Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application printable pdf download

Aetna Individual Medicare Supplement Plan Application

Aetna Life Insurance Company

[151 Farmington Avenue, MS 3128, Hartford, CT 06156]

[PLEASE MAIL APPLICATIONS TO:]

[PO Box 13547, Pensacola, FL 32591-3547]

INSTRUCTIONS:

To be considered complete, all sections on this form must be filled out, unless marked optional. Please sign and date the

form and make a copy for your records. Incomplete forms could delay processing your enrollment. The sale of a

Medicare supplement policy is prohibited where an individual has Medicare supplement coverage in force and does not

desire to replace the existing policy or where the Medicare supplement policy would duplicate benefits to which the

individual would be entitled under a Medicare Advantage plan. For information call [1-800-557-5078]; [TTY/TDD (Hearing

Impaired) 1-888-200-6124.]

PLEASE READ THE FOLLOWING CONSUMER PROTECTION INFORMATION:

You do not need more than one Medicare Supplement 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 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 suspension.

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 suspension.

Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement

insurance and medical assistance through the state Medicaid program, including benefits as a Qualified Medicare

Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

GR-68004-4 (4-11) NY

[C] R-POD

Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application