KPS Application
Thank you for your interest in the KPS Health Plans Medicare
Supplement plan!
Attached is a copy of the policy Enrollment Form and we have
supplied you with a link to a printable copy of the Outline of
Coverage.
Should you decide to apply by mail/fax/email, the printable
application needs to be reviewed and signed by an Agent before
it can be submitted to KPS Health Plans. You may email, fax or
mail it in to CDA Insurance:
•
Fax: 1.541.284.2994
•
Email: client.services@cda-insurance.com
• Secure File Upload: Click here
•
Mail: CDA Insurance LLC
PO Box 26540
Eugene, Oregon 97402
Other Important Information
Download Medicare’s Choosing a Medigap Policy Guide (.pdf)
Download Policy Outline (.pdf)
Download Application (.pdf)
Our website: http://www.hiwa.us
If you should have any questions on the application, please call
us at 1.800.884.2343 or 1.541.434.9613.
143KPS-2014-010314
SECTION 1
PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS FORM
h e a l t h p l a n s Enrollment Application for Medicare Supplement
PLEASE PRINT – Answer all questions completely and accurately to ensure timely processing
Name (Last, First, Middle): Birth Date:
Address (Street, City, State, Zip):
Telephone: rMALE
rFEMALE rSINGLE
rMARRIED
Social Security Number (required): Medicare Claim Number:
MEDICARE CLAIM NUMBER Please, copy the numbers shown as “MEDICARE CLAIM NUMBER” on the Medicare Health Insurance card issued to you by the Social Security Administration.
Enter effective date of “Hospital (Part A)” coverage shown on your Medicare Health Insurance card.
Month: Day: Year:
Enter effective date of “Medical (Part B)” coverage shown on your Medicare Health Insurance card.
Month: Day: Year:
• You must be enrolled in the KPS Medicare Supplement Plan you have chosen for a period of three (3) consecutive months before KPS will provide benefits for any condition for which you received medical advice, treatment, medicine, or diagnostic testing during the three (3) month period immediately preceding your KPS Medicare Supplement contract effective date. This waiting period will be waived if KPS receives your application within six (6) months of you turning age 65 or your enrollment in Medicare Part B;
or it will be reduced to the extent you had prior coverage under another Medicare supplement plan or other more comprehensive coverage, and you did not have a break in coverage of more than 63 days. Please provide proof of prior coverage with this application.
• If you intend to terminate existing Medicare
supplement or Medicare Advantage insurance and replace it with a contract to be issued by KPS Health Plans, please complete the enclosed “Notice To Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage.” Retain one copy for your records and return a completed/signed copy to KPS.
• You do not need more than one Medicare supplement contract.
• If you purchase this contract, you may want to evaluate your existing health coverage and decide if you need multiple coverages.
• If you are 65 or older, you may be eligible for benefits under Medicaid and may not need a Medicare supplement contract.
• If you become eligible for Medicaid after purchasing this contract, the benefits and premiums under your Medicare supplement contract 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 contract (or, if that is no longer available, a substantially equivalent contract) will be reinstated if requested within 90 days of losing Medicaid eligibility.
• If the Medicare supplement contract provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your contract was suspended, the reinstated contract will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
• If you are eligible for, and have enrolled in a Medicare supplement contract 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 contract can be suspended, if requested, while you are covered under the employer or union-based group health benefit plan. If you suspend your Medicare supplement contract under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement contract (or, if that is no longer available, a substantially equivalent contract) will be reinstated if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement contract provided coverage for outpatient
Page 1 of 6
PO Box 34803 | Seattle, WA 98124-1803
PLAN CHOICE
r
PLAN A (2010 STANDARDIZED)r
PLAN F (2010 STANDARDIZED)r
PLAN Kr
PLAN Nh e a l t h p l a n s
prescription drugs and you enrolled in Medicare Part D while your contract was suspended, the reinstated contract 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 a “Qualified Medicare Beneficiary” (QMB) and a
“Specified Low-Income Medicare Beneficiary” (SLMB).
PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. (MARK YES OR NO WITH AN “X”) 1. (a) Did you turn age 65 in the last six (6) months? r YES r NO
(b) Did you enroll in Medicare Part B in the last six (6) months? r YES r NO 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.)
r YES r NO
(If no, proceed to next question) (a) Will Medicaid pay your premiums for this Medicare supplement contract? r YES r NO (b) Do you receive any benefits from Medicaid other than payments toward your
Medicare Part B premium? r YES r NO
3. (a) 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)
r YES r NO
(If no, proceed to next question) If yes, what are your start and end dates? If you are still covered under this plan,
please 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 contract? r YES r NO (c) Was this your first time in this type of Medicare plan? r YES r NO (d) Did you drop a Medicare supplement contract to enroll in the Medicare plan? r YES r NO 4. (a) Do you have another Medicare supplement contract in force? r YES r NO
(If no, proceed to next question) If yes, with what company and what plan do you have? Company:
Plan:
(b) If yes, do you intend to replace your current Medicare supplement
contract with this contract? r YES r NO
5. Have you had coverage under any other health insurance within the past 63
days? (For example, an employer, union or individual plan.) r YES r NO (If no, proceed to next section) (a) If yes, with what company and what kind of contract?:
b) What are your dates of coverage under the other contract? If you are still
covered under this plan, please leave “END” blank. Start: End:
Enrollment Application for Medicare Supplement
Page 2 of 6
SECTION 2
143KPS-2014-010314
HEALTH STATEMENT Please indicate whether or not you have been diagnosed with any of the following conditions within the last five (5) years. Each condition must be checked “Yes” or “No.” Please provide details of any conditions marked “Yes.” ConditionYear DiagnosedName of Disease or InjurySurgery
Name & Address of Hospital or Physician
1. Aids or HIV PositiverYESrNO 2. ArthritisrYESrNO 3. Alcoholism/Chemical DependencyrYESrNO 4. Dementia (e.g., Alzheimer’s)rYESrNO 5. Back ConditionsrYESrNO 6. Cancer, LeukemiarYESrNO 7. CataractsrYESrNO 8. Vein or Artery DiseaserYESrNO 9. Heart DiseaserYESrNO 10. High Blood PressurerYESrNO 11. Intestinal Conditions (e.g. , stomach bowel)rYESrNO
HEALTH STATEMENT REQUIREMENTS If you are 65 years of age or older, and you are applying for a Medicare supplement plan for the first time more than six (6) months since you first enrolled in Medicare Part B you must complete the health statement. In compliance with Washington State law, the health statement must be completed either by you
or on your behalf by a relative, legal guardian, or physician. Completion of a health statement is
not required if: 1. You are 65 years of age or older and applying within six (6) months of your first enrollment under Medicare Part B; or 2. You are transferring from another Medicare Supplement Plan A to the KPS Medicare Supplement Plan A (2010 Standardized); or 3. You are transferring from a Medicare Supplement plan other than Plan A to a KPS Medicare Supplement Plan; or 4. You are transferring from more comprehensive coverage to a KPS Medicare Supplement Plan. If any of these circumstances (1-4) apply to you, please skip the health statement on the next page and continue to page 5 to complete the rest of this application. If none of these circumstances (1-4) apply to you, please complete the health statement that follows.
SECTION 3 Continued on next page
HEALTH STATEMENT Please indicate whether or not you have been diagnosed with any of the following conditions within the last five (5) years. Each condition must be checked “Yes” or “No.” Please provide details of any conditions marked “Yes.” ConditionYear DiagnosedName of Disease or InjurySurgery Name & Address of Hospital or Physician
12. Kidney/Bladder ConditionsrYESrNO 13. Liver ConditionsrYESrNO 14. Parkinson’s DiseaserYESrNO 15. DiabetesrYESrNO 16. Emphysema/Lung DisordersrYESrNO 17. Gall Bladder ConditionsrYESrNO 18. GlaucomarYESrNO 19. Prostate DisordersrYESrNO 20. Mental Health Conditions (e.g., depression)rYESrNO 21. StrokerYESrNO 22. Conditions Requiring Hospitalization or SurgeryrYESrNO
Continued from page 3 PLEASE LIST ANY PRESCRIPTION DRUGS YOU ARE TAKING Name of DrugReason Taken
143KPS-2014-010314
h e a l t h p l a n s
If you have 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 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.
ACKNOWLEDGEMENTS:
Please read and initial each of the following statements:
― I am applying for enrollment with KPS Health Plans.
― I represent that all statements and answers on this application and health questionnaire (if applicable) are complete and true to the best of my ability and knowledge.
― I understand it is a crime to knowingly provide false, incomplete, or misleading information to an
insurance company for the purpose of defrauding the company; penalties include imprisonment, fines, and denial of insurance benefits.
― I understand coverage is available to me based on the following:
• My residence in Washington State
• My enrollment in Medicare Parts A and B
• My eligibility for Medicare due to age (65 or over)
― I understand that a true copy of this application will be attached to my contract when it is issued.
― I have received a copy of the following (all are required):
__ Guide to Health Insurance for People with Medicare
__ Notice to Applicant Regarding Replacement of Medicare Supplement Insurance __ Outline of Coverage
― I understand and agree that coverage does not begin until KPS notifies me of my coverage effective date.
― I authorize any physician, hospital, or other provider of service to disclose to KPS any medical information that may be requested and understand that such information will be kept confidential, except as may be necessary to administer the provisions of my contract.
― I authorize the Centers for Medicare and Medicaid Services (CMS) to release to KPS any information from Title XVIII (Medicare) that is required to process my claims in conjunction with Medicare, if applicable.
This authorization is ongoing for as long as I am or will be eligible for Medicare and remain enrolled in this plan.
― I understand that KPS will not pay benefits during the first three (3) months after my effective date for any condition for which medical advice was given or treatment was recommended by or received from a physician within three months before the effective date of coverage.
― I understand that this waiting period will be waived if KPS receives my application within six (6) months of my turning age 65 or enrolling in Medicare Part B; or it will be reduced to the extent I had prior coverage under another Medicare supplement plan or other more comprehensive coverage with no break in coverage of more than 63 days, and I provide proof of that coverage with this application.
― I have read and personally completed all of the requested information on this form. (If not, please attach a letter of explanation.)
Page 5 of 6
Signature of Applicant____________________________________________ Signature Date:____________
SECTION 4
Enrollment Application for Medicare Supplement
h e a l t h p l a n s Enrollment Application for Medicare Supplement
PO Box 34803 | Seattle, WA 98124-1803
360-478-6786 • Toll-free 800-628-3753 • TTY 360-478-6849
Page 6 of 6
Please mail your completed application to:
KPS HEALTH PLANS | PO Box 34803 | Seattle, WA 98124-1803
Upon approval of this application your coverage will begin either the first of the following month OR the first of (month).
(You may request a later effective date up to 90 days from the date of this application.)_______________________
FOR INSURANCE PRODUCER USE ONLY:
The following must be completed by an insurance producer. All information must be completed, including the notice of replacement coverage (if applicable) included with this application, or the application will be returned.
1. List any other medical or health insurance contracts sold to the applicant:
2. List contracts that are still in force:
3. List contracts sold in the past five years that are no longer in force:
FOR INSURANCE PRODUCER VERIFICATION, FOR INSURANCE PRODUCER ONLY.
The following MUST be completed AFTER the applicant has completed the application. To the best of my knowledge, the answers on this application are complete and accurate.
Insurance Producer Name - as licensed: Agency Name: Ins. Producer No.:
Mailing Address: City: State: Zip: Telephone No.:
Insurance Producer Signature: Date:
The following KPS in-house insurance producer has reviewed and accepted this application:
In-house Insurance Producer Name - as licensed: Ins. Producer No.:
In-house Insurance Producer Signature: Date:
SECTION 5
Dann Loewenthal CDA Insurance LLC 5864
PO Box 26540 Eugene OR 97402 800.884.2343
1
GMA-JAN14 12/03/13
Statement to applicant by issuer or insurance Producer:
I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement contract will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement contract is being purchased for the following reason(s) (check one):
_______ Additional benefits
________No change in benefits, but lower premiums ________Fewer benefits and lower premiums
________My plan has outpatient prescription drug coverage and I am enrolling in Part D
________Disenrollment from a Medicare Advantage plan; (Please explain reason for disenrollment) __________________
__________________________________________________________________________________________________________
________________________________________________________________________________________
________Other (please specify) _______________________________________________________________
1 If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. If you have had your current Medicare supplement policy less than three months, health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.
2 State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) to the extent such time was spent (depleted) under original policy.
3 If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.
Notice to applicant regarding replacement of
Medicare Supplement Insurance or Medicare Advantage
Save this notice! It may be important to you in the future
According to information you have furnished, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a contract to be issued by KPS Health Plans. Your new contract will provide thirty 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.
If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other disability coverage you have that may duplicate this contract.
Do not cancel your present contract until you have received your new contract
and are sure that you want to keep it.
Applicant’s name (please print) _________________________________________________________________
Applicant’s signature ________________________________________________________________________
Date ____________________________________________________________________________________
Agency name ______________________________________________________________________________
Main Office: 400 Warren Avenue | Bremerton, WA 98337
Mailing Address: PO Box 34803 | Seattle, WA 98124-1803
Phone Number: 1-800-552-7114
Complete and sign pages 1 and 2, and then return to KPS Health Plans.
Please keep the copy for your records.
Medicare Supplement Plan Change Request Form
14-KPS-1326-07
PERSONAL INFORMATION
Name (as it appears on Medicare card) PLEASE PRINT CLEARLY USING BLACK OR BLUE INK ONLY Mr.
Mrs.
Ms.
First name Middle Initial Last name
Birth date Male
Female Permanent residential street address (do not use a P.O. box or a mail delivery service)
Street address
City County State Zip
Mailing address (if different than above)
Address In care of
City County State Zip
Premium billing address (if different than above)—we will send your monthly bill here.
Address In care of
City County State Zip
Contact information
Telephone (primary) Telephone (secondary) KPS Health Plans Member ID
KPS Health Plans | PO Box 34803, Seattle, WA 98124-1803 360-478-6786 | Toll-free: 800-628-3753 | TTY: 360-478-6849
Please make a copy of this form for your records.
Medicare Supplement Plan Change Request Form
MEDICARE INFORMATION
Please complete this section with the information on your red, white, and blue Medicare card. You must have Medicare Parts A and B to remain enrolled in a Medicare Supplement plan.
Medicare Claim Number ___________________________
Part A (hospital) effective date _______________________
Part B (medical) effective date _______________________
PLAN INFORMATION
Plan A (2010 Standardized): $135 Plan K: $87
Plan F (2010 Standardized): $251 Plan N: $141
ACKNOWLEDGEMENTS & SIGNATURE
I acknowledge that:
• I am requesting enrollment with KPS Health Plans.
• I am eligible for a KPS Health Plans Medicare Supplement based on my residence in Washington State, my enrollment in Medicare Parts A and B, and my eligibility for Medicare is due to age.
• A true copy of this request will be attached to my contract when it is issued.
• Coverage on this new plan does not begin until KPS notifies me of my coverage effective date.
• I authorize any physician, hospital, or other provider of service to disclose to KPS Health Plans any medical information that may be requested and understand that such information will be kept confidential, except as may be necessary to administer the provisions of my contract.
• I authorize the Centers for Medicare and Medicaid Services (CMS) to release to KPS Health Plans any information from Title XVIII (Medicare) that is required to process my claims in conjunction with Medicare, if applicable. This authorization is ongoing for as long as I am or will be eligible for Medicare and remain enrolled in this plan.
I declare that all statements and answers on this application are complete and true to the best of my ability and knowledge. I understand it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company; penalties include imprisonment, fines, and denial of insurance benefits.
Your signature Date
If you are the authorized representative, you must sign above and provide the following information.
Proof of your authority (e.g. Durable Power of Attorney) must be presented upon request.
Name Phone
Relationship to applicant
Please complete this form if you wish to have your monthly premium payment automatically withdrawn, changed, or cancelled from your bank account. This is an optional free service for your convenience. KPS arranges with your bank a transfer on or about the 10th of each month for the next month’s coverage. The funds transfer will appear on your monthly bank statement. KPS will notify you in advance if there is to be any change in the amount of your premium.
PLEASE NOTE: After your application is approved, it may take approximately one month to complete the arrangement with your bank. If you receive any premium bills, it means the funds transfer process has not been completed and you should remit payment before the 10th of the month of coverage. The automatic payment system will take effect for the following months, and you will no longer receive bills.
APP1212 PO Box 339 | Bremerton, Washington 98337 | kpshealthplans.com
Authorization Agreement for Automatic Premium Payment
(If not issued yet, leave blank)
* As used herein, the term “bank” includes all types of financial institutions, including commercial banks, savings banks, savings and loans and credit unions. The signature(s) above gives KPS Health Plans permission to disclose the financial information for the above account to the Name on the bank account. Only billing and payment information will be given to above payee, nothing will be given regarding claims or claims payment. I have the right to revoke this permission at any time, by signing the cancellation section of my copy of this form and returning it to KPS Health Plans at the below address.
________________________________________
NAME ON ACCOUNT
________________________________________
BANK NAME
________________________________________
BRANCH NAME
________________________________________
BRANCH ADDRESS
________________________________________
CITY
________________________________________
STATE/ZIP CODE
________________________________________
CHECKING ACCOUNT#
________________________________________
ROUTING NUMBER
________________________________________
SIGNATURE OF ACCOUNT HOLDER(S)
________________________________________
SIGNATURE OF SUBSCRIBER
________________________________________
DATE
(print as shown on your bank statement)
(1st 9 digits on the bottom of check) (exactly as shown on your bank statement)
(If different than name on account)
SUBSCRIBER NAME _________ _________________ KPS ID# ____________________________________
To cancel premium payment account
I no longer wish to participate in the KPS Health Plans automatic premium payment process. Please discontinue deducting premium payments from my bank account, effective_____________. I understand KPS will continue to provide health care coverage for me (and my family) and I will be billed on a monthly basis.
SIGNATURE _________________________________
DATE________ ______________________________
Automatic premium payment account To change premium payment account
Please fill out your new bank information on the left-hand side and your old bank information below.
Please fill out below to start your automatic monthly premium payment.
__________________________________________
NAME ON ACCOUNT
__________________________________________
PREVIOUS BANK NAME
__________________________________________
PREVIOUS ACCOUNT#
__________________________________________
SIGNATURE OF PAYEE/DATE
__________________________________________
SIGNATURE OF SUBSCRIBER/DATE
144KPS-2014-01
