Fill - Free fillable Form will be used to determine your acceptance PDF form

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Application Form

AARP

Medicare Supplement Insurance Plans

Insured by

UnitedHealthcare Insurance Company (UnitedHealthcare),

Horsham, PA 19044

Note: Plans and rates are only good for residents of the state of Iowa. The information you provide on this Application

Form will be used to determine your acceptance and rate.

Instructions

Fill in all requested information on this Application Form and sign in all places a signature is needed.

Provide additional information about yourself and your Medicare Insurance.

___________________________ _________________________________________________________

1A. Phone Number 1B. Email address (optional). Include periods (.) and symbols (@).

By providing your address, phone number and/or email address, you are agreeing to receive information and be contacted

by UnitedHealthcare Insurance Company.

1C. Birthdate ________________________ 1D. Gender _____________

Month Day Year

1E. Medicare Number _____________________________ (From your Medicare card.)

1F. Medicare Start: Hospital (Part A) ____________________ Medical (Part B) ___________________

Month Year Month Year

1G. Will your Medicare Part A and Part B be active on your AARP Medicare Supplement Plan start date? _____________

AARP Membership Number (If you are already a member) ___________________________________________

_____________________________________ ____ __________________________________________

Applicant First Name MI Last Name

Permanent Home Address (P.O. Box/PMB is not allowed)

______________________________________________________________________________________

Mailing Address (if different from permanent address)

______________________________________________________________________________________

____________________________

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Choose your Plan and start date.

Is your acceptance guaranteed?

Plan Choice

2A. You are eligible to apply if all of these are true:

• you are an AARP member,

• you are age 65 or older,

• you are enrolled in Medicare Parts A and B,

• you are not enrolled in more than one Medicare supplement plan at the

same time,

• if you are entitled to guaranteed acceptance, please look at “Your Guide” to

determine which Plans you are eligible for guaranteed acceptance in without

having to answer health questions.

__________________________

Plan Start Date

2B. Your Plan will start on the ﬁrst day of the month following receipt and

approval of this Application Form and receipt of your ﬁrst month’s payment. If

you would like your Plan to start on a later date (the ﬁrst day of a future month),

please indicate the date:

____________________

Month Day Year

3A. Will your AARP Medicare Supplement Plan start date be within 6 months after you

turn age 65 or enroll in Medicare Part B?

____________________

• If YES, your acceptance is guaranteed. Go directly to Section 9. You do not have to

answer the questions in Sections 4, 5, 6, 7 and 8.

• If NO, you must answer Question 3B.

3B. Do you have guaranteed issue rights, as listed in the Guaranteed Acceptance section

of “Your Guide”? If YES, see Your Guide for the documentation you will need to

provide from your prior insurer or employer.

____________________

• If YES, and you are applying for a Plan that is eligible for guaranteed acceptance as

deﬁned in the Guaranteed Acceptance Section in “Your Guide”, skip directly to Section 9.

If YES and you are applying for a Plan that is NOT eligible for guaranteed acceptance as

deﬁned in the Guaranteed Acceptance Section in “Your Guide”, continue to Section 4.

• If you answered NO to both questions in Section 3, continue to Section 4.

Answer this health question only if your acceptance is not guaranteed as deﬁned

in Section 3.

4A. Within the past 2 years, did a medical professional provide treatment or advice to

you for any problems with your kidneys?

____________________

If you answered YES or NOT SURE to question 4A, we may follow up for additional information.

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5A. Within the past 90 days, were you hospitalized as an inpatient (not including

overnight outpatient observation)?

____________________

5B. Are you currently being treated or living in any type of nursing facility other than an

assisted living facility?

____________________

5C. Has a medical professional told you that you have End-Stage Renal (Kidney) Disease

or that you require dialysis?

____________________

5D. Within the past 2 years, did a medical professional tell you that you may need any of

the following that has NOT been completed?

• hospital admittance as an inpatient

• joint replacement

• organ transplant

• surgery for cancer

• back or spine surgery

• heart or vascular surgery

____________________

Answering YES to any question in Section 5 will result in a denial of coverage.

If your health status changes in the future, allowing you to answer NO to all of the questions in this section, please

submit a new application at that time.

If you answered NOT SURE to any question in Section 5, we may follow up for additional information.

Answer these eligibility health questions only if your acceptance is not guaranteed

as deﬁ ned in Section 3.

Answer these health questions to determine your rate only if your acceptance is not

guaranteed as deﬁ ned in Section 3.

6A. Within the past 2 years, did you have (as determined by a medical professional) or

were you diagnosed, treated, given medical advice or prescribed medications/reﬁ lls for

any of the following conditions?

• Atrial Fibrillation or Flutter

• Artery or Vein Blockage

• Peripheral Vascular Disease (PVD)

• Cardiomyopathy

• Congestive Heart Failure (CHF)

• Coronary Artery Disease (CAD)

• Chronic Obstructive Pulmonary Disease (COPD) or Emphysema

• Chronic Kidney Disease

• Diabetes, but only if you have circulation problems or Retinopathy

• Cancer including Melanoma (but not other skin cancers), Leukemia and Lymphoma

• Cirrhosis of the Liver

• Macular Degeneration, but only if you have the wet form

• Multiple Sclerosis

• Rheumatoid Arthritis

• Systemic Lupus Erythematosus (SLE)

____________________

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Answer these health questions to determine your rate only if your acceptance is not

guaranteed as deﬁned in Section 3. (continued)

6B. Within the past 2 years, did you have (as determined by a medical professional) a

Heart Attack, Stroke, Transient Ischemic Attack (TIA) or Mini-Stroke?

____________________

If you answered YES to any question in Section 6, your rate will be the Level 2 rate.

See the enclosed “Cover Page – Rates.”

If you answered NOT SURE to any question, we may follow up for additional information.

Tell us about your medical providers.

Provide the following information for all physicians that you have seen within the past two years. We may

follow up with your physicians for additional information.

_______________________________________________________________________________________

Primary Physician Phone #

_______________________________________________________________________________________

Address

_______________________________________________________________________________________

City State ZIP Code

_______________________________________________________________________________________

Specialist Name Specialty

_______________________________________________________________________________________

Diagnosis/Condition

_______________________________________________________________________________________

Specialist Name Specialty

_______________________________________________________________________________________

Diagnosis/Condition

Tell us about your tobacco usage – Do not answer this question if you are in your

Open Enrollment or you are entitled to guaranteed issue.

8A. At any time within the past 12 months, have you smoked tobacco cigarettes or used

any other tobacco product?

____________________

If you answered YES to Question 8A, your rate will be the tobacco rate. See “Cover Page - Rates.”

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Your past and current coverage

Review the statements.

• You do not need more than one Medicare supplement 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.

• 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,

Questions about Medicaid

9A. Are you covered for medical assistance through the state Medicaid program?

(Medicaid is a state-run health care program that helps with medical costs for people

with low or limited income. It is not the federal Medicare program.) Note to applicant:

If you are participating in a “Spend-down Program” and have not met your “Share of

Cost”, answer NO to this question.

If YES, you must answer Questions 9B and 9C.

____________________

9B. Will Medicaid pay your premiums for this Medicare supplement policy?

____________________

9C. Do you receive any beneﬁts from Medicaid other than payments toward your

Medicare Part B premium?

____________________

Questions about Medicare Advantage plans (sometimes called Medicare Part C)

9D. Have you had coverage from any Medicare plan other than original Medicare within

the past 63 days (for example, a Medicare Advantage plan, a Medicare HMO, or PPO)?

If YES, you must answer Questions 9E through 9H.

____________________

9E. Provide the start and end dates of your Medicare plan other than original Medicare.

If you are still covered under this plan, leave the end date blank.

Start Date

____________________

Month Day Year

End Date

____________________

Month Day Year

9F. If you are still covered under the Medicare plan other than original Medicare, do you

intend to replace your current coverage with this new Medicare supplement policy?

(When you receive conﬁrmation that this Medicare Supplement plan has been issued,

you will need to cancel your Medicare Advantage Plan. Please contact your Medicare

Advantage insurer for instructions on how to cancel, using the customer service number

on the back of your ID card.)

____________________

9G. Was this your ﬁrst time in this type of Medicare plan?

____________________

9H. Did you drop a Medicare supplement policy to enroll in the Medicare plan?

____________________

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Your past and current coverage (continued)

Questions about Medicare supplement plans

9I. Do you have another Medicare supplement policy in force?

If so, what insurance company and what plan do you have?

Insurance Company: _________________________________________________

Policy: ___________________________________________________________

If YES, you must answer Question 9J.

____________________

9J. Do you intend to replace your current Medicare supplement policy with this policy?

____________________

Questions about any other type of health insurance coverage

9K. Have you had coverage under any other health insurance within the past 63 days

(for example, an employer, union, or individual plan)?

If YES, you must answer Questions 9L through 9N.

____________________

9L. If so, with what insurance company and what kind of policy?

Insurance Company:_______________________________________________

Policy:

9M. What are your dates of coverage under the other policy? Leave the end date blank

if you are still covered under the policy.

Start Date

____________________

Month Day Year

End Date

____________________

Month Day Year

9N. Are you replacing this health insurance?

____________________

_______________________________________________________________ __________________

Your Signature (required) Today’s Date (required)

Month Day Year

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Authorization and Veriﬁcation of Application Information

Read carefully, and sign and date in the signature box.

• I declare the answers on this Application Form are complete and true to the best of my knowledge and belief and are

the basis for issuing coverage. I understand that this Application Form becomes a part of the insurance contract and that

if the answers are incomplete, incorrect or untrue, UnitedHealthcare Insurance Company may have the right to rescind my

coverage, adjust my premium, or reduce my beneﬁts.

• Any person who, knowingly and with intent to defraud any insurance company or other person, ﬁles an application for

insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading,

information concerning any fact material thereto, commits a fraudulent insurance act when determined by a court of

competent jurisdiction, and as such may be subject to criminal and civil penalties.

• I understand coverage, if provided, will not take effect until issued by UnitedHealthcare Insurance Company, the actual

premium is not determined until coverage is issued and that this Application Form and payment of the initial premium does

not guarantee coverage will be provided.

• I acknowledge receipt of the Guide to Health Insurance for People with Medicare and the Outline of Coverage.

If the Application Form is being completed through an Agent or Broker:

• I understand an agent or broker discussing Plan options with me is appointed by UnitedHealthcare Insurance Company,

and may be compensated based on my enrollment in a Plan.

• I understand that an agent or broker cannot change or waive any terms or requirements related to this Application Form

and its contents, underwriting, premium or coverage and cannot grant approval.

Authorization for the Release of Medical Information

I authorize UnitedHealthcare Insurance Company and its afﬁliates (“The Company”) to obtain from any health care provider,

licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical facility, health care clearinghouse,

pharmacy beneﬁt manager, insurance company, or other organization, institution or person, or The Company’s own

information, any data or records about me or my mental or physical health. I understand the purpose of this disclosure

and use of my information is to allow The Company to determine my eligibility for coverage and rate. I understand this

authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my eligibility to enroll

in the health plan or to receive beneﬁts, if permitted by law. I understand the information I authorize The Company to obtain

and use may be re-disclosed to a third party only as permitted under applicable law, and once re-disclosed, the information

may no longer be protected by Federal privacy laws. I understand I may end this authorization if I notify The Company, in

writing, prior to the issuance of coverage. After coverage is issued, this authorization is not revocable. If not revoked, this

authorization is valid for 24 months from the date of my signature.

Please see “Your Guide” to determine if the following pre-existing condition waiting period applies to you.

I understand the plan will not pay beneﬁts for stays beginning or medical expenses incurred during the ﬁrst

3 months of coverage if they are due to conditions for which medical advice was given or treatment

recommended by or received from a physician within 3 months prior to the insurance effective date.

My signature indicates I have read and understand all contents of this Application Form and have answered

all questions to the best of my ability.

_______________________________________________________________ __________________

Your Signature (required) Today’s Date (required)

Month Day Year

Note: If you are signing as the legal representative (e.g., POA, Guardian, Conservator, etc.) for the applicant, please send a complete

copy of the appropriate legal documentation and check this box.

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Agent/Broker must complete the following information and include the notice of replacement coverage, if

appropriate, with this Application Form. All information must be complete or the Application Form will be returned.

1. List any other health insurance policies issued to the applicant:

_____________________________________________________________________________________

2. List policies issued which are still in force:

_____________________________________________________________________________________

3. List policies issued in the past 5 years which are no longer in force:

_____________________________________________________________________________________

Agent Name (PLEASE PRINT) _______________________ ___ _____________________________________

First Name MI Last Name

______________________________________ ________________________ ___________________

Agent Signature (required) Agent ID (required) Today’s Date (required)

Month Day Year

___________________________________________________ _______________________________

Agent Email Address Agent Phone Number

______________________________________ ____________________________________________

Broker Name Broker ID

For Agent/Broker Use Only

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