application for medicare supplement insurance · 2017-03-06 · heartland national life insurance...
TRANSCRIPT
HNAPP2010MO
HEARTLAND NATIONAL
LIFE INSURANCE COMPANY
Medicare Supplement Administrative Office:
PO Box 10812, Clearwater, FL 33757-8812
APPLICATION FOR
MEDICARE SUPPLEMENT INSURANCE
MISSOURI
HN
OC
2010
MO
E
ffec
tive:
01-
01-2
011
Pag
e 1
of 1
9
HE
AR
TLA
ND
NA
TIO
NA
L LI
FE IN
SU
RA
NC
E C
OM
PA
NY
O
utlin
e of
Med
icar
e S
uppl
emen
t Cov
erag
eB
enef
it P
lans
A, D
, F, G
, M, a
nd N
Ben
efit
Cha
rt o
f Med
icar
e S
uppl
emen
t Pla
ns S
old
for
Eff
ectiv
e D
ates
on
or A
fter
Jun
e 1,
2010
This
cha
rt s
how
s th
e be
nefit
s in
clud
ed i
n ea
ch o
f th
e st
anda
rd M
edic
are
supp
lem
ent
plan
s.
Eve
ry c
ompa
ny m
ust
mak
e P
lan
“A”
avai
labl
e. S
ome
plan
s m
ay n
ot b
e av
aila
ble
in y
our
stat
e. P
lans
E, H
, I, a
nd J
are
no
long
er a
vaila
ble
for
sale
. B
asic
Ben
efits
:��
Hos
pita
lizat
ion
– P
art A
coi
nsur
ance
plu
s co
vera
ge fo
r 36
5 ad
ditio
nal d
ays
afte
r M
edic
are
bene
fits
end.
��
Med
ical
Exp
ense
s –
Par
t B
coi
nsur
ance
(ge
nera
lly 2
0% o
f M
edic
are-
appr
oved
exp
ense
s) o
r co
paym
ents
for
hos
pita
l out
patie
nt
serv
ices
. P
lans
K, L
, and
N r
equi
re in
sure
ds to
pay
a p
ortio
n of
Par
t B c
oins
uran
ce o
r co
paym
ents
. ��
Blo
od –
Fir
st th
ree
pint
s of
blo
od e
ach
year
. ��
Hos
pice
– P
art A
coi
nsur
ance
AB
C
D
FF*
GK
L
MN
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce*
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 50%
Hos
pita
lizat
ion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basi
c be
nefit
s pa
id a
t 75%
Bas
ic,
incl
udin
g 10
0%
Par
t B
coin
sura
nce
Bas
ic, i
nclu
ding
10
0 %
Par
t B
coin
sura
nce
exce
pt u
p to
$2
0 co
paym
ent
for
offic
e vi
sit,
and
up to
$50
co
paym
ent f
or
ER
S
kille
d N
ursi
ng
Faci
lity
Coi
nsur
ance
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
50%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
75%
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Ski
lled
Nur
sing
Fa
cilit
y C
oins
uran
ce
Par
t A
Ded
uctib
le
Par
t A
Ded
uctib
le
Par
t A
Ded
uctib
le
Par
t A
Ded
uctib
le
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
75%
Par
t A
Ded
uctib
le
50%
Par
t A
Ded
uctib
le
Par
t A
Ded
uctib
le
P
art B
D
educ
tible
P
art B
D
educ
tible
P
art B
E
xces
s (1
00 %
)
Par
t B
Exc
ess
(100
%)
Fo
reig
n Tr
avel
E
mer
genc
y
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Fore
ign
Trav
el
Em
erge
ncy
Out
- of-
pock
et
limit
$464
0 pa
id a
t 100
%
afte
r lim
it re
ache
d
Out
-of -
Poc
ket
limit
$232
0 pa
id a
t 100
%
afte
r lim
it re
ache
d
*Pla
n F
also
has
an
optio
n ca
lled
a hi
gh d
educ
tible
Pla
n F.
Thi
s hi
gh d
educ
tible
pla
n pa
ys th
e sa
me
bene
fits
as P
lan
F af
ter
one
has
paid
a
cale
ndar
yea
r $2
000
dedu
ctib
le.
Ben
efits
fro
m h
igh
dedu
ctib
le p
lan
F w
ill n
ot b
egin
unt
il ou
t-of
-poc
ket
expe
nses
exc
eed
$200
0. O
ut-
of-p
ocke
t ex
pens
es f
or t
his
dedu
ctib
le a
re e
xpen
ses
that
wou
ld o
rdin
arily
be
paid
by
the
Pol
icy.
Th
ese
expe
nses
incl
ude
the
Med
icar
e de
duct
ible
s fo
r P
art A
and
Par
t B, b
ut d
o no
t inc
lude
the
plan
’s s
epar
ate
fore
ign
trav
el e
mer
genc
y de
duct
ible
.
Effe
ctiv
e 12
-01-
2010
HEA
RTL
AN
D N
ATI
ON
AL
LIFE
INSU
RA
NC
E C
OM
PAN
YO
ne-T
ime
Polic
y Fe
e $2
5
Issu
eN
on-T
obac
co U
ser
Issu
eA
gePl
an A
Plan
DPl
an F
Plan
GPl
an M
Plan
NA
gePl
an A
Plan
DPl
an F
Plan
GPl
an M
Plan
N0-
641,
430
1,92
52,
102
1,95
41,
791
1,52
20-
641,
589
2,13
82,
336
2,17
21,
990
1,69
165
1,30
71,
697
1,88
81,
726
1,58
31,
339
651,
452
1,88
62,
098
1,91
71,
759
1,48
766
1,30
91,
707
1,89
41,
736
1,59
21,
347
661,
454
1,89
82,
105
1,92
81,
769
1,49
667
1,31
01,
717
1,90
01,
744
1,60
11,
353
671,
455
1,90
82,
110
1,93
91,
779
1,50
368
1,33
41,
758
1,94
01,
786
1,63
81,
387
681,
482
1,95
52,
156
1,98
51,
821
1,54
169
1,35
81,
799
1,98
01,
828
1,67
61,
420
691,
509
2,00
12,
201
2,03
11,
863
1,57
970
1,38
11,
840
2,02
01,
871
1,71
41,
454
701,
536
2,04
82,
246
2,07
81,
905
1,61
771
1,40
51,
881
2,06
01,
913
1,75
21,
487
711,
563
2,09
42,
292
2,12
41,
947
1,65
572
1,43
01,
925
2,10
21,
954
1,79
11,
522
721,
589
2,13
82,
336
2,17
21,
990
1,69
173
1,45
01,
968
2,14
51,
998
1,83
01,
560
731,
611
2,18
62,
385
2,22
02,
034
1,73
274
1,47
12,
011
2,18
82,
042
1,86
81,
597
741,
634
2,23
32,
433
2,26
92,
077
1,77
375
1,49
12,
054
2,23
12,
087
1,90
71,
635
751,
657
2,28
12,
482
2,31
82,
120
1,81
476
1,51
22,
097
2,27
42,
131
1,94
61,
673
761,
679
2,32
82,
530
2,36
62,
163
1,85
577
1,53
32,
139
2,31
92,
173
1,98
51,
709
771,
703
2,37
72,
577
2,41
42,
206
1,89
978
1,53
92,
166
2,34
52,
199
2,00
81,
733
781,
711
2,40
62,
606
2,44
32,
232
1,92
679
1,54
52,
193
2,37
12,
225
2,03
01,
758
791,
718
2,43
52,
635
2,47
22,
258
1,95
380
1,55
22,
220
2,39
72,
251
2,05
31,
783
801,
726
2,46
52,
664
2,50
12,
284
1,98
081
1,55
82,
247
2,42
22,
277
2,07
61,
808
811,
733
2,49
42,
694
2,53
02,
310
2,00
782
1,56
72,
272
2,44
82,
305
2,10
11,
831
821,
741
2,52
52,
721
2,56
12,
335
2,03
483
1,57
62,
301
2,47
92,
334
2,12
81,
858
831,
751
2,55
72,
754
2,59
32,
364
2,06
484
1,58
42,
331
2,50
92,
363
2,15
51,
885
841,
760
2,59
02,
787
2,62
52,
393
2,09
485
1,59
32,
360
2,53
92,
392
2,18
21,
912
851,
770
2,62
22,
821
2,65
82,
422
2,12
486
1,60
22,
389
2,56
92,
421
2,20
91,
939
861,
780
2,65
52,
854
2,69
02,
452
2,15
587
1,61
02,
419
2,59
82,
453
2,23
51,
965
871,
790
2,68
72,
887
2,72
52,
483
2,18
388
1,61
82,
431
2,61
12,
465
2,24
51,
974
881,
798
2,70
02,
901
2,73
92,
495
2,19
389
1,62
52,
443
2,62
42,
476
2,25
61,
984
891,
807
2,71
42,
915
2,75
32,
508
2,20
490
1,63
42,
455
2,63
72,
488
2,26
71,
994
901,
815
2,72
82,
929
2,76
72,
521
2,21
591
1,64
32,
467
2,65
02,
501
2,27
82,
003
911,
824
2,74
22,
944
2,78
12,
534
2,22
692
1,65
12,
479
2,66
32,
514
2,29
02,
013
921,
833
2,75
62,
959
2,79
52,
547
2,23
793
1,66
02,
490
2,67
62,
527
2,30
12,
023
931,
841
2,77
02,
974
2,80
92,
560
2,24
794
1,66
92,
503
2,68
92,
540
2,31
32,
033
941,
851
2,78
42,
989
2,82
32,
573
2,25
895
1,67
72,
516
2,70
22,
553
2,32
52,
042
951,
861
2,79
83,
005
2,83
72,
586
2,26
996
1,68
62,
529
2,71
62,
566
2,33
72,
052
961,
871
2,81
23,
020
2,85
12,
598
2,28
197
1,69
52,
542
2,73
02,
579
2,34
92,
063
971,
880
2,82
63,
035
2,86
52,
611
2,29
398
1,70
32,
555
2,74
42,
592
2,36
12,
074
981,
890
2,84
03,
050
2,87
92,
624
2,30
599
1,71
22,
568
2,75
82,
605
2,37
32,
084
991,
900
2,85
43,
065
2,89
32,
637
2,31
7
Mod
al F
acto
rs:
Sem
i Ann
ual:
0.5
000
Qua
rterly
: 0.
2500
0
M
onth
ly: .
0833
3
MIS
SOU
RI S
tand
ard
Plan
s M
ALE
Rat
es -
AN
NU
AL
For u
se in
zip
cod
es:
All
zips
exc
ept 6
30-6
33, 6
40-6
41
Toba
cco
Use
r
HN
OC
2010
MO
Rat
e P
g 1
of 4
Effe
ctiv
e 12
-01-
2010
HEA
RTL
AN
D N
ATI
ON
AL
LIFE
INSU
RA
NC
E C
OM
PAN
YO
ne-T
ime
Polic
y Fe
e $2
5
Issu
eN
on-T
obac
co U
ser
Issu
eA
gePl
an A
Plan
DPl
an F
Plan
GPl
an M
Plan
NA
gePl
an A
Plan
DPl
an F
Plan
GPl
an M
Plan
N0-
641,
668
2,24
52,
452
2,27
92,
089
1,77
50-
641,
853
2,49
52,
725
2,53
42,
322
1,97
365
1,52
51,
979
2,20
22,
013
1,84
71,
562
651,
693
2,20
02,
448
2,23
72,
053
1,73
566
1,52
71,
992
2,21
02,
025
1,85
71,
571
661,
696
2,21
42,
456
2,24
92,
064
1,74
567
1,52
82,
003
2,21
62,
035
1,86
71,
579
671,
697
2,22
62,
462
2,26
22,
075
1,75
468
1,55
62,
051
2,26
32,
084
1,91
11,
618
681,
729
2,28
12,
515
2,31
62,
124
1,79
869
1,58
42,
099
2,31
02,
133
1,95
61,
657
691,
760
2,33
52,
568
2,37
02,
174
1,84
270
1,61
22,
147
2,35
62,
182
2,00
01,
696
701,
792
2,38
92,
621
2,42
42,
223
1,88
671
1,63
92,
195
2,40
32,
231
2,04
41,
735
711,
823
2,44
32,
674
2,47
82,
272
1,93
072
1,66
82,
245
2,45
22,
279
2,08
91,
775
721,
853
2,49
52,
725
2,53
42,
322
1,97
373
1,69
22,
296
2,50
22,
331
2,13
41,
819
731,
880
2,55
02,
782
2,59
12,
373
2,02
174
1,71
62,
346
2,55
32,
383
2,18
01,
864
741,
906
2,60
62,
839
2,64
72,
423
2,06
975
1,74
02,
397
2,60
32,
434
2,22
51,
908
751,
933
2,66
12,
895
2,70
42,
473
2,11
776
1,76
42,
447
2,65
42,
486
2,27
11,
952
761,
959
2,71
72,
952
2,76
12,
524
2,16
577
1,78
82,
496
2,70
52,
535
2,31
61,
993
771,
987
2,77
33,
006
2,81
62,
574
2,21
578
1,79
62,
528
2,73
52,
565
2,34
22,
022
781,
996
2,80
73,
040
2,85
02,
604
2,24
779
1,80
32,
559
2,76
62,
596
2,36
92,
051
792,
005
2,84
13,
074
2,88
42,
635
2,27
880
1,81
12,
591
2,79
62,
626
2,39
52,
080
802,
013
2,87
53,
108
2,91
82,
665
2,31
081
1,81
82,
622
2,82
62,
656
2,42
22,
109
812,
022
2,90
93,
142
2,95
22,
695
2,34
182
1,82
82,
651
2,85
62,
689
2,45
12,
136
822,
031
2,94
63,
174
2,98
72,
724
2,37
383
1,83
82,
685
2,89
22,
723
2,48
22,
167
832,
042
2,98
43,
213
3,02
52,
758
2,40
884
1,84
82,
719
2,92
72,
757
2,51
42,
199
842,
054
3,02
13,
252
3,06
32,
792
2,44
385
1,85
92,
753
2,96
22,
791
2,54
52,
230
852,
065
3,05
93,
291
3,10
12,
826
2,47
886
1,86
92,
787
2,99
82,
825
2,57
72,
262
862,
076
3,09
73,
330
3,13
92,
860
2,51
487
1,87
92,
822
3,03
22,
861
2,60
72,
292
872,
088
3,13
53,
368
3,17
92,
897
2,54
688
1,88
72,
836
3,04
72,
875
2,62
02,
303
882,
098
3,15
03,
384
3,19
52,
911
2,55
989
1,89
62,
850
3,06
22,
889
2,63
22,
315
892,
108
3,16
63,
401
3,21
22,
926
2,57
290
1,90
62,
864
3,07
72,
903
2,64
52,
326
902,
118
3,18
33,
417
3,22
82,
941
2,58
491
1,91
62,
878
3,09
22,
918
2,65
72,
337
912,
128
3,19
93,
435
3,24
52,
956
2,59
792
1,92
72,
892
3,10
72,
933
2,67
12,
349
922,
138
3,21
63,
452
3,26
12,
971
2,60
993
1,93
72,
906
3,12
22,
948
2,68
52,
360
932,
148
3,23
23,
470
3,27
72,
986
2,62
294
1,94
72,
921
3,13
72,
964
2,69
92,
371
942,
160
3,24
83,
488
3,29
43,
001
2,63
595
1,95
72,
936
3,15
32,
979
2,71
32,
383
952,
171
3,26
53,
505
3,31
03,
016
2,64
796
1,96
72,
951
3,16
92,
994
2,72
72,
394
962,
182
3,28
13,
523
3,32
63,
032
2,66
197
1,97
72,
966
3,18
53,
009
2,74
12,
407
972,
194
3,29
73,
541
3,34
33,
047
2,67
598
1,98
72,
981
3,20
23,
024
2,75
42,
419
982,
205
3,31
43,
558
3,35
93,
062
2,68
999
1,99
72,
996
3,21
83,
039
2,76
82,
432
992,
216
3,33
03,
576
3,37
63,
077
2,70
3
MIS
SOU
RI S
tand
ard
Plan
s M
ALE
Rat
es -
AN
NU
AL
For u
se in
zip
cod
es:
630-
633,
640
-641
Mod
al F
acto
rs:
Sem
i Ann
ual:
0.5
000
Qua
rterly
: 0.
2500
0
M
onth
ly: .
0833
3
Toba
cco
Use
r
HN
OC
2010
MO
Rat
e P
g 2
of 4
Effe
ctiv
e 12
-01-
2010
HEA
RTL
AN
D N
ATI
ON
AL
LIFE
INSU
RA
NC
E C
OM
PAN
YO
ne-T
ime
Polic
y Fe
e $2
5
Issu
eN
on-T
obac
co U
ser
Issu
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gePl
an A
Plan
DPl
an F
Plan
GPl
an M
Plan
NA
gePl
an A
Plan
DPl
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Plan
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an M
Plan
N0-
641,
244
1,67
41,
828
1,70
01,
558
1,32
40-
641,
382
1,86
02,
031
1,88
91,
731
1,47
165
1,13
71,
476
1,64
31,
501
1,37
81,
164
651,
264
1,64
11,
825
1,66
81,
531
1,29
466
1,13
81,
486
1,64
81,
510
1,38
61,
171
661,
265
1,65
01,
831
1,67
71,
540
1,30
167
1,13
91,
495
1,65
21,
517
1,39
21,
177
671,
266
1,66
01,
836
1,68
61,
548
1,30
868
1,16
01,
530
1,68
81,
554
1,42
61,
206
681,
290
1,70
01,
875
1,72
71,
584
1,34
069
1,18
01,
566
1,72
41,
591
1,45
91,
236
691,
313
1,74
01,
914
1,76
81,
621
1,37
370
1,20
11,
602
1,75
91,
628
1,49
31,
265
701,
337
1,78
01,
953
1,80
91,
658
1,40
571
1,22
11,
637
1,79
51,
664
1,52
61,
294
711,
361
1,82
01,
992
1,85
01,
695
1,43
772
1,24
41,
674
1,82
81,
700
1,55
81,
324
721,
382
1,86
02,
031
1,88
91,
731
1,47
173
1,26
31,
712
1,86
61,
738
1,59
21,
356
731,
402
1,90
22,
074
1,93
11,
769
1,50
774
1,28
11,
750
1,90
41,
776
1,62
51,
389
741,
421
1,94
42,
116
1,97
31,
807
1,54
275
1,29
91,
787
1,94
21,
813
1,65
91,
421
751,
441
1,98
62,
158
2,01
51,
845
1,57
876
1,31
81,
825
1,98
01,
851
1,69
21,
454
761,
460
2,02
82,
200
2,05
71,
882
1,61
477
1,33
41,
861
2,01
71,
890
1,72
71,
486
771,
482
2,06
82,
242
2,10
11,
919
1,65
178
1,34
01,
885
2,04
01,
913
1,74
71,
508
781,
488
2,09
42,
267
2,12
71,
942
1,67
579
1,34
71,
908
2,06
31,
935
1,76
81,
529
791,
495
2,12
02,
292
2,15
21,
965
1,69
980
1,35
31,
932
2,08
51,
958
1,78
81,
551
801,
501
2,14
62,
317
2,17
81,
987
1,72
381
1,36
01,
956
2,10
81,
981
1,80
91,
572
811,
508
2,17
22,
341
2,20
42,
010
1,74
682
1,36
41,
977
2,13
02,
006
1,82
71,
592
821,
515
2,19
72,
367
2,22
82,
031
1,76
983
1,37
22,
002
2,15
62,
031
1,85
11,
616
831,
524
2,22
52,
397
2,25
62,
057
1,79
584
1,37
92,
027
2,18
22,
057
1,87
51,
639
841,
533
2,25
32,
426
2,28
42,
083
1,82
185
1,38
72,
052
2,20
82,
083
1,89
91,
663
851,
541
2,28
12,
455
2,31
22,
109
1,84
786
1,39
42,
077
2,23
32,
109
1,92
21,
687
861,
550
2,30
92,
484
2,34
02,
135
1,87
387
1,40
12,
104
2,26
02,
134
1,94
41,
710
871,
557
2,33
82,
511
2,37
12,
160
1,90
088
1,40
72,
115
2,27
12,
145
1,95
41,
718
881,
565
2,35
02,
524
2,38
22,
171
1,90
989
1,41
52,
125
2,28
32,
156
1,96
31,
727
891,
572
2,36
22,
537
2,39
42,
182
1,91
990
1,42
22,
136
2,29
52,
166
1,97
31,
736
901,
580
2,37
42,
550
2,40
62,
192
1,92
991
1,43
02,
147
2,30
72,
177
1,98
31,
744
911,
588
2,38
62,
563
2,41
82,
203
1,93
992
1,43
72,
158
2,31
92,
188
1,99
31,
753
921,
595
2,39
82,
576
2,43
02,
214
1,94
893
1,44
52,
169
2,33
12,
199
2,00
21,
761
931,
603
2,40
92,
589
2,44
22,
225
1,95
894
1,45
32,
179
2,34
32,
210
2,01
21,
770
941,
610
2,42
12,
602
2,45
42,
236
1,96
895
1,46
02,
190
2,35
42,
220
2,02
21,
779
951,
618
2,43
32,
615
2,46
62,
246
1,97
796
1,46
82,
201
2,36
62,
231
2,03
11,
787
961,
625
2,44
52,
628
2,47
82,
257
1,98
797
1,47
52,
212
2,37
82,
242
2,04
11,
796
971,
634
2,45
72,
641
2,48
92,
268
1,99
798
1,48
32,
223
2,39
02,
253
2,05
11,
805
981,
643
2,46
92,
654
2,50
22,
280
2,00
799
1,49
02,
233
2,40
22,
264
2,06
11,
813
991,
651
2,48
12,
667
2,51
52,
292
2,01
6
For u
se in
zip
cod
es:
All
zips
exc
ept 6
30-6
33, 6
40-6
41M
ISSO
UR
I Sta
ndar
d Pl
ans
FEM
ALE
Rat
es -
AN
NU
AL To
bacc
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ser
Mod
al F
acto
rs:
Sem
i Ann
ual:
0.5
000
Qua
rterly
: 0.
2500
0
M
onth
ly: .
0833
3
HN
OC
2010
MO
Rat
e P
g 3
of 4
Effe
ctiv
e 12
-01-
2010
HEA
RTL
AN
D N
ATI
ON
AL
LIFE
INSU
RA
NC
E C
OM
PAN
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Polic
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Plan
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Plan
N0-
641,
452
1,95
32,
133
1,98
31,
818
1,54
50-
641,
613
2,17
02,
370
2,20
42,
020
1,71
665
1,32
71,
722
1,91
61,
751
1,60
81,
358
651,
474
1,91
42,
129
1,94
51,
787
1,50
966
1,32
81,
734
1,92
31,
761
1,61
71,
366
661,
475
1,92
52,
136
1,95
71,
797
1,51
867
1,32
91,
744
1,92
81,
770
1,62
41,
373
671,
477
1,93
72,
142
1,96
71,
806
1,52
668
1,35
31,
785
1,96
91,
813
1,66
31,
407
681,
504
1,98
32,
187
2,01
51,
848
1,56
469
1,37
71,
827
2,01
11,
856
1,70
21,
441
691,
532
2,03
02,
233
2,06
31,
891
1,60
170
1,40
11,
869
2,05
31,
899
1,74
11,
475
701,
560
2,07
62,
278
2,11
11,
934
1,63
971
1,42
51,
910
2,09
41,
942
1,78
01,
509
711,
588
2,12
32,
323
2,15
81,
977
1,67
772
1,45
21,
953
2,13
31,
983
1,81
81,
545
721,
613
2,17
02,
370
2,20
42,
020
1,71
673
1,47
31,
997
2,17
72,
027
1,85
71,
583
731,
635
2,21
92,
419
2,25
32,
064
1,75
874
1,49
42,
041
2,22
12,
071
1,89
61,
620
741,
658
2,26
82,
468
2,30
22,
108
1,79
975
1,51
62,
085
2,26
52,
116
1,93
51,
658
751,
681
2,31
72,
517
2,35
12,
152
1,84
176
1,53
72,
129
2,31
02,
160
1,97
41,
696
761,
704
2,36
62,
567
2,40
02,
196
1,88
277
1,55
62,
171
2,35
42,
205
2,01
51,
734
771,
729
2,41
32,
616
2,45
12,
239
1,92
778
1,56
42,
199
2,38
02,
231
2,03
91,
759
781,
736
2,44
32,
645
2,48
12,
265
1,95
479
1,57
12,
226
2,40
72,
258
2,06
31,
784
791,
744
2,47
32,
674
2,51
12,
292
1,98
280
1,57
92,
254
2,43
32,
284
2,08
71,
809
801,
751
2,50
42,
703
2,54
12,
318
2,01
081
1,58
62,
282
2,46
02,
311
2,11
11,
835
811,
759
2,53
42,
732
2,57
22,
345
2,03
782
1,59
12,
307
2,48
52,
340
2,13
21,
857
821,
768
2,56
32,
762
2,59
92,
370
2,06
483
1,60
02,
336
2,51
52,
370
2,16
01,
885
831,
778
2,59
62,
796
2,63
22,
400
2,09
484
1,60
92,
365
2,54
52,
400
2,18
71,
913
841,
788
2,62
82,
830
2,66
52,
431
2,12
485
1,61
82,
394
2,57
52,
431
2,21
51,
940
851,
798
2,66
12,
864
2,69
82,
461
2,15
586
1,62
72,
423
2,60
62,
461
2,24
31,
968
861,
808
2,69
42,
898
2,73
02,
491
2,18
587
1,63
42,
454
2,63
72,
490
2,26
81,
995
871,
817
2,72
82,
930
2,76
62,
520
2,21
688
1,64
22,
467
2,65
02,
502
2,27
92,
005
881,
826
2,74
22,
945
2,78
02,
533
2,22
889
1,65
12,
480
2,66
42,
515
2,29
12,
015
891,
835
2,75
62,
960
2,79
32,
545
2,23
990
1,65
92,
492
2,67
82,
528
2,30
22,
025
901,
843
2,76
92,
975
2,80
72,
558
2,25
091
1,66
82,
505
2,69
12,
540
2,31
32,
035
911,
852
2,78
32,
990
2,82
12,
570
2,26
292
1,67
72,
517
2,70
52,
553
2,32
52,
045
921,
861
2,79
73,
005
2,83
52,
583
2,27
393
1,68
62,
530
2,71
92,
565
2,33
62,
055
931,
870
2,81
13,
020
2,84
92,
596
2,28
494
1,69
52,
543
2,73
32,
578
2,34
72,
065
941,
879
2,82
53,
035
2,86
32,
608
2,29
695
1,70
42,
555
2,74
72,
591
2,35
92,
075
951,
887
2,83
93,
050
2,87
72,
621
2,30
796
1,71
22,
568
2,76
12,
603
2,37
02,
085
961,
896
2,85
33,
066
2,89
02,
633
2,31
897
1,72
12,
580
2,77
52,
616
2,38
12,
095
971,
906
2,86
73,
081
2,90
42,
646
2,33
098
1,73
02,
593
2,78
82,
628
2,39
32,
105
981,
916
2,88
03,
096
2,91
92,
660
2,34
199
1,73
92,
606
2,80
22,
641
2,40
42,
116
991,
927
2,89
43,
111
2,93
52,
674
2,35
2
MIS
SOU
RI S
tand
ard
Plan
s FE
MA
LE R
ates
- A
NN
UA
LFo
r use
in z
ip c
odes
: 63
0-63
3, 6
40-6
41
Toba
cco
Use
r
Mod
al F
acto
rs:
Sem
i Ann
ual:
0.5
000
Qua
rterly
: 0.
2500
0
M
onth
ly: .
0833
3
HN
OC
2010
MO
Rat
e P
g 4
of 4
HNOC2010MO Effective: 01-01-2011 Page 2 of 19
PREMIUM INFORMATION
Heartland National Life Insurance Company may change your premium on any premium due date if a new table of rates is applicable to the policy. The change in the table of rates will apply to all covered persons in the same class. Class is defined as issue age, sex, underwriting class, state and zip code of residence.
Premiums are based on your issue age.
DISCLOSURES Use this outline to compare benefits and premiums among policies.
This outline shows benefits and premiums of Policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale.
READ YOUR POLICY VERY CAREFULLY This is only an outline describing your Policy’s most important features. The Policy is your insurance contract. You must read the Policy itself to understand all of the rights and duties of both you and Heartland National Life Insurance Company.
RIGHT TO RETURN POLICY If you find that you are not satisfied with your Policy, you may return it to: Heartland National Life Insurance Company, Medicare Supplement Administration, P.O. Box 10814, Clearwater, Florida 33757-8814. If you send the Policy back to us within 30 days after you receive it, we will treat the Policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICEThis Policy may not fully cover all of your medical costs. Neither Heartland National Life Insurance Company nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new Policy, be sure to answer truthfully and completely all questions about your medical and health history. Heartland National Life Insurance Company may cancel your Policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
Please refer to your Policy for details.
HNOC2010MO Effective: 01-01-2011 Page 3 of 19
PLAN AMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1132 $0 $1132 (Part A deductible)
61st thru 90th day All but $283 a day $283 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $566 a day $566 a day $0 — Once lifetime reserve days
are used:
—Additional 365 days $0 100% of Medicare eligible expenses
$0**
— Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $141.50 a day $0 Up to $141.50 a day 101st day and after $0 $0 All costs
BLOOD
First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care
Medicarecopayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
HNOC2010MO Effective: 01-01-2011 Page 4 of 19
PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $162 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICAREPAYS PLAN PAYS YOU PAY
MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,
First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible)Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0
PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible)Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
PARTS A & B
SERVICES MEDICAREPAYS PLAN PAYS YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES
— Medically necessary skilled care services and medical supplies 100% $0 $0
— Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible)Remainder of Medicare Approved Amounts 80% 20% $0
HNOC2010MO Effective: 01-01-2011 Page 5 of 19
PLAN D MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1132 $1132 (Part A deductible) $0 61st thru 90th day All but $283 a day $283 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $566 a day $566 a day $0 — Once lifetime reserve
days are used:
— Additional 365 days $0 100% of Medicare eligible expenses
$0**
— Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $141.50 a day Up to $141.50 a day $0 101st day and after $0 $0 All costs
BLOOD
First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care
Medicareco-payment/coinsurance $0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
HNOC2010MO Effective: 01-01-2011 Page 6 of 19
PLAN D
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $162 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,
First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0
PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
(continued)
HNOC2010MO Effective: 01-01-2011 Page 7 of 19
PLAN D PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES — Medically necessary skilled
care services and medical supplies 100% $0 $0
— Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000.
20% and amounts over the $50,000 lifetime maximum.
HNOC2010MO Effective: 01-01-2011 Page 8 of 19
PLAN F
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and suppliesFirst 60 days All but $1132 $1132 (Part A deductible) $0 61st thru 90th day All but $283 a day $283 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $566 a day $566 a day $0 — Once lifetime reserve
days are used:
—Additional 365 days $0 100% of Medicare eligible expenses
$0**
— Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $141.50 a day Up to $141.50 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care
Medicareco-payment/coinsurance $0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
HNOC2010MO Effective: 01-01-2011 Page 9 of 19
PLAN F
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $162 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAYMEDICAL EXPENSES –IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,
First $162 of Medicare Approved Amounts* $0 $162 (Part B deductible) $0 Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0
PART B EXCESS CHARGES(Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved amounts* $0 $162 (Part B deductible) $0 Remainder of Medicare Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
(continued)
HNOC2010MO Effective: 01-01-2011 Page 10 of 19
PLAN F
PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS YOU PAYHOME HEALTH CARE MEDICARE APPROVED SERVICES
— Medically necessary skilled care services and medical supplies 100% $0 $0
— Durable medical equipment First $162 of Medicare Approved Amounts* $0 $162 (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0
OTHER SERVICES – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS PLAN PAYS YOU PAYFOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
HNOC2010MO Effective: 01-01-2011 Page 11 of 19
PLAN G
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1132 $1132 (Part A deductible) $0 61st thru 90th day All but $283 a day $283 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $566 a day $566 a day $0 — Once lifetime reserve days
are used:
— Additional 365 days $0 100% of Medicare eligible expenses
$0**
— Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $141.50 a day Up to $141.50 a day $0 101st day and after $0 $0 All costs
BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care
Medicareco-payment/coinsurance $0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
HNOC2010MO Effective: 01-01-2011 Page 12 of 19
PLAN G
MEDICARE (PART B) – MEDICAL SERVICES-PER – CALENDAR YEAR
*Once you have been billed $162 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,
First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0
PART B EXCESS CHARGES(Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
(continued)
HNOC2010MO Effective: 01-01-2011 Page 13 of 19
PLAN G PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES
— Medically necessary skilled care services and medical supplies 100% $0 $0
— Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250
Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000.
20% and amounts over the $50,000 lifetime maximum
HNOC2010MO Effective: 01-01-2011 Page 14 of 19
PLAN M MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1132 $566 (50% of Part A deductible)
$566 (50% of Part A deductible)
61st thru 90th day All but $283 a day $283 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $566 a day $566 a day $0 — Once lifetime reserve
days are used:
— Additional 365 days $0 100% of Medicare eligible expenses
$0**
— Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $141.50 a day Up to $141.50 a day $0 101st day and after $0 $0 All costs
BLOOD
First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care
Medicareco-payment/coinsurance $0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
HNOC2010MO Effective: 01-01-2011 Page 15 of 19
PLAN M
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $162 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,
First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0
PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
(continued)
HNOC2010MO Effective: 01-01-2011 Page 16 of 19
PLAN M PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES — Medically necessary skilled
care services and medical supplies 100% $0 $0
— Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000.
20% and amounts over the $50,000 lifetime maximum.
HNOC2010MO Effective: 01-01-2011 Page 17 of 19
PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY
HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1132 $1132 (Part A deductible) $0 61st thru 90th day All but $283 a day $283 a day $0 91st day and after: — While using 60 lifetime
reserve days All but $566 a day $566 a day $0 — Once lifetime reserve
days are used:
— Additional 365 days $0 100% of Medicare eligible expenses
$0**
— Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE*
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts $0 $0 21st thru 100th day All but $141.50 a day Up to $141.50 a day $0 101st day and after $0 $0 All costs
BLOOD
First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0
HOSPICE CARE
You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care
Medicareco-payment/coinsurance $0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
HNOC2010MO Effective: 01-01-2011 Page 18 of 19
PLAN N
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*Once you have been billed $162 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $162 of Medicare Approved Amounts*
$0 $0 $162 (Part B deductible)
Remainder of Medicare Approved Amounts
Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Up to $20 per office visit and up to $50 per emergency visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
(continued)
HNOC2010MO Effective: 01-01-2011 Page 19 of 19
PLAN N PARTS A & B
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES — Medically necessary skilled
care services and medical supplies 100% $0 $0
— Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime
maximum benefit of $50,000.
20% and amounts over the $50,000 lifetime maximum.
HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 1 of 7
HEARTLAND NATIONAL LIFE INSURANCE COMPANY Home Office: Indianapolis, Indiana 46280
Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812
APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE
Application #:
Applicant (Exactly as shown on your Medicare ID Card) Residence Address:
Last Street
First MI City
Indicate the Medicare Supplement Plan Applied for: State Zip Code
Plan: ___________________________________
Phone: (______) _______ - _________________
SOCIAL SECURITY NUMBER MEDICARE CLAIM NUMBER
AGE DATE OF BIRTH GENDER HEIGHT WEIGHT
Month Day Year
Male
Female _____ ft _____ in ________ lbs
PREMIUM PAYMENT
Modal Premium: $ Policy Fee: $
Total Submitted Premium: $ Requested Effective Date:
or Draft Initial Premium
PLEASE SELECT THE METHOD OF PAYMENT YOU WANT
Annual Semiannual Quarterly Monthly Bank Draft
I authorize Bank Draft payments. Account Type: Checking
Savings Amount to be drafted: $ ______________
Bank Routing # (9 digits): Bank Account # (do not include check #): Select Bank Draft Day: (Cannot be more than 10 days beyond effective day)
_____________________ ________________________________ ______________________________
Bank Name: _______________________________________________________
Name(s) of Depositor(s): _______________________________________________
Signature of Depositor: _______________________________________________ Date: _______________
Please include a voided check on a separate sheet of paper.
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HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 2 of 7
PLEASE ANSWER ALL ELIGIBILITY QUESTIONS
1. Have you used tobacco in any form in the past 12 months? Yes No
2. Are you covered under Medicare Part A? Yes No
If YES, what is your Part A effective date? _____/_____/_____
If NO, what is your eligibility date? _____/_____/_____
3. Are you covered under Medicare Part B?
Yes No
If YES, what is your Part B effective date? _____/_____/_____
If NO, what is your eligibility date? _____/_____/_____
4. Are you applying during a guaranteed issue period? (If YES please attach proof of eligibility). Yes No
MEDICARE & INSURANCE INFORMATION (MUST BE COMPLETED)
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare Supplement policy, or that you had certain rights to buy such a policy you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the notice from your prior insurer with our application. PLEASE ANSWER ALL QUESTIONS. Please Mark Yes or No with an “X”.
To the best of your knowledge:
1. Did you turn age 65 in the last six months? Yes No
2. Did you enroll in Medicare Part B in the last six months? Yes No
If “Yes”, what is the effective date? ______/______/______
3. Are you covered for medical assistance through the state Medicaid program? Yes No
NOTE TO APPLICANT: If you are participating in a “Spend-Down” program and have not met your “Share of Cost,” please answer NO to this question. If Yes, answer a-b below.
(a) Will Medicaid pay your premiums for this Medicare Supplement policy? Yes No
(b) Do you receive any benefits from Medicaid OTHER THAN payment toward your Medicare Part B premium? Yes No
4. (a) If you had coverage from any Medicare plan other than original Medicare within the last 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO) fill in your start and end dates. (If you are still covered under the other policy, leave “END” blank.) Start ____/____/____ End ____/____/____
If YES, with which company ________________________________________________
Company telephone number: ____________________ Policy number: ______________
(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy? Yes No
(c) Was this your first time in this type of Medicare plan? Yes No
(d) Did you drop a Medicare Supplement plan to enroll in this Medicare plan? Yes No
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HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 3 of 7
MEDICARE & INSURANCE INFORMATION (Continued)
5. (a) Do you have another Medicare Supplement policy in force? Yes No
(b) If yes with which company:
with which plan:
what paid-to-date do you have? ______/______/______
Company telephone number: ____________________________________________
(c) If yes, do you intend to replace your current Medicare Supplement policy with this policy? Yes No
6. Have you had coverage under any other health insurance within the past 63 days (for example, an employer, union, or individual plan)? Yes No
(a) If yes, with which company :___________________________________________
what kind of policy__________________________________________________
what paid-to-date do you have? ______/______/______
Company telephone number: __________________________________________
(b) What are your dates of coverage under the other policy? (If you are still covered under the other policy, leave “END” blank.) Start ____/_____/_____ End ____/_____/_____
IMPORTANT STATEMENTS TO BE READ AND SIGNED BY THE APPLICANT
(1) You do not need more than one Medicare Supplement Insurance Policy.
(2) If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.
(3) You may be eligible for benefits under Medicaid and may not need a Medicare Supplement Insurance Policy.
(4) If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement Insurance 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.
(5) 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.
(6) Counseling services may be available in your state to provide advice concerning your purchase of a Medicare Supplement Insurance policy 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).
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HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 4 of 7
HEALTH QUESTIONS
Do not answer health questions 1-15 if you are in an open enrollment or guaranteed issue period. Please see page 6 for an explanation of open enrollment /guaranteed issue period information.
NOTICE TO APPLICANT: Please answer all of the following questions. Please verify the accuracy and completeness of the medical information on this application. Incomplete or false information on this application could jeopardize future claims. If you answer YES to any of the following questions 1 - 14, you are not eligible for coverage.
1. Are you currently hospitalized or confined to a nursing facility; or, are you bedridden or confined to a wheelchair?
Yes No
2. Have you been diagnosed with emphysema, chronic obstructive pulmonary disease (COPD) or other chronic pulmonary disorders?
Yes No
3. Have you been diagnosed with Parkinson’s disease, systemic lupus, myasthenia gravis, multiple or lateral sclerosis, osteoporosis with fractures, cirrhosis or kidney disease requiring dialysis?
Yes No
4. Have you been diagnosed with Alzheimer’s disease, senile dementia, or any other cognitive disorder?
Yes No
5. Have you been diagnosed with or treated for acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC)?
Yes No
6. If you have diabetes, do you have any of the following conditions: diabetic retinopathy, peripheral vascular disease, neuropathy, any heart condition (including high blood pressure), or kidney disease? If you do not have diabetes, this question should be answered “NO.”
Yes No
7. Do you have diabetes that has ever required more than 50 units of insulin daily? Yes No
8. Within the past two years have you been treated for or been advised by a physician to have treatment for internal cancer, alcoholism, drug abuse, mental or nervous disorder requiring psychiatric care or have you had any amputation caused by disease?
Yes No
9. Within the past two years have you been treated for or been advised by a physician to have treatment for heart attack, heart, coronary or carotid artery disease (not including high blood pressure), peripheral vascular disease, congestive heart failure or enlarged heart, stroke, transient ischemic attacks (TIA) or heart rhythm disorders?
Yes No
10. Within the past two years have you been treated for degenerative bone disease, crippling/disabling or rheumatoid arthritis or have you been advised to have a joint replacement?
Yes No
11. Have you been advised by a physician that surgery may be required within twelve (12) months for cataracts?
Yes No
12. Have you been advised by a physician to have surgery, medical tests, treatment or therapy that has not been performed?
Yes No
13. Have you been hospital confined three or more times in the last two years? Yes No
14. Have you had an organ transplant or been advised by a physician to have an organ transplant?
Yes No
Return to Company.
HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 5 of 7
HEALTH QUESTIONS Continued
15. Are you taking or have you taken any prescription or over-the-counter medications within the past 12 months? If YES, please list the drug(s) below along with the date prescribed, dosage/frequency and diagnosis/medical condition for each medication. Attach a separate sheet if needed.
Yes No
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/ Medical Condition
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/Medical Condition
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/Medical Condition
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/Medical Condition
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/Medical Condition
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/Medical Condition
Medication Name (copy off pharmacy label)
Date Originally Prescribed
Dosage and Frequency
Diagnosis/Medical Condition
PRIMARY CARE PHYSICIAN INFORMATION
Physician’s Name: _____________________________________________________________________
Telephone Number: ____________________________________________________________________
Return to Company.
HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 6 of 7
OPEN ENROLLMENT/GUARANTEED ISSUE PERIOD INFORMATION Open Enrollment: You are eligible for Open Enrollment and will not need to answer Health Questions 1-15 on pages 4 and 5 of this application if (a) you are within six months of purchasing Medicare Part B coverage for the first time; or (b) you were eligible for early Medicare and you are within six months of turning age 65.
Guaranteed Issue For Eligible Persons Under the Balanced Budget Act of 1997: The following are definitions of the categories of individuals who are eligible for Guaranteed Issue under the Balanced Budget Act of 1997:
(a) Enrolled under an employee welfare benefit plan that that provides health benefits that supplement the benefits under Medicare; and the plan terminates, or the plan ceases to provide all such supplemental health benefits to the individual, or the individual leaves the plan; or
(b) Enrolled in a Medicare Advantage plan or Program of All-Inclusive Care for the Elderly (PACE) and the organization’s certification or plan is terminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of the individual, the plan is terminated within a residence area, the organization substantially violated a material policy provision, or a material misrepresentation was made to the individual; or
(c) Enrolled in a Medicare risk contract, health care prepayment plan, cost contract or Medicare Select plan, or similar organization, and the organization’s certification or plan is terminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of the individual, the plan is terminated within a residence area, the organization substantially violated a material policy provision, or a material misrepresentation was made to the individual; or
(d) Enrolled in a Medicare Supplement policy and coverage discontinues due to insolvency, substantial violation of a material policy provision, or material misrepresentation; or
(e) Enrolled under a Medicare Supplement policy, terminates and enrolls for the first time in a Medicare Advantage, a risk or cost contract, or a Medicare Select plan, a PACE provider, and then terminates coverage within 12 months of enrollment; or
(f) Upon first becoming eligible for benefits under Part A at age 65, enrolls in a Medicare Advantage or PACE provider and then disenrolls within 12 months; or
(g) Terminates Medicare Supplement coverage within 30 days of their annual policy anniversary.
Documentation of these events must be submitted with the application. You must apply within 63 days of the date of termination of previous coverage in order to qualify as an eligible person.
AGENT’S CERTIFICATION
The undersigned Agent certifies that the Applicant has read, or has had read to them, the completed application and that the Applicant realizes that any false statement or misrepresentation in the application may result in loss of coverage under the policy.
TO BE COMPLETED BY AGENT (Attach separate sheet, if necessary)
1. List any other health insurance policy you have sold to the Applicant that is still in force.
2. List any other health insurance policy you have sold to the Applicant in the past five (5) years that is no longer in force.
I certify that:
1. I have accurately recorded the information supplied by the Applicant; and 2. I have given an outline of coverage for the policy applied for and a Guide To Health Insurance for People With
Medicare to the Applicant.
Date Agent #1 Signature
Agent #1 Name (please print) Agent # Split %
Date
Agent #2 Signature
Agent #2 Name (please print) Agent # Split %
Return to Company.
HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 7 of 7
AUTHORIZATION AND CERTIFICATION
I hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager or other medical facility, insurance or reinsurance company, Medical Information Bureau (MIB), consumer reporting agency, Division of Motor Vehicles, the Veterans Administration or other medical or medically-related facility, insurance company or Medicare, that has any records or knowledge of me or my health to give Heartland National Life Insurance Company, or its reinsurers, any such information. I understand that I am authorizing Heartland National Life Insurance Company to receive my health information and prescription drug usage history. The released information received by Heartland National Life Insurance Company will remain protected by federal and/or state regulations as long as it is maintained by the health plan. Any information that is disclosed pursuant to this authorization may be redisclosed as provided herein or as required or authorized by law and may then no longer be covered by federal rules governing privacy and confidentiality of health information. Medical information will not be used to decline coverage if I am applying during an open enrollment or guaranteed issue period.
I understand that the information requested is necessary for evaluation and underwriting of my application for the Medicare Supplement Insurance Policy for which I have applied; to determine eligibility for insurance, risk rating or policy issue determinations; obtain reinsurance; administer claims and determine or fulfill responsibility for coverage and provision of benefits; and to conduct other legally permissible activities that relate to any coverage I have, or have applied for, with Heartland National Life Insurance Company. I understand that telephone interviews may be a part of the application process and that any information obtained from such telephone interviews may be used to decline my application for coverage. I understand that failure to provide the authorization to Heartland National Life Insurance Company will result in the rejection of the Medicare Supplement Insurance Policy coverage. I understand that I may revoke this authorization at any time by notifying Heartland National Life Insurance Company in writing at their Medicare Supplement Administrative Office: P.O. Box 10812, Clearwater, Florida 33757-8812. I understand that such revocation will not have any effect on actions Heartland National Life Insurance Company took prior to their receiving the revocation notice. I understand that this authorization will be valid for twenty-four (24) months from the date signed if used in connection with an application for an insurance policy, reinstatement of an insurance policy, or change in policy benefits. A photocopy of this authorization will be treated in the same manner as the original. I understand that I or my authorized representative am entitled to a copy of this authorization.
To the best of my knowledge and belief, all of the answers to the questions contained in this application are true and complete and I understand and agree that: (a) the insurance shall not take effect until my Medicare coverage is effective, the application has been accepted and approved by the Company, the first premium has been paid, and the policy has been delivered to the applicant; and (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing. The undersigned applicant certifies that the applicant has read, or had read to him, the completed application and that he realizes that any false statements or misrepresentations therein material to the risk may result in loss of coverage under the policy to which this application is a part. I understand that any change in my health history prior to delivery of this policy may be used in the underwriting evaluation process.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I wish to apply for a Medicare supplement insurance policy. I acknowledge that I have received or been given access to review: (a) an Outline of Coverage for the policy applied for, and (b) a ”Guide to Health Insurance for People with Medicare.”
Signed at: State Applicant’s Signature Date This section to be completed by an agent.
Signed at: State Writing Agent’s Signature and Agent Number Date
Policy Mailing Preference: Mail to Agent Mail to Applicant
Return to Company.
MSREPL2010
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE
OR MEDICARE ADVANTAGE
HEARTLAND NATIONAL LIFE INSURANCE COMPANY
Home Office: Indianapolis, Indiana 46280 Medicare Supplement Administrative Office: P. O. Box 10812 Clearwater, Florida 33757-8812
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE!
According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Heartland National Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY AGENT: I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):
Additional benefits. No change in benefits, but lower premiums
Fewer benefits and lower premiums.
Change in benefits (Gaining additional benefit(s), but losing some existing benefit(s)).
My plan has outpatient drug coverage and I am enrolling in Part D.
Disenrollment from a Medicare Advantage Plan. Please explain reason for disenrollment.
Other (please specify) ________________________________________________________________
If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
Signature of Agent, Broker or Other Representative Agent’s Printed Name and Address
The above “Notice to Applicant” was delivered to me on:
Applicant’s Signature Date
Return to Company.
HNAPP2010MO HEARTLAND NATIONAL LIFE INSURANCE COMPANY Page 7 of 7
AUTHORIZATION AND CERTIFICATION
I hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager or other medical facility, insurance or reinsurance company, Medical Information Bureau (MIB), consumer reporting agency, Division of Motor Vehicles, the Veterans Administration or other medical or medically-related facility, insurance company or Medicare, that has any records or knowledge of me or my health to give Heartland National Life Insurance Company, or its reinsurers, any such information. I understand that I am authorizing Heartland National Life Insurance Company to receive my health information and prescription drug usage history. The released information received by Heartland National Life Insurance Company will remain protected by federal and/or state regulations as long as it is maintained by the health plan. Any information that is disclosed pursuant to this authorization may be redisclosed as provided herein or as required or authorized by law and may then no longer be covered by federal rules governing privacy and confidentiality of health information. Medical information will not be used to decline coverage if I am applying during an open enrollment or guaranteed issue period.
I understand that the information requested is necessary for evaluation and underwriting of my application for the Medicare Supplement Insurance Policy for which I have applied; to determine eligibility for insurance, risk rating or policy issue determinations; obtain reinsurance; administer claims and determine or fulfill responsibility for coverage and provision of benefits; and to conduct other legally permissible activities that relate to any coverage I have, or have applied for, with Heartland National Life Insurance Company. I understand that telephone interviews may be a part of the application process and that any information obtained from such telephone interviews may be used to decline my application for coverage. I understand that failure to provide the authorization to Heartland National Life Insurance Company will result in the rejection of the Medicare Supplement Insurance Policy coverage. I understand that I may revoke this authorization at any time by notifying Heartland National Life Insurance Company in writing at their Medicare Supplement Administrative Office: P.O. Box 10812, Clearwater, Florida 33757-8812. I understand that such revocation will not have any effect on actions Heartland National Life Insurance Company took prior to their receiving the revocation notice. I understand that this authorization will be valid for twenty-four (24) months from the date signed if used in connection with an application for an insurance policy, reinstatement of an insurance policy, or change in policy benefits. A photocopy of this authorization will be treated in the same manner as the original. I understand that I or my authorized representative am entitled to a copy of this authorization.
To the best of my knowledge and belief, all of the answers to the questions contained in this application are true and complete and I understand and agree that: (a) the insurance shall not take effect until my Medicare coverage is effective, the application has been accepted and approved by the Company, the first premium has been paid, and the policy has been delivered to the applicant; and (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing. The undersigned applicant certifies that the applicant has read, or had read to him, the completed application and that he realizes that any false statements or misrepresentations therein material to the risk may result in loss of coverage under the policy to which this application is a part. I understand that any change in my health history prior to delivery of this policy may be used in the underwriting evaluation process.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I wish to apply for a Medicare supplement insurance policy. I acknowledge that I have received or been given access to review: (a) an Outline of Coverage for the policy applied for, and (b) a ”Guide to Health Insurance for People with Medicare.”
Signed at: State Applicant’s Signature Date This section to be completed by an agent.
Signed at: State Writing Agent’s Signature and Agent Number Date
Policy Mailing Preference: Mail to Agent Mail to Applicant
Leave with Applicant
MSREPL2010
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE
OR MEDICARE ADVANTAGE
HEARTLAND NATIONAL LIFE INSURANCE COMPANY
Home Office: Indianapolis, Indiana 46280 Medicare Supplement Administrative Office: P. O. Box 10812 Clearwater, Florida 33757-8812
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE!
According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Heartland National Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY AGENT: I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):
Additional benefits. No change in benefits, but lower premiums
Fewer benefits and lower premiums.
Change in benefits (Gaining additional benefit(s), but losing some existing benefit(s)).
My plan has outpatient drug coverage and I am enrolling in Part D.
Disenrollment from a Medicare Advantage Plan. Please explain reason for disenrollment.
Other (please specify) ________________________________________________________________
If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
Signature of Agent, Broker or Other Representative Agent’s Printed Name and Address
The above “Notice to Applicant” was delivered to me on:
Applicant’s Signature Date
Leave with Applicant
All premium checks must be payable to: Heartland National Life Insurance Company. Do not make checks payable to the agent or leave the Payee blank.EFFECTIVE DATE will be the date of the application or the date of approval.
Received from______________________________________________________________________________________________
the sum of $ ____________________________________________ dollars for ________________months premium,
with application. If for any reason the application is not approved and the policy is not issued, this
premium is to be refunded. No liability is created or assumed by the Company, except for refund of this
premium, until the policy applied for has been issued.
Date Receipt and Outline of Coverage was prepared __________________________________________________
By (Agent’s Signature) ______________________________________________________________________________________
RECEIPT