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010
836‑052‑0142
Guaranteed Issue for Eligible Persons
836‑052‑0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate
836‑052‑0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020.
836‑052‑0145
Loss Ratio Standards and Refund or Credit of Premium
836‑052‑0151
Filing and Approval of Policies and Certificates and Premium Rates
836‑052‑0156
Permitted Compensation Arrangements
836‑052‑0160
Required Disclosure Provisions
836‑052‑0165
Requirements for Application Forms, Replacement Coverage
836‑052‑0170
Filing Requirements for Advertising
836‑052‑0175
Standards for Marketing
836‑052‑0180
Appropriateness of Recommended Purchase and Excessive Insurance
836‑052‑0185
Reporting of Multiple Policies
836‑052‑0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates
836‑052‑0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing
836‑052‑0194
Separability
836‑052‑0225
Durational Limits for Health Maintenance Organizations
836‑052‑0230
Provider Services Limits for Insurers and Health Care Contractors
836‑052‑0500
Statutory Authority
836‑052‑0508
Definitions
836‑052‑0516
Policy Definitions
836‑052‑0526
Policy Practices and Provisions
836‑052‑0531
Long Term Care Insurance Partnership Program
836‑052‑0546
Required Policy Provisions
836‑052‑0556
Required Disclosure of Rating Practices to Consumers
836‑052‑0566
Initial Rate Filing Requirements
836‑052‑0576
Prohibition Against Post-Claims Underwriting, Applications
836‑052‑0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies
836‑052‑0596
Standards for Covered Services
836‑052‑0606
Use and Definition of “Home” or Similar Wording
836‑052‑0616
Requirement to Offer Inflation Protection
836‑052‑0626
Requirements for Application Forms and Replacement Coverage
836‑052‑0636
Reporting Requirements
836‑052‑0637
Annual Rate Certification Requirements
836‑052‑0639
Training for Insurance Producers
836‑052‑0646
Benefits Provided Through Advancement of Life Insurance Proceeds
836‑052‑0656
Reserve Standards
836‑052‑0666
Loss Ratio
836‑052‑0676
Premium Rate Schedule Increases
836‑052‑0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings
836‑052‑0686
Filing Requirements for Out-of-State Group Policies
836‑052‑0696
Filing Requirements for Advertising
836‑052‑0706
Standards for Marketing
836‑052‑0716
Disclosure Statement
836‑052‑0726
Suitability
836‑052‑0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates
836‑052‑0738
Availability of New Services or Providers
836‑052‑0740
Right to Reduce Coverage and Lower Premiums
836‑052‑0746
Nonforfeiture Benefit Requirement
836‑052‑0756
Standards for Benefit Triggers
836‑052‑0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts
836‑052‑0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met
836‑052‑0770
Prompt Payment of Clean Claims
836‑052‑0776
Standard Format Outline of Coverage
836‑052‑0786
Requirement to Deliver Shopper’s Guide
836‑052‑0790
Disclosure of Benefits Paid
836‑052‑0800
Purpose
836‑052‑0810
Replacement Upon Termination
836‑052‑0840
Termination of Coverage
836‑052‑0850
Multiple Employer Trusts
836‑052‑0860
Form of Notice to Group Policyholder
836‑052‑1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0165’s source at or​.us