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MUTUAL of OMAHA INSURANCE COMPANY
UNITED WORLD LIFE INSURANCE COMPANY
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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
http://www.mutualofomaha.com/sales_professionals/index.html 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 Colorado
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.
New Jersey
Plan C available to people ages 50-64.
Guarantee Issue if within 6 months of Part B enrollment.
North Carolina 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 HEALTH QUESTIONS
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.

Source: http://blogs.mutualofomaha.com/donlilly/files/2008/10/m26589_1008.pdf