Cigna Medicare Supplement Insurance Cigna Health And Life . - NAAIP

Section VII. Medical QuestionsIF YOU ARE ELIGIBLE FOR OPEN ENROLLMENT OR GUARANTEED ISSUE(BASED ON YOUR ANSWERS IN SECTION(S) V & VI), DO NOT ANSWER THE QUESTIONS IN THIS SECTION.It is important that you provide truthful and accurate answers to the questions in this section as your answers form the basis of ourdetermination of your eligibility for this coverage. Failure to provide complete and accurate information, if it is determined to be material toour assessment, may result in future denial of benefits and/or rescission of this coverage.PART A. MEDICAL QUESTIONS – If the answer to any question in Part A is YES, you are not eligible for coverage. If you answered NO to all questionsin this Section, please continue to Part B.YES NO1. Are you currently confined, scheduled for admission, or in the last two (2) years have you been confined to a nursingfacility or assisted living facility? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2.Do you currently receive home health care services or, in the last two (2) years, have you received home health careservices for more than three (3) separate periods of care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.Do you currently have a terminal illness or are you currently in the hospital, pending hospital admission, or have youbeen hospitalized more than two (2) times in the last two (2) years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4.Do you currently receive assistance bathing, transferring, toileting, eating, dressing, or are you bedridden; or have youbeen advised by a medical professional to use the assistance of a wheelchair, walker, or motorized mobility aid? . . . . . .5.Do you have now or in the last two (2) years have you been treated for (including surgery) or advised by a medicalprofessional to have treatment or surgery for the following conditions:a. internal cancer, leukemia, malignant melanoma, Hodgkin’s disease, or lymphoma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .b. angina, atherosclerosis, arteriosclerosis, peripheral vascular disease, heart attack, irregular heartbeat, atrialfibrillation, cardiomyopathy, congestive heart failure, angioplasty, stent placement, carotid artery disease, coronaryartery disease (CAD), heart valve surgery, coronary bypass, cardiac pacemaker, implantable or subcutaneousdefibrillator? (You should answer NO if your only treatment is with maintenance medication.) . . . . . . . . . . . . . . . . . . . . . . . .c. Parkinson’s disease, myasthenia gravis, cerebral palsy, muscular dystrophy, multiple sclerosis or amyotrophic lateralsclerosis (Lou Gehrig’s disease)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .d. Paget’s disease, rheumatoid arthritis, disabling arthritis, systemic lupus, osteoporosis with fractures, or paralysis? . . .e. chronic kidney disease, Addison’s disease, renal insufficiency, renal failure, any kidney disease requiring dialysis,pancreatitis, or any condition requiring an organ transplant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .f. diabetes with hypertension requiring three (3) or more hypertension medications to control or diabetes requiringmore than 50 units of insulin daily to control? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .g. diabetes with: neuropathy, retinopathy, vascular disease, or tobacco use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .h. chronic obstructive pulmonary disease (COPD), chronic obstructive lung disease (COLD), emphysema, chronicbronchitis, or any other chronic lung or respiratory disorder requiring the use of oxygen? . . . . . . . . . . . . . . . . . . . . . . . .i. major depression, bipolar disorder, schizophrenia, or a paranoid disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .j. dementia, senility, Alzheimer’s disease, or organic brain disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .k. unrepaired aneurysm, hemophilia, anemia requiring repeated blood transfusions, or any other blood disorder? . . .l. hepatitis (other than hepatitis A), alcohol or drug abuse, cirrhosis of the liver, or other liver disease? . . . . . . . . . . . . . .m. stroke or transient ischemic attack (TIA)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.Do you have now or at any time have you been treated for or advised by a medical professional to have treatment foramputation caused by disease or organ transplant other than corneas? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.Have medical tests, treatment, therapy, or surgery been advised but not performed or is any surgery anticipated?(This excludes mammograms, pap tests, colonoscopies, or PSA tests which were advised for routine screeningpurposes only.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8.Have you ever been diagnosed with or received treatment from a physician or an appropriately-licensed clinicalprofessional acting within his/her scope for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex(ARC), or Human Immunodeficiency Virus (HIV) infection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CHLIC-MS-HHD-APP-TXPage 3 of 601/16

Section VII. Medical Questions (cont’d.)PART B. HEIGHT/WEIGHT AND MEDICATIONS – The answers to questions in Part B are subject to the Company’s Underwriting review. Pleaseprovide complete details as requested.9.Height (ft.-in.) Weight (lbs.)10. Please list any prescription medications taken or prescribed in the past two (2) years.MedicationDates takenCondition taken forAGENT NOTES – Please provide any other information that you believe may assist in our Underwriting determination:CHLIC-MS-HHD-APP-TXPage 4 of 601/16

Section VIII. Important Statements for Applicant to Read You do not need more than one Medicare Supplement policy.If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need more than one type of coverage inaddition to your Medicare benefits.You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy.If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy canbe suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy (or, if thatis no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If theMedicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policywas suspended, the reinstituted policy will not have outpatient prescription drug coverage but will otherwise be substantially equivalentto your coverage before the date of the suspension.If you are eligible for and have enrolled in a Medicare Supplement policy by reason of disability and you later become covered by anemployer or union-based group health plan, the benefits and premiums under your Medicare Supplement policy can be suspended, ifrequested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare Supplement policyunder 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 orunion-based group health plan. If the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolledin Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage but willotherwise be substantially equivalent to your coverage before the date of the suspension.Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement insurance andconcerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and aSpecified Low-income Medicare Beneficiary (SLMB).I hereby apply to Cigna Health and Life Insurance Company for coverage to be issued based upon the truth and completeness of the answersto the above questions, and understand and agree that: (1) no agent has the authority to waive the answer to any questions on the application;(2) no insurance will be effective until (a) a policy has been issued by the Company and (b) the initial premium has been paid; and (3) I havereceived the Outline of Medicare Supplement Coverage for the policy applied for, the required Guide to Health Insurance for People withMedicare, and the MIB Notice.CAUTION: Please review your answers to the questions on the application. It is important to the issuance of this policy that all questions areanswered correctly and truthfully.A recorded telephone interview may be used as part of the underwriting on your application for insurance.Telephone number ()Best time to callI understand that the Medicare Supplement policy applied for will not cover loss due to Pre-Existing Condition(s) unless the expense for thatloss is incurred more than six (6) months after the effective date of coverage. This provision does not apply if, as of the date of application, youhad a Continuous Period of Creditable Coverage which did not expire more than 63 days ago and such coverage, while in force, lasted for atleast six (6) months. If, as of the date of application, you had less than six (6) months prior Creditable Coverage, the Pre-Existing Conditionslimitation will be reduced by the aggregate amount of Creditable Coverage. This provision does not apply if you are applying for and are issuedthis policy under Guaranteed Issue status.Applicant’s printed nameSignature of Applicant DateCHLIC-MS-HHD-APP-TXPage 5 of 601/16

Section IX. Agent(s) CertificationAgent(s) shall list any health insurance policies sold to the Applicant.1.List any other health policies or coverages sold to the Applicant which are still in force (if this does not apply, state “NONE”).2.List any other health policies or coverages sold to the Applicant in the past five (5) years which are no longer in force (if this does not apply,state “NONE”).3.YES NOHave you submitted any applications or have knowledge of any applications submitted for this Applicant that havebeen declined? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If YES, provide details below.4.Have you reviewed the application for correctness and omissions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5.I certify that I have provided the Applicant with the following documents:a. Application packet (phone sales only)b. Guide to Health Insurance for People with Medicarec. Outline of Medicare Supplement Coveraged. MIB Noticee. otherI further certify that I have delivered the documents to the Applicant (check all that apply; must select at least one):In persondateMaildateEmaildateFaxdateother (explain)dateYES6.Was the application completed by you in the Applicant’s physical presence? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.Was the application completed by you over the phone? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8.Do you have knowledge or reason to believe the replacement of existing insurance may be involved? . . . . . . . . . . . . . . . .If YES, give name of Company, reason, and termination dateNOI certify that I have interviewed the Applicant, asked all of the questions as written on the application, and I have truly and accurately recordedon the application the information supplied to me by the Applicant.Printed name of licensed AgentSignature of licensed AgentWriting numberPercentagePrinted name of 2nd licensed AgentSignature of 2nd licensed AgentWriting numberPercentageCHLIC-MS-HHD-APP-TXPage 6 of 601/16

CIGNA HEALTH AND LIFE INSURANCE COMPANYPO Box 559015, Austin, Texas 78755-9015 866-459-4272MEDICARE SUPPLEMENT SUPPLEMENTARY APPLICATIONDefinitions of Eligible Person for Guaranteed Issue and Creditable CoverageAn eligible person is an individual described in any of the following paragraphs:1) The individual is enrolled under an employee welfare benefit plan that provides health benefits which supplementthe benefits under Medicare and the plan terminates or the plan ceases to provide supplemental health benefits tothe individual or the individual is enrolled under an employee welfare benefit plan that is primary to Medicare andthe plan terminates or the plan ceases to provide all health benefits to the individual because the individual leavesthe plan;2) The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part Cof Medicare and any of the following circumstances apply or the individual is 65 years of age or older and is enrolledwith a Program of All-inclusive Care for the Elderly (PACE) provider under section 1894 of the Social Security Act andthere are circumstances similar to the following that would permit discontinuance of the individual’s enrollment withthe provider if such individual were enrolled in a Medicare Advantage plan:A) The certification of the organization or plan has been terminated;B) The organization has terminated or otherwise discontinued providing the plan in the area in which theindividual resides;C) The individual is no longer eligible to elect the plan because of a change in the individual’s place of residence orother change in circumstances specified by the Secretary, but not including termination of the individual’senrollment on the basis described in section 1851(g)(3)(B) of the Social Security Act (where the individual hasnot paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards undersection 1856), or the plan is terminated for all individuals within a residence area;D) The individual demonstrates, in accordance with guidelines established by the Secretary, that:i) the organization offering the plan substantially violated a material provision of the organization’s contractunder 42 U.S.C. Chapter 7, Subchapter XVIII, Part D, in relation to the individual including the failure toprovide an individual on a timely basis medically-necessary care for which benefits are available under theplan or the failure to provide the covered care in accordance with applicable quality standards; orii) the organization or agent or other entity acting on the organization’s behalf materially misrepresented theplan’s provisions in marketing the plan to the individual; orE) The individual meets other exceptional conditions as the Secretary may provide;3) The individual is enrolled with an entity listed in subparagraphs A - D of this paragraph and enrollment ceases underthe same circumstances that would permit discontinuance of an individual’s election of coverage under paragraph 2of this subsection:A) an eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost);B) a similar organization operating under demonstration project authority, effective for periods beforeApril 1, 1999;C) an organization under an agreement under section 1833(a)(1)(A) of the Social Security Act (health careprepayment plan); orD) an organization under a Medicare Select policy;4) The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:A) of the insolvency of the issuer or bankruptcy of the non-issuer organization or of other involuntary terminationof coverage or enrollment under the policy;B) the issuer of the policy substantially violated a material provision of the policy; orC) the issuer or an agent or other entity acting on the issuer’s behalf materially misrepresented the policy’sprovisions in marketing the policy to the individual;CHLIC-SUP-APP-TXRETURN TO COMPANY1 OF 203/16

5) The individual was enrolled under a Medicare supplement policy and terminates enrollment and subsequentlyenrolls for the first time with: any Medicare Advantage organization under a Medicare Advantage plan under Part Cof Medicare, any eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost),any similar organization operating under demonstration project authority, any PACE provider under section 1894 ofthe Social Security Act, or a Medicare Select policy and the subsequent enrollment is terminated by the individualduring any period within the first 12 months of the subsequent enrollment (during which the individual is permittedto terminate the subsequent enrollment under section 1851(e) of the Social Security Act);6) The individual, upon first becoming enrolled in Medicare Part B for benefits at age 65 or older, enrolls in a MedicareAdvantage plan under Part C of Medicare or with a PACE provider under section 1894 of the Social Security Act anddisenrolls from the plan or program no later than 12 months after the effective date of enrollment;7) The individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollmentin Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in MedicarePart D along with the application for a policy described in subsection (c)(4) of this section;8) The individual loses eligibility for health benefits under Title XIX of the Social Security Act (Medicaid); or9) The individual meets the following requirements:A) the individual was enrolled in both the federal Medicare program and the Texas Health Insurance Pool onDecember 31, 2013; andB) the individual’s Pool coverage terminated on or after December 31, 2013.If any of the definitions apply to you, please complete an Application for Medicare Supplement Insurance and submitevidence of the date of termination or disenrollment. Application must be made for coverage no later than 63 days oftermination or disenrollment.The following is a definition of Creditable Coverage:Creditable Coverage means (a) a self-funded or self-insured employee welfare benefit plan that provides health benefitsand that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001et seq.); (b) a group health benefit plan provided by a health insurance carrier or an HMO; (c) an individual health insurance policy or evidence of coverage; (d) Part A or Part B of Title XVIII of the Social Security Act; (e) Title XIX of the SocialSecurity Act, other than coverage consisting solely of benefits under section 1928; (f ) Chapter 55 of Title 10 (CHAMPUS);(g) a medical care program of the Indian Health Service or of a tribal organization; (h) a state health benefits risk pool;(i) a health plan offered under Chapter 89 of Title 5 (Federal Employees Health Benefits Program); (j) a public health plan(as defined in federal regulation); (k) a health benefit plan under section 5(e) of the Peace Corps Act (22 United StatesCode 2504(e)); or (l) short-term, limited duration insurance.I acknowledge receipt of this Supplementary Application.Signature of ApplicantCHLIC-SUP-APP-TXRETURN TO COMPANY2 OF 2Date03/16

PRE-AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERCIGNA HEALTH AND LIFE INSURANCE COMPANY PO BOX 559015 AUSTIN, TX 78755-9015Proposed Insured’s namePolicy number (if available)Financial institution name and telephone numberFinancial institution address9-digit routing numberAccount numberRequested withdrawal date (1st - 28th)Withdraw payment: Monthly QuarterlyType of account: Personal checking account Semi-annually Personal savings account Annually Corporate/business checkingName of employer groupPurpose for submitting this Authorization (check appropriate box(es)): New authorization Change in checking/savings account Change in financial institution Change in existing coverageFor checking account:Refer to the sections onthe sample check.For savings account:Please verify with your bankthe account and routingnumber of your savings account.APPLICANT INFORMATION FOR FINANCIAL INSTITUTIONS: Asa convenience to me, I hereby request and authorize you to payand charge to my account, drafts drawn on my account by andpayable to Cigna Health and Life Insurance Company providedthere are sufficient funds in said account to pay the same onpresentation. Such drafts will bear my printed name. I alsoauthorize Cigna Health and Life Insurance Company and anyfinancial institution it uses to initiate credit entries to my accountor to provide refund of premium or association fees (if applicable).I authorize you to accept and to credit these entries to myaccount. In the event Cigna Health and Life Insurance Companymistakenly deposits funds into my account, I authorize CignaHealth and Life Insurance to debit my account for an amountnot to exceed the original amount of credit. This authorizationshall remain in effect until revoked by me in writing, and untilyou actually receive such notice. I agree that you shall be fullyprotected in honoring any such draft. I agree that your rights inrespect to any such draft shall be the same as if it were a checksigned personally by me. I further agree that if any such draft isdishonored, whether intentionally or inadvertently, you shall beunder no liability whatsoever even though such dishonor resultsin the forfeiture of insurance.APPLICANT INFORMATION FOR CIGNA HEALTH AND LIFEINSURANCE COMPANY: It is understood that the initial draftwill occur when the policy is issued. All subsequent drafts willbe drawn on or about the requested date each month. Thepresentation of s

Cigna Medicare Supplement Insurance Cigna Health and Life Insurance Company All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. . PO Box 559015, Austin, TX 78755-9015 (866) 459-4272 Application is for: New business .