application for medicare supplement insurance · 2017-03-06 · heartland national life insurance...

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

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,

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

o U

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

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,

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.


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.


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


PLAN D MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



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**




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


HOSPICE CARE



Medicareco-payment/coinsurance $0



PLAN D

MEDICARE (PART B) – MEDICAL SERVICES – PER 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)


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.


PLAN F

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


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


days are used:

—Additional 365 days $0 100% of Medicare eligible expenses

$0**




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.





PLAN F



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)


PLAN F

PARTS A & B

SERVICES MEDICARE PAYS PLAN PAYS YOU PAYHOME HEALTH CARE MEDICARE APPROVED SERVICES


— 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


PLAN G

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies


reserve days All but $566 a day $566 a day $0 — Once lifetime reserve days

are used:


$0**





BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

HOSPICE CARE






PLAN G

MEDICARE (PART B) – MEDICAL SERVICES-PER – CALENDAR YEAR




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)


PLAN G PARTS A & B

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES




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


PLAN M MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



HOSPITALIZATION*


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


days are used:


$0**





BLOOD


HOSPICE CARE






PLAN M






(continued)


PLAN M PARTS A & B










PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



HOSPITALIZATION*




days are used:


$0**





BLOOD


HOSPICE CARE






PLAN N



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.


(continued)


PLAN N PARTS A & B









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.

Return to Company.


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

Return to Company.


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).

Return to Company.


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.


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




Diagnosis/Medical Condition





















PRIMARY CARE PHYSICIAN INFORMATION

Physician’s Name: _____________________________________________________________________

Telephone Number: ____________________________________________________________________

Return to Company.


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.


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.


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

application for medicare supplement insurance · 2017-03-06 · heartland national life insurance...

Documents