3. Applicant is enrolled in an MA,
other Medicare managed care,
PACE or Medicare supplement
(including Select) and the plan:
• Violates the insurance contract
(for example, by failing to
provide necessary medical
care), or
• Was misrepresented in
marketing to the individual
A, B, C, F, K, L, N or, if available
in your area, Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G
or Medicare Select N
• Applicant’s name.
• Plan Type – confirmation that it’s a
Medicare Advantage, other Medicare
managed care, Program of All-Inclusive
Care for the Elderly (PACE) or Medicare
Supplement (including Select) being
replaced.
• Coverage termination date.
• Termination reason.
4. Applicant is enrolled in a
Medicare supplement plan
(including Select) that is
involuntarily terminated (for
example, company bankruptcy).
A, B, C, F, K, L, N or, if available
in your area, Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• Applicant’s name.
• Plan Type – confirmation that it’s a
Medicare supplement plan being lost.
• Insurer name.
• Reason for involuntary termination.
• If available, documentation of
bankruptcy of insurer.
• Coverage termination date.
5. Applicant dropped Medicare
supplement coverage to enroll
for the first time in an MA, other
Medicare managed care, PACE,
or Select plan, and dropped that
plan within two years.
- If the previous plan you
had was an AARP Medicare
Supplement Plan, then you
may apply for Plans A, B, C, F,
K, L, N or, if available in your
area, Medicare Select N. Also,
you can apply for Plan G or, if
available in your area, Medicare
Select G without having to
answer health questions only if
Plan G or Medicare Select G was
the Plan you previously had.
- If the previous Medicare
Supplement Plan** you had was
with another insurer, then you
can only apply for Plans A, B, C,
F, K, L, N or, if available in your
area, Medicare Select N.
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• See information at the top of this
chart.
6. On first enrolling in Medicare
Part A at age 65***, applicant
enrolled in an MA or PACE plan at
the same time, and dropped that
plan within two years.
***NOTE: The MA or PACE plan
effective date must be equal to
the Medicare Part A effective
date for this qualifying event to
apply.
A, B, C, F, G, K, L, N or, if
available in your area, Medicare
Select G or Medicare Select N
A, B, G, K, L, N or, if available in
your area, Medicare Select G or
Medicare Select N
• See information at the top of this
chart.
*Also, there is a 2-month open enrollment period after the loss of group health insurance coverage. Applicants with a 65th birthday or a
Medicare Part A Effective Date prior to 1/1/2020 may apply for Plans A, B, C, F, G, K, L, N or, if available in your area, Medicare Select G or
Medicare Select N. Applicants with a 65th birthday and a Medicare Part A Effective Date on or after 1/1/2020 may apply for Plans A, B,
G, K, L, N or, if available in your area, Medicare Select G or Medicare Select N. Proof of loss of the group health insurance coverage must
be submitted with the Application Form.
**Prior Plan can also be a Medicare Select or High Deductible version of the Plan being applied for.
If you have any questions on your guaranteed right to insurance, you may wish to contact the administrator of your prior health
insurance plan or your local state department on aging.
Additional Information
Exclusions
____________________________________________________________
n Benefits provided under Medicare.
n Care not meeting Medicare’s standards.
n Injury or sickness payable by Workers’ Compensation or similar laws.
n Stays or treatment provided by a government-owned or -operated hospital or facility unless payment of charges is required by law.
