MUTUAL of OMAHA INSURANCE COMPANY UNITED WORLD LIFE INSURANCE COMPANY _______________________________________________________________________________________________ _______________________________________________________________________________________________ MEDICARE SUPPLEMENT UNDERWRITING GUIDELINES TABLE OF CONTENTS Contacts . Page 1
Addresses for Mailing and Delivery Receipts
Introduction. Page 2 Policy Issue Guidelines . Page 3
Medicare Select to Medicare Supplement Conversion Privilege
Medicare Advantage (MA) . Page 7
Medicare Advantage (MA) Annual Election Period
Medicare Advantage (MA) Proof of Disenrollment
Premium . Page 9
Completing the Premium on the Application
General Administrative Rule – 12 Month Rate
Application. Page 12
Part II – Existing Coverage Information
Part IV – Important Statement and Signatures
Health Questions. Page 14
Partial List of Medications Associated with Uninsurable Health Conditions
Required Forms . Page 17
Producer Information Page (Brokerage ONLY)
Agent or Witness Certification for Non English Speaking and/or Reading Applicants
State Special Forms .Page 17
Arkansas – Documentation of Solicitation of Medicare Related Products
California Agent / Applicant Meeting Form
Guarantee Issue and Open Enrollment Notice for California
Iowa – Important Notice before You Buy Health Insurance
Kentucky – Medicare Supplement Comparison Statement for Kentucky
Louisiana – Your Rights Regarding the Release and Use of Genetic Information
Notice Concerning Policyholder Rights in Insolvency under the Minnesota Life and Health Insurance
Montana – Montana Privacy Notice - Personal Information
Nebraska – Senior Health Counseling Notice
New Mexico – New Mexico Confidential Abuse Information
New York – Medicare Supplement Plan B Disclosure Agreement
Pennsylvania – Guarantee Issue and Open Enrollment Notice
CONTACTS Addresses for Mailing New Business and Delivery Receipts When mailing or shipping your new business applications be sure to use the pre addressed envelopes. Agency Mailing Information Please forward all completed applications to your appropriate Division Office, who will forward them onto Mutual of Brokerage Mailing Information Mailing Address Overnight/Express Address FAX Number for New Business (Brokerage ONLY) - ACH Applications Sales Professional Access (SPA) Links
Important Phone Numbers Phone Number INTRODUCTION
This guide provides information about the evaluation process used in the underwriting and issuing of Medicare
supplement insurance policies. Our goal is to process each application as quickly and efficiently as possible while
assuring proper evaluation of each risk. To ensure we accomplish this goal, the producer or applicant will be
contacted directly by underwriting if there are any problems with an application. POLICY ISSUE GUIDELINES
All applicants must be covered under Medicare Part A & B in Michigan and Washington; in all other states, only Part
A is required. Policy issue is state specific. The applicant’s state of residence controls the application, forms, premium
and policy issue. If an applicant has more than one residence, the state where taxes are filed should be considered as
the state of residence. Please refer to your introductory materials for required forms specific to your state. Open Enrollment To be eligible for open enrollment, an applicant must be at least 64½ years of age (in most states) and be within six
months of his/her enrollment in Medicare Part B.
Applicants covered under Medicare Part B prior to age 65 are eligible for a six-month open enrollment period upon
Additional Open Enrollment periods for Residents of the following states: California – Annual open enrollment lasting 90 days, beginning 60 days before and ending 30 days after the
individuals birthday, during which time a person may replace any Medicare Supplement policy with a policy of equal
or lesser benefits. Coverage will not be made effective prior to the individuals birthday. Please include
documentation verifying the Plan information and paid to date of the current coverage. If replacing a pre-standardized
Plan a copy of the current policy or policy schedule is required. Connecticut – Year round open enrollment. Maine – One month open enrollment period every year in June for Plan A.
Individuals who have had a Medicare Supplement plan or another health plan that supplements benefits provided by
Medicare within 90 days are eligible for a plan that provides equal or lesser benefits. Please include documentation
verifying the Plan information or the benefits of the coverage being replaced. Also be sure to include documentation
showing the current coverage is in force or was in force within the last 90 days. New York – Year round open enrollment. Vermont – Year round open enrollment. Washington – Individuals who currently have a standardized Medicare Supplement plan may replace the plan as
indicated below on an open enrollment basis.
Persons with a Plan A may only move to another Plan A.
Persons with a Plan B, C, D E, F or G may move to any other Plan B, C, D, E, F or G. (Whether higher or
lower in benefits compared to current plan).
Persons with a Plan H, I, or J may move to another same Plan H, I or J or another less comprehensive
Please include documentation verifying the Plan information and paid-to-date of the current coverage
States with Under Age 65 Requirements California
Guarantee Issue if within 6 months of Part B enrollment. Not available for individuals with end
Guarantee Issue if within 6 months of Part B enrollment. Connecticut
Plan A available from Mutual of Omaha.
Guarantee Issue if within 6 months of Part B enrollment. Illinois
Guarantee Issue if within 6 months of Part B enrollment. Louisiana
All plans are available. Coverage is guaranteed issue if applied for within six months of Part Benrollment.
Guarantee Issue if within 6 months of Part B enrollment. Kentucky
No Guarantee Issue. Applications will be underwritten.
Guarantee Issue if within 6 months of Part B enrollment. Maryland
Guarantee Issue if within 6 months of Part B enrollment. Minnesota
Basic and Extended Basic plans available.
Guarantee Issue if within 6 months of Part B enrollment. Mississippi
Guarantee Issue if within 6 months of Part B enrollment. NewJersey
Plan C available to people ages 50-64.
Guarantee Issue if within 6 months of Part B enrollment. NorthCarolina Plan A available.
Guarantee Issue if within 6 months of Part B enrollment. Oklahoma
Plan A is available. Coverage is guaranteed issue if applied for within six months of Part Benrollment.
Guarantee issue if within 6 months of Part B enrollment. Pennsylvania
Guarantee issue if within 6 months of Part B enrollment. South Dakota
Guarantee issue if within 6 months of Part B enrollment.
Not available for individuals with end stage renal disease. Selective Issue Applicants over the age of 65 and at least six months beyond enrollment in Medicare Part B will be selectively
underwritten. All health questions must be answered. The answers to the health questions on the application will
determine the eligibility for coverage. If any health questions are answered “Yes,” the applicant is not eligible for
coverage. Applicants will be accepted or declined. Elimination endorsements will not be used. Application Dates
Open Enrollment – Up to six months prior to the month the applicant turns age 65
New York applicants may be taken up to 90 days prior to the month the applicant turns age 65
Underwritten Cases – Up to 60 days prior to the coverage requested effective date
Coverage Effective Dates Coverage will be made effective as indicated below:
1. Between age 64½ and 65 years old – The first of the month the individual turns age 65
2. All Others – Application date or date of termination of other coverage, whichever is later
Replacements A “replacement” takes place when an applicant wishes to exchange an existing Medicare supplement policy from
Mutual of Omaha or United World, one of our affiliate companies (internal), or any other company (external), for a
newer or different Medicare supplement/Select policy. Internal replacements are processed the same as external,
requiring a fully completed application.
A policyowner wanting to apply for a non-tobacco plan must complete a new application and qualify for coverage.
The policy to be replaced must be inforce on the date of replacement. All replacements involving a Medicare
supplement, Medicare Select or Medicare Advantage plan must include a completed Replacement Notice. One copy is
to be left with the applicant; one copy should accompany the application.
The Medicare supplement policy cannot be issued in addition to any other Medicare supplement, Select or Medicare
Medicare Select to Medicare Supplement Conversion Privilege Policyowners covered under a Medicare Select plan with Mutual of Omaha or United World may decide they no
longer wish to participate in our hospital network. Coverage may be converted to one of our Medicare supplement
plans not containing network restrictions. We will make available any Medicare supplement policy offered in their
state that provides equal or lesser benefits. A new application must be completed; however, evidence of insurability
will not be required if the Medicare Select policy has been inforce for at least six months at the time of conversion. Telephone Interviews Random telephone interviews with applicants will be conducted on underwritten cases. Please be sure to advise your
clients that Underwriting may be calling to verify the information on their application. Pharmaceutical Information Mutual of Omaha and United World have implemented a process to support the collection of pharmaceutical
information for underwritten Medicare supplement applications. In order to obtain the pharmaceutical information as
requested, please be sure to include a completed “Authorization to Disclose Personal Information (HIPAA)” form
with all underwritten applications. This form can be found in the Application Packet. Prescription information noted
on the application will be compared to the additional pharmaceutical information received. This additional
information will not be solely used to decline coverage. Policy Delivery Receipt Delivery receipts are required on all policies issued in Kentucky, Louisiana, Nebraska, and South Dakota.
Two copies of the delivery receipt will be included in the policy package. One copy is to be left with the client. The
second copy must be returned to Mutual of Omaha/United World in the postage paid envelope, which is also included
Guarantee Issue Rules The rules listed below can also be found in the Guide to Health Insurance. These are the Federal requirements. Mutual of Omaha and United World offer all plans available on a guarantee issue basis. Guarantee Issue Situation Client has the right to buy. . .
Client is in the original Medicare Plan and has an
Medigap Plan A, B, C, F, K or L that is sold in client’s
employer group health plan (including retiree or COBRA
coverage) or union coverage that pays after Medicare
If client has COBRA coverage, client can either buy a
Medigap policy right away or wait until the COBRA
Note: In this situation, state laws may vary.
Client is in the original Medicare Plan and has a Medicare
Medigap Plan A, B, C, F, K or L that is sold by any
SELECT policy. Client moves out of the Medicare
insurance company in client’s state or the state they are
You can keep your Medigap policy or you may want to
Client’s Medigap insurance company goes bankrupt and
Medigap Plan A, B, C, F, K or L that is sold in client’s
the client looses coverage, or client’s Medigap policy
coverage otherwise ends through no fault of client. MEDICARE ADVANTAGE (MA) Medicare Advantage (MA) Annual Election Period General Election Periods for Medicare Advantage (MA) Time frame Allows for…
There are many types of election periods other than the ones listed above. If there is a question as to whether or not
the MA client can disenroll, please refer the client to the local SHIP office for direction. Medicare Advantage (MA) Proof of Disenrollment If applying for Medicare supplement, Underwriting cannot issue coverage without proof of disenrollment. If a
member disenrolls from Medicare, the MA plan must notify the member of his/her Medicare supplement guarantee
Disenroll during AEP and OEP
Complete the MA section on the Medicare supplement application; and
1. Send ONE of the following with the application
A copy of the applicant’s MA plan’s disenrollment notice
b. A copy of the letter the applicant sent to his/her MA plan requesting disenrollment
A signed statement that the applicant has requested to be disenrolled from his/her MA plan. If an individual is disenrolling after March 31 (outside AEP/OEP):
1. Complete the MA section on the Medicare supplement application; and
2. Send a copy of the applicant’s MA plan’s disenrollment notice with the application.
For any questions regarding MA disenrollment eligibility, contact your State Health Insurance Assistance Program
(SHIP) office or call 1-800-MEDICARE, as each situation presents its own unique set of circumstances. The SHIP
office will help the client disenroll and return to Medicare. Guarantee Issue Rights The rights listed below can also be found in the Guide to Health Insurance. These are the Federal requirements. Mutual of Omaha and United World offer all plans available on a guarantee issue basis. Guarantee Issue Situation Client has the right to…
Client’s MA plan is leaving the Medicare program,
buy a Medigap Plan A, B, C, F, K or L that is sold in the
stops giving care in his/her area, or client moves out of
client’s state by any insurance carrier. Client must
Client joined an MA plan when first eligible for
buy any Medigap plan that is sold in your state by any
Medicare Part A at age 65 and within the first year of
joining, decided to switch back to Original Medicare.
Client dropped his/her Medigap policy to join an MA
obtain client’s Medigap policy back if that carrier still
Plan for the first time, have been in the plan less than a
sells it. If his/her former Medigap policy is not
available, the client can buy a Medigap Plan A, B, C, F,
K or L that is sold in his/her state by any insurance
Client leaves an MA plan because the company has not
buy Medigap plan A, B, C, F, K or L that is sold in the
client’s state by any insurance company.
If you believe another situation exists, please contact the client’s local SHIP office. Calculating Premium Utilize Outline of Coverage
Determine ZIP code where the client resides and find the correct rate page for that ZIP code
Find Age/Gender - Verify that the age and date of birth are the exact age as of the application date
Tobacco rates do not apply during Open Enrollment or Guarantee Issue situations in the following states: Types of Medicare Policy Ratings Community-rated - The same monthly premium is charged to everyone who has the Medicare policy, regardless of
age. Premiums are the same no matter how old the applicant is. Premiums may go up because of inflation and other
Issue-age-rated – The premium is based on the age the applicant is when the Medicare policy is bought. Premiums
are lower for applicants who buy at a younger age, and won’t change as they get older. Premiums may go up because
of inflation and other factors, but not because of applicant’s age. Attained-age-rated – The premium is based on the applicants current age so the premium goes up as the applicant
gets older. Premiums are low for younger buyers, but go up as they get older. In addition to change in age, premiums
may also go up because of inflation and other factors. Rate Type Available by State Tobacco / Non- Attained, Issue, or Tobacco Rates During Tobacco Rates Gender Rates Community Rated Open Enrollment Completing the Premium on the Application Initial Premium
The premium calculated from the outline will be the amount you enter on the Premium Collected box located
Circle the appropriate mode for the initial payment. Renewal Premium
Determine how the client wants to be billed going forward (renewal) and select the appropriate mode on the
Renewal Mode section on the application.
Indicate, based on the mode selected, the renewal premium. Monthly direct is not allowed
NOTE: If utilizing electronic funds as a method of payment, please complete the Authorization To Withdraw Collection of Premium
At least one month’s premium must be submitted with the application. If a mode other than monthly is selected, then
the full modal premium must be submitted with the application. In California only one month’s premium can be
NOTE: The Company does not accept post-dated checks or payments from Third Parties, including any Foundations
as premium for Medicare Supplement/Select. Business Checks
If premium is paid by business account, complete the information located on the Producer Information form. Conditional Receipt
The Conditional Receipt must be completed and provided to applicant if premium is collected.
NOTE: Do not mail a copy of the receipt with the application. Shortages
The company will communicate with the producer by telephone, e-mail or FAX in the event of a premium shortage.
The application will be held in pending until the balance of the premium is received. Producers may communicate
with Underwriting by calling 1-800-995-9324 or by FAX at 1-402-351-2552.
The company will make all refunds to the applicant in the event of rejection, incomplete submission, overpayment,
Our General Administrative Rule – 12 Month Rate
Our current administrative practice is not to adjust rates for 12 months from the effective date of coverage. APPLICATION
Properly completed applications should be finalized within 5-7 days of receipt at Mutual of Omaha/United World.
The ideal turnaround time provided to the producer is 11-14 days, including mail time. Application Sections The Medicare supplement application consists of the Plan Information section and 4 parts that must be completed.
Please be sure to review your applications for the following information before submitting. Plan Information
This section should indicate the plan or policy form selected, effective date, premium paid, and the premium
payment mode selected — both initial and renewal
Part I — General Information
Please complete the client’s residence address in full. If premium notices are to be mailed to an address other
than the applicant’s residence address, please complete the mailing address in full Age and Date of Birth are
Complete the client’s Social Security Number and E-mail address (if one is available)
Verify the applicant answered “Yes” to receiving the Guide to Health Insurance and Outline of Coverage. It is
required to leave these two documents with the client at the time the application is completed
Answer the tobacco question. (Refer to the Calculating Premium section on page 13 for list of states where
Tobacco rates do not apply during Open Enrollment or Guarantee Issue situations)
Part II — Existing Coverage Information
Please indicate if the applicant is covered under Parts A and B of Medicare
Complete the applicant’s Medicare card number if they are covered under Medicare and the date they will be
If the applicant is applying during a Guarantee Issue period, be sure to include proof of eligibility
If the applicant has had coverage from any Medicare plan other than original Medicare within the past 63
days including a Medicare Advantage plan, or a Medicare HMO or PPO , or are still covered under this plan,
complete question #5 and include the replacement notice
If the applicant has had any other health insurance coverage in the past 63 days, including coverage through a
union, employer plan, or other non-Medicare supplement coverage, complete question #6
If the applicant has a Medicare supplement insurance policy inforce, complete question #7. If the applicant is
replacing another Medicare supplement policy, include the replacement notice
Verify if the applicant is covered through his/her state Medicaid program
List any other health insurance policies have been sold to the applicant by the Producer
Part III — Health/Medical Questions
If the applicant is applying during an open enrollment or a guarantee issue period, do not answer the health
If applicant is not considered to be in open enrollment or a guarantee issue situation, all health questions must
be answered, including the question regarding prescription medications
NOTE: In order to be considered eligible for coverage, all health questions must be answered “No.” For questions
on how to answer a particular health question, see the Health Questions section of this Guide for clarification. Part IV — Important Statements and Signatures
Applicant must read the important statements prior to signing application
Signatures and dates: required by both applicant and producer. The producer must be appointed in the state
NOTE: Applicant’s signature must match name of applicant on the application. In rare cases where applicant
cannot sign his/her name, a mark (“X”) is acceptable. For their own protection, producers are advised against
If someone other than the applicant is signing the application (i.e., Power of Attorney), please include copies
of the papers appointing that person as the legal representative
Unless an application is completed during open enrollment or a guarantee issue period, all health questions, including
the question regarding prescription medications, must be answered. Our general underwriting philosophy is to deny
Medicare supplement coverage if any of the health questions are answered “Yes.” For a list of uninsurable conditions
and the related medications associated with these conditions, please refer to page 17.
There may, however, be situations where an applicant has been receiving medical treatment or taking prescription
medication for a long-standing and controlled health condition. Those conditions are listed in health questions 8, 9
A condition is considered to be controlled if there have been no changes in treatment or medications for at least two
years. If this situation exists and you would like consideration to be given to the application, answer the appropriate
question “Yes,” and attach an explanation stating how long the condition has existed and how it is being controlled.
Be sure to include the names and dosages of all prescription medications.
If you have had questions about the interpretation of health questions f and g on the application, please see the
People with diabetes mellitus that require, or has ever required, more than 50 units of insulin daily, or people with
diabetes (insulin dependent or treated with oral medications) who also have one or more of the complicating
conditions listed in question f on the application, are not eligible for coverage. For purposes of this question,
hypertension (high blood pressure) is considered a heart condition. Some additional questions to ask your client to
determine if he/she does have a complication include:
2. Does he/she have numbness or tingling in the toes or feet?
3. Does he/she have problems with circulation? Pain in the legs?
Consideration for coverage may be given to those persons with well-controlled cases of hypertension and diabetes. A
case is considered to be well controlled if the person is taking less than 50 units of insulin daily or no more than two
oral medications for diabetes and no more than two medications for hypertension. A combination of less than 50 units
of insulin a day and one oral medication would be the same as two oral medications if the diabetes were well
controlled. In general, to verify stability, there should be no changes in the dosages or medications for at least two
years. Individual consideration will be given where deemed appropriate. We consider hypertension to be stable if
recent average blood pressure readings are 150/85 or lower. Uninsurable Health Conditions Applications should not be submitted if applicant has the following conditions:
Chronic Obstructive Pulmonary Disease (COPD)
Other chronic pulmonary disorders to include:
In addition to the above conditions, the following will also lead to a decline:
Asthma requiring continuous use of three or more medications including inhalers
Taking any medication that must be administered in a physician’s office
Advised to have surgery, medical tests, treatment or therapy
Partial List of Medications Associated with Uninsurable Health Conditions This list is not all-inclusive. An application should not be submitted if a client is taking any of the following
*Coverage not available for individuals with diabetes in MN. REQUIRED FORMS Application Only current Medicare supplement applications may be used in applying for coverage. A copy of the completed
application will be made by Mutual of Omaha/United World and attached to the policy to make it part of the contract.
The Producer or designated office staff is responsible for submitting completed applications to Mutual of Omaha/
Producer Information Page (Brokerage ONLY) Producers must include their name and Social Security number. A maximum of two producers is allowed and they
should indicate the commission percentage shares, which must total 100%. Authorization to Withdraw Funds Form If premiums are paid by automatic bank draft, complete this form. Conditional Receipt Must be completed and provided to applicant as receipt for premium collected. HIPAA Authorization Form Required with all underwritten applications. Replacement Form The replacement form must be completed, signed and submitted with the application when replacing any Medicare
supplement or Medicare Advantage application. A signed replacement notice must be left with the applicant; a second
signed replacement notice must be submitted with the application.
In New York, the replacement form must also be completed when replacing any other health insurance. Select Disclosure Agreement The Select Disclosure Agreement form must be signed and submitted with the application when a Select plan is
chosen (Select plan not available in all states). Agent or Witness Certification for Non English Speaking and/or Reading Applicants If the applicant does not speak English, this form is to be completed by the Agent if the Agent is translating or by a
witness if a witness is translating. A copy must be submitted with the application and a copy left with the Applicant. State Special Forms Forms specifically mandated by states to accompany point of sale material. Arkansas Documentation of Solicitation of Medicare Related Products – To be completed by Agent and retained by
the Agent in the applicant’s file. California California Agent / Applicant Meeting Form – To be completed and signed by the United World
representative and given to the Applicant when a meeting to discuss Medicare Supplement Insurance is
Guarantee Issue and Open Enrollment Notice for California – This form includes the requirements for
individuals who are eligible for Guaranteed Issue. This form must be read and signed by the Applicant and
Agent. A copy must be submitted with the application and a copy left with the Applicant. Florida Certification Form – This form is to be completed by the Agent, then signed by the Agent and
Applicant. A copy must be submitted with the application and a copy left with the Applicant. Important Notice before You Buy Health Insurance – To be left with the Applicant. Kentucky
Medicare Supplement Comparison Statement for Kentucky – When replacing a Medicare supplement,
Medicare Advantage or other health insurance policy, this form is to be reviewed with the Applicant,
completed and signed by Agent and Applicant. The form must be submitted with the application. Illinois Illinois Checklist – To be completed and signed by Agent and Applicant. A copy must be submitted with the
application and a copy left with the Applicant. Louisiana Your Rights Regarding the Release and Use of Genetic Information – This form is to be left with the Applicant. Minnesota Notice Concerning Policyholder Rights in Insolvency under the Minnesota Life and Health Insurance Guaranty Association Law – To be reviewed with the Applicant then signed by the Agent and Applicant. A
copy must be submitted with the application and a copy left with the Applicant. Agent Information Form – This form is be completed and signed by the Agent and left with the applicant. Montana Privacy Notice - Personal Information – This form is to be left with the Applicant. Nebraska Senior Health Counseling Notice – This form is to be left with the Applicant. New Mexico New Mexico Confidential Abuse Information – Optional form, submit copy if completed. Medicare Supplement Plan B Disclosure Agreement – To be signed and dated by Applicant if purchasing
Plan B. A copy must be submitted with the application and a copy left with the Applicant. Pennsylvania Guarantee Issue and Open Enrollment Notice – To be left with the Applicant.
ACTIONS EDUCATIVES ET VIE SCOLAIRE A.T.S.E.M. AGENTS SPECIALISES DES ECOLES MATERNELLES PUBLIQUES DE LA VILLE DE ROUEN JUIN 1998 - ASSISTANCE EDUCATIVE AU PERSONNEL ENSEIGNANT. - MISE EN ETAT DE PROPRETE DES MATERIELS ET DES LOCAUX OBJECTIF DE LA CHARTE La prÈsente charte est Ètablie en vue de dÈfinir les missions et de fixer les conditions de travaildes personnels des Èc