Medicare Supplement Tool

1 Client Info

2 Health Conditions

3 Medications

4 Results

📄 Carrier Applications

Select a carrier to view the application checklist and open the agent portal.

📄 Bankers Fidelity

View checklist + key health questions

📄 Aetna Senior Supplemental

View checklist + key health questions

📄 Heartland National Life

View checklist + agent portal

📄 Mutual of Omaha

View checklist + agent portal

📄 Medico / Wellabe

View checklist + key health questions

🔗 Aflac

Same UW guidelines as Aetna

📄 Healthspring (HCSC)

View checklist + key health questions

📄 Humana

View checklist + key health questions

📄 UnitedHealthcare (AARP)

View checklist + Level 2 rate triggers

Bankers Fidelity — Application Guide

8-page application. Check each box as you collect the information from your client.

✓ Info to Collect — Page 1: Proposed Insured & Plan

Full legal name (first, middle, last) Date of birth Social Security Number Gender Place (state) of birth Residence address (street, city, state, zip) Mailing address (if different) Residence county Email address Home & cell phone numbers Requested effective date (NOT 29th, 30th, or 31st) Plan selected: A / B / D / G / HD-G / K / N Tobacco use in last 2 years? (Yes = Standard rate) Underwriting class: Preferred or Standard Is client in Open Enrollment or 63-day GI window?

✓ Info to Collect — Page 2: Medicare & Premium

Medicare Beneficiary Identifier (from Medicare card) Medicare Part A effective date Medicare Part B effective date Social Security Disability? (if applicable) Household discount eligibility — married/living with 50+ housemate for 12+ months? Premium payment method: bank draft, check, or credit card Recurring billing mode: annual, semi-annual, quarterly, monthly Voided check (if using bank draft) Payor info (if different from insured)

✓ Info to Collect — Other Health Insurance (Page 3, ALL applicants)

Ask every client:
1. On Medicaid? Will Medicaid pay premiums?
2. Any Medicare Advantage or Medicare HMO/PPO in last 63 days? (If replacing — complete Replacement Form)
3. Currently have another Medicare Supplement? (If replacing — complete Replacement Form)
4. Any other health insurance in last 63 days (employer, union, individual)?

✓ Info to Collect — Physician & Health (Pages 4–6, Underwritten ONLY)

Primary care physician: name, address, phone Height (feet/inches) and weight (lbs) All current medications + condition each is prescribed for Date of onset for each condition/medication

🚫 Health Question KNOCKOUTS — Coverage NOT Available (Questions 7–11)

Any YES answer to these = do not proceed with underwritten application:
• Hospitalized, needs ADL help, walker/wheelchair, or confined to bed/nursing facility in past 1 month
• Received occupational, speech, or physical therapy in past 1 month
• Implanted cardiac defibrillator, 50+ units insulin/day, supplemental oxygen, disabling arthritis, angina, hepatitis C (w/liver damage), infusions/injections in a facility (excl. allergies/B12/osteoporosis/knee pain), or pending surgery/tests — in past 6 months
• Amputation (disease), hospitalization for mental health, new heart attack/stroke/TIA, heart/circulatory surgery, or osteoporosis fracture — in past 2 years
• Cancers, alcohol/drug abuse, PVD/PAD, Crohn\'s/colitis, AFib, or spinal stenosis — in past 2 years
• Diabetes with complications (retinopathy, neuropathy, nephropathy, skin ulcers, circulatory surgery, heart attack, stroke) — in past 10 years
• Organ transplant, HIV/AIDS, or any of these conditions EVER: COPD, CHF, chronic kidney disease, end-stage renal, MS, Parkinson\'s, rheumatoid arthritis, lupus, ALS, myeloma, leukemia, lymphoma, Alzheimer\'s, dementia, bipolar, schizophrenia, cardiomyopathy, and more

⚠ Standard Rate Only Triggers (Question 12)

Answer YES = Standard rate applies (NOT declined):
• Diabetes with no complications, requiring ≤50 units insulin/day — last 6 months
• Macular degeneration NOT requiring injections — last 6 months
• Sleep apnea requiring CPAP — last 6 months
• Cardiac arrhythmia requiring pacemaker — last 6 months
• Osteoporosis treated by infusion — last 6 months

🔗 Open BF Agent Portal

Aetna Senior Supplemental — Application Guide

13-page NC application. Check each box as you collect info from your client.

✓ Info to Collect — Section 1: Applicant Information

Full name (exactly as on Medicare card) Phone number Residential address (street, apt, city, state, zip) Mailing address (if different) Email address Social Security Number Date of birth & age Gender (Male / Female) Height (feet and inches) Weight (pounds) Legal US resident? (Yes/No) Medicare card number Medicare Part A effective date Medicare Part B effective date

✓ Info to Collect — Section 2: Plan & Premium

Plan selected Requested effective date (NOT 29th, 30th, or 31st) Household discount? — same-time applicant or existing Aetna policy? Payment mode: Annual / Semi-Annual / Quarterly / Monthly EFT Initial premium payment method: Check or EFT Mail policy to: Applicant or Agent? Bank routing & account number + voided check (if EFT)

✓ Info to Collect — Section 3: Eligibility Questions (ALL applicants)

Ask every client — answer required regardless of OE/GI status:
1. Did client turn 65 in the last 6 months? Did they enroll in Part B in last 6 months?
2. Are they on Medicaid? Will Medicaid pay the premium?
3. Had Medicare Advantage or HMO/PPO in last 63 days? (still covered? intend to replace?)
4. Have another Medicare Supplement currently? (intend to replace?)
5. Had any other health insurance (employer, union, individual) in last 63 days?

✓ Info to Collect — Sections 5–6: Health History & Physicians (Underwritten ONLY)

Brain/mental/nervous disorder in last 24 months Hospitalizations or ER visits in last 5 years (reason & diagnosis) All current medications + reason for each Primary care physician name & phone Specialists seen in last 24 months (up to 3) + diagnosis

🚫 Section 4 Health Question KNOCKOUTS (Underwritten ONLY — skip for OE/GI)

Any YES answer to Questions 1–11 = Aetna DECLINES:
• Wheelchair or motorized mobility device dependent
• Currently hospitalized, bedbound, in nursing facility, or receiving home health care / PT
• Ever: CHF, unoperated aneurysm, or defibrillator
• Ever: Leukemia, lymphoma, multiple myeloma, or cirrhosis
• Ever: Parkinson\'s, ALS, Alzheimer\'s, dementia, MS, muscular dystrophy, or cerebral palsy
• Ever: Chronic kidney disease, kidney failure requiring dialysis, or Addison\'s disease
• Ever: Organ transplant or bone marrow/stem cell transplant
• Ever: HIV / AIDS
• Diabetes using insulin and complications (retinopathy, neuropathy, PVD) OR history of heart attack/stroke
• Diabetes with medication adjusted for uncontrolled blood sugar in last 12 months
• Last 36 months (Q5C): Internal cancer, melanoma, or Hodgkin\'s disease — if diagnosed/treated within 36 months = decline. If more than 36 months ago and no longer active, Aetna CAN accept. Always confirm no current treatment or recurrence.
• Ever (Q3B): Leukemia, lymphoma, multiple myeloma, cirrhosis — no time limit, always decline
• Last 24 months: Enlarged heart, stroke/TIA, PVD/neuropathy/amputation (disease), lupus, osteoporosis with fractures, Paget\'s disease, disabling arthritis, lung disorder needing nebulizer or oxygen or 3+ meds
• Last 12 months: Pending surgery or test results, heart attack or valve disorder, wet macular degeneration with injections, pacemaker, PSA >4.5 (under 70) or >6.5 (70+), seizure, blood pressure >175 systolic or >100 diastolic

⚠ Tobacco — Question 12

Tobacco use in past 12 months (including vaping/e-cigarettes) = Higher premium rate but does NOT disqualify the client.

🔗 Open Aetna Agent Portal

Heartland National Life — Application Guide

App 90090 NC — Plans A, G, N. Submit within 30 days of signature date.

✓ Info to Collect — Section A/B: Plan & Applicant

Plan selected (A, G, or N) Requested effective date (1st–28th only) Deliver policy to: Applicant or Agent? Full legal name (First / Middle Initial / Last) Residence address (street, city, state, zip) Mailing address (if different) Phone number & email Date of birth & current age Social Security Number Gender, Height, Weight

✓ Info to Collect — Section C/D: Medicare & Household Discount

Medicare card number (MBI) Medicare Part A effective date Medicare Part B effective date Household discount? — 7% if spouse/civil union partner OR adult (18+) living with client continuously for 12+ months If household discount: collect name, DOB, and address of household resident

✓ Info to Collect — Section E: Previous or Existing Coverage

Ask every client — required on ALL applications:
• On Medicaid? Will Medicaid pay premiums? Any Medicaid benefits beyond Part B?
• Had Medicare Advantage or HMO/PPO in last 63 days? Still covered? Intend to replace?
• Have another Medicare Supplement currently? Intend to replace?
• Had any other health insurance in last 63 days (employer, union, individual)?

✓ Info to Collect — Section J: Payment

Modal premium amount (from rate sheet) $25 one-time policy fee 7% household discount applied? (multiply premium × .93) Payment mode: Annual / Semi-Annual / Quarterly / Monthly Bank Draft Bank routing & account number + voided check (required for bank draft) Applicant signature on bank draft authorization

✓ Enrollment Type — Section F

Open Enrollment: Turned 65 in last 6 months OR enrolled in Part B in last 6 months → Skip Sections G–I.

Guaranteed Issue: Qualifying event (MA plan termination, employer plan loss, etc.) → Skip Sections G–I. Attach proof of qualifying event.

Underwritten: Outside OE/GI windows → Must answer ALL of Sections G, H, and I (medications).

🚫 Section G — Auto-Decline Conditions (Any YES = Do Not Submit)

Questions G1–G7 — any YES = automatic decline:
• Wheelchair or motorized mobility device (G1)
• Currently hospitalized, bedbound, in nursing home or assisted living (G2)
• Chronic kidney disease (Stages 3, 4, or 5), kidney failure, dialysis (G3A)
• Emphysema, COPD, chronic pulmonary disorder requiring oxygen (G3B)
• Alzheimer\'s, dementia, or any cognitive disorder (G3C)
• Parkinson\'s, MS, ALS, Huntington\'s disease, or cerebral palsy (G3D)
• Systemic lupus, scleroderma, or myasthenia gravis (G3E)
• Chronic hepatitis or cirrhosis (G3F)
• HIV / AIDS / ARC or positive HIV test (G3G)
• Organ or stem cell transplant — excluding cornea (G4)
• Osteoporosis with resulting fracture (G5)
• Diabetes with complications: retinopathy, neuropathy, PAD, PVD, stroke, TIA, any heart disorder, or kidney disease (G6)
• Implanted cardiac defibrillator (G7)

⚠ Section H — 2-Year Lookback (May Not Be Eligible — Underwriting Review)

Questions H8–H12 — YES triggers underwriting review, not automatic decline. Attach written explanation of how long condition has existed and how it is being controlled.

• H8A: Coronary artery disease, angina, heart attack, angioplasty, bypass surgery, or stent — last 2 years
• H8B: Cardiomyopathy, CHF, aneurysm, PAD, PVD, vascular angioplasty, endarterectomy, carotid artery disease, heart/valve disorder, AFib, other rhythm disorder, pacemaker — last 2 years
• H8C: Alcoholism or drug abuse — last 2 years
• H8D: Mental/nervous disorder requiring treatment or hospitalization — last 2 years
• H8E: Internal cancer, lymphoma, or melanoma — last 2 years
• H8F: Stroke or TIA — last 2 years
• H8G: Degenerative bone disease, spinal stenosis, RA, psoriatic arthritis, arthritis restricting mobility, or advised to have joint replacement — last 2 years
• H9A: Diabetes with high blood pressure AND more than 2 medications for either condition
• H9B: Diabetes with any medication changes in the past 2 years
• H10: Hospitalized 3 or more times in the past 2 years for same/similar condition
• H11: Advised by a physician to have treatment, diagnostics, or surgery not yet performed
• H12: Tobacco/nicotine/e-cigarette use in past 12 months (higher rate — not a disqualifier)

✓ Section I — Medication Information (Underwritten Only)

Ask: currently taking OR prescribed any Rx or OTC meds in the last 2 years? For each medication: name (from pharmacy label), dosage, frequency Has client taken it for more than 2 years? (Y/N) Prescribed by primary physician? (Y/N) Diagnosis/condition for each medication

📅 Rate & Replacement

Tobacco rate = standard rate × 1.15 (ask about tobacco/vaping/nicotine in last 12 months).
Replacing another plan? → Complete both copies of the Replacement Notice (HNRN). Agent keeps one copy; leave one with applicant.

🔗 Open Heartland Agent Portal

Mutual of Omaha — Application Guide

Form NA6012-31 NC — Plans A, G, HD-G, N (also F for pre-2020 eligible). Via SPA portal or paper.

✓ Info to Collect — Sections A & B: Plan & Applicant

Plan selected (A, G, HD-G, or N; F if Medicare eligible before 1/1/2020) Requested effective date Deliver policy to: Applicant or Producer? Full legal name (First / Middle Initial / Last) Residence address (state of residence controls app & rate) Mailing address (if different) Home phone & email Date of birth & exact age as of application date Social Security Number Gender, Height, Weight Paperless EOB preference (Y/N) How did you hear about us? (check applicable box)

✓ Info to Collect — Sections C & D: Medicare & Household Discount

Medicare Beneficiary Identifier (MBI number — required for claim processing; call 1-877-617-5587 if not yet available) Medicare Part A effective date Medicare Part B effective date (or planned enrollment date if not yet enrolled) Household discount? — resident age 60+ who has lived with client 12+ months, OR spouse/civil union partner (Section D) If household discount: collect name, DOB, and address of household resident

✓ Info to Collect — Section E: Previous or Existing Coverage

Ask every client — required on ALL applications:
• On Medicaid? Will Medicaid pay premiums? Any Medicaid benefits beyond Part B?
• Have another Medicare Supplement currently? Intend to replace? Planned termination date?
• Had Medicare Advantage or HMO/PPO in last 63 days? Still covered? Intend to replace?
• Had any other health insurance in last 63 days (employer, union, individual)?

✓ Section F: Open Enrollment / Guaranteed Issue

Open Enrollment: At least 64½ years old AND within 6 months before/after Part B effective date → No health questions. Skip Sections G & H → go directly to Section I.

Guaranteed Issue: Qualifying event (MA plan termination, employer plan ending, insolvency, etc.) → No health questions. Attach proof of qualifying event. Skip G & H → go to Section I.

Selective (Underwritten): Outside OE/GI → Must answer all of Sections G (health) and H (medications).

🚫 Section G Part A — Auto-Decline Conditions (Questions 9–15, Any YES = Do Not Submit)

Any YES = automatic decline:
• Wheelchair or motorized mobility device (Q9)
• Currently hospitalized, bedbound, nursing home, or assisted living (Q10)
• CKD Stages 3–5, kidney failure, dialysis (Q11A)
• Emphysema, COPD, chronic pulmonary disorder requiring oxygen (Q11B)
• Alzheimer\'s, dementia, or any cognitive disorder (Q11C)
• Parkinson\'s, MS, ALS, Huntington\'s disease, or cerebral palsy (Q11D)
• Systemic lupus, scleroderma, or myasthenia gravis (Q11E)
• Chronic hepatitis or cirrhosis (Q11F)
• HIV / AIDS / ARC (Q11G)
• Organ or stem cell transplant — excluding cornea (Q12)
• Osteoporosis with resulting fracture (Q13)
• Diabetes with complications: retinopathy, neuropathy, PAD, PVD, stroke, TIA, any heart disorder, or kidney disease (Q14)
• Implanted cardiac defibrillator (Q15)

⚠ Section G Part B — 2-Year Lookback (Questions 16–19, May Not Be Eligible — Underwriting Review)

YES triggers underwriting review — attach explanation of how long the condition has existed and how it is being controlled.

• Q16A: Coronary artery disease, angina, heart attack, angioplasty, bypass surgery, stent — last 2 years
• Q16B: Cardiomyopathy, CHF, aneurysm, PAD, PVD, vascular angioplasty, endarterectomy, carotid artery disease, heart/valve disorder, AFib, rhythm disorder, pacemaker — last 2 years
• Q16C: Alcoholism or drug abuse — last 2 years
• Q16D: Mental/nervous disorder requiring treatment or hospitalization — last 2 years
• Q16E: Internal cancer, lymphoma, or melanoma — last 2 years
• Q16F: Stroke or TIA — last 2 years
• Q16G: Degenerative bone disease, spinal stenosis, RA, psoriatic arthritis, arthritis restricting mobility, or joint replacement advised — last 2 years
• Q17A: Diabetes with high blood pressure AND more than 2 medications for either condition
• Q17B: Diabetes with any medication changes in past 2 years
• Q18: Hospitalized 3 or more times in past 2 years for same/similar condition
• Q19: Advised by physician to have treatment, diagnostics, or surgery not yet performed
• Q20: Tobacco/nicotine/e-cigarette use in past 12 months (tobacco rate applies — not a disqualifier)

⚖ Build Chart — Class Ratings

MO uses three rate classes in most states (NC included):
• Standard: No rate adjustment
• Class I: +10% rate factor (slightly underweight or overweight)
• Class II: +20% rate factor (significantly overweight)
• Outside all ranges: Decline

The build chart tool above shows the exact class for your client's height and weight. Note: Some states (CA, CT, FL) do NOT use class ratings and decline outside Standard range.

✓ Section H: Medication Information (Underwritten Only)

✓ Method of Payment Form (Required — Return Pages 1 & 2)

Initial premium amount (age at application date) Payment method: Paper Check or Automatic Bank Withdrawal Ongoing payment: Monthly EFT date OR quarterly/semi-annual/annual billing frequency Bank routing number (9 digits) & account number — OR attach voided check Account type: Checking or Savings Authorized signature on EFT authorization

🔗 MO Advisor Portal (SPA) 🔗 MO Broker Portal

Medico / Wellabe — Application Guide

Submit online via MyEnroller at apply.myenroller.com — Plans A, F* (pre-2020), G, N.

✓ Info to Collect — Applicant & Plan

Full legal name (First, MI, Last) Date of birth & age Social Security Number Gender Residential address (street, city, state, zip) Mailing address (if different) Home phone & email Medicare number (from card) Medicare Part A effective date Medicare Part B effective date Plan selected: A, F* (pre-2020 only), G, or N Requested effective date Height (ft/in) and weight (lbs) Tobacco use in last 12 months? (Yes = rate factor)

✓ Open Enrollment / Guaranteed Issue Status

Ask every client — answer required on ALL applications:
• Turned 65 in last 6 months? Enrolled in Part B in last 6 months? → Open Enrollment (skip health questions)
• On Medicaid? Will Medicaid pay premiums?
• Had Medicare Advantage in last 63 days? → may qualify for Guaranteed Issue
• Currently have another Medicare Supplement? Replacing it?
• Any other health insurance (employer, union, individual) in last 63 days?

🚫 Part C — Automatic Decline Questions (Any YES = Do Not Submit)

Any YES answer = Medico declines:
• Currently hospitalized, in a nursing/ALF/hospice, using a wheelchair, or bedridden
• Receiving home health care or currently on hospice
• Metastatic cancer or cancer recurrence — no time limit
• Implanted cardiac defibrillator
• Diabetes requiring more than 50 units insulin/day — last 6 months
• Diabetes with 3 or more diabetes medications — last 6 months
• Diabetes with complications: stroke, TIA, heart disease, CHF, PVD, retinopathy, neuropathy, nephropathy, skin ulcers, or diabetic coma
• Organ transplant, bone marrow transplant, or stem cell transplant — excluding corneas
• HIV / AIDS
• Internal cancer, leukemia, lymphoma, myeloma, or melanoma — within past 24 months

⚠ Part D — Review Questions (Subject to Underwriting — May Result in Decline)

YES triggers review — provide details on duration and control:
• CAD, angina, heart attack, angioplasty, bypass surgery, stent — last 2 years
• AFib, cardiomyopathy, CHF, PAD/PVD, aneurysm, pacemaker, heart valve disorder — last 2 years
• Stroke or TIA — last 2 years
• COPD, emphysema, or chronic lung disorder requiring oxygen — ever
• CKD Stages 3–5, kidney failure, or dialysis — ever
• Alzheimer\'s disease or dementia — ever
• Parkinson\'s disease, MS, ALS, or other permanent neurological disorder — ever
• Alcohol or drug abuse (including counseling) — last 2 years
• Mental/nervous disorder requiring treatment or hospitalization — last 2 years
• Degenerative bone disease, spinal stenosis, RA, or psoriatic arthritis — last 2 years
• Diabetes with high blood pressure AND 3+ total medications for either condition — last 2 years

⚖ Build Chart — Rate Classes

Medico/Wellabe uses four rate classes:
• Preferred: In the preferred weight range — best rate
• Standard I: Slightly outside preferred range — rate factor 1.10
• Standard II: Further outside range — rate factor 1.25
• Outside all ranges: Automatic decline

Tobacco use adds a separate rate factor (1.25). Use the build chart preview above for your client's exact class.

✓ Medications & Payment

All current medications: name, dosage, frequency, reason Check ALL medications against Medico uninsurable drug list Payment method: EFT (bank draft) or check If EFT: bank routing number (9 digits) & account number Payment frequency: monthly, quarterly, semi-annual, or annual

🔗 Open MyEnroller (Submit App)

Healthspring (HCSC) — Application Guide

Cigna National Health Insurance Company — Plans A, F*, G, N. Phone Verification required for all underwritten applications (866-825-4822).

✓ Info to Collect — Section A: Personal Information

Full name (First, MI, Last) Date of birth & age Gender (Male / Female) Residential address (street, city, state, zip) Mailing address (if different) Phone number Social Security Number Email (optional — triggers electronic policy delivery consent) Household discount? (lives with another adult 18+? → 6%) Other household member with Cigna/HCSC policy? → additional 14% (total 20%)

✓ Section B: Medicare Information

Medicare number (from card) Medicare Part A effective date Medicare Part B effective date Client must have BOTH Parts A & B on requested effective date

✓ Sections C & D: Plan, Effective Date & OE/GI Status

Plan selected: A, F* (pre-2020 only), G, or N Requested effective date Turned 65 in last 6 months? (OE) Enrolled in Part B in last 6 months? (OE) On Medicaid? (GI may apply) Had Medicare Advantage in last 63 days? (GI may apply) Have existing Medicare Supplement? Replacing? (Replacement notice required) Other health insurance in last 63 days?

🚫 Section E Part A — Hard Decline Conditions (Any YES = Not Eligible)

Q1: Confined or scheduled for admission to nursing/ALF in last 2 years
Q2: Currently receiving home health care, OR 3+ separate periods of home health in last 2 years
Q3: Terminal illness diagnosis; hospitalized or pending admission; OR hospitalized more than 2 times in last 2 years
Q4: Requires ADL assistance (bathing, transferring, toileting, eating, dressing); bedridden; OR advised to use wheelchair/walker/motorized mobility in last 7 years
Q5: In last 6 months — diabetes with hypertension requiring 3+ hypertension meds, OR diabetes requiring more than 50 units insulin daily
Q6: In last 2 years — heart attack, CHF, coronary bypass, or stroke (Note: answer NO if only treatment was fewer than 3 concurrent cardiovascular meds and treatment has not changed in 2 years)
Q7 (7-year lookback): MS, muscular dystrophy, ALS; Paget\'s disease, disabling RA, disabling arthritis, osteoporosis with fractures, paralysis; CKD, Addison\'s disease, renal insufficiency/failure, dialysis, cirrhosis, organ transplant; bipolar disorder, schizophrenia, paranoid disorder, severe depression (or depression treated for 12 months before effective date); Alzheimer\'s disease; organic brain disorder; unrepaired aneurysm, hemophilia, blood disorder; permanent implantable cardiac defibrillator
Q8 (2-year lookback): Cancer (excluding basal/squamous cell; excluding melanoma); anemia requiring repeated blood transfusions; alcohol or drug abuse (including counseling); pancreatitis; seizure
Q9 (7-year): Amputation caused by disease; organ transplant (not corneas)
Q11 (7-year): AIDS / ARC / HIV

⚠ Section E Part B — Rate Class Triggers (Subject to Underwriting Review)

Rate class is determined by underwriting. Guidelines:
• Preferred: OE/GI, OR answered NO to Q13a, Q14, and Q15
• Standard: Tobacco use (Q13a = YES), NO to Q13b, Q14, Q15
• Standard II: No tobacco, but YES to Q13b, Q14, or Q15
• Standard III: Tobacco AND YES to Q13b, Q14, or Q15

Q13a: Tobacco use in last 12 months
Q13b: If tobacco — also have a heart condition, vascular condition, or diabetes?
Q14 (2-year lookback): Angioplasty, atherosclerosis, arteriosclerosis, PAD, carotid artery disease, CAD, angina, cardiomyopathy, stent, heart valve surgery, AFib, irregular heartbeat, pacemaker, or TIA (answer NO if fewer than 3 concurrent cardio meds and treatment unchanged in 2 years)
Q15 (7-year lookback): COPD, emphysema, chronic lung disorder needing permanent oxygen; diabetes with neuropathy, retinopathy, or vascular disease; cerebral palsy, myasthenia gravis, systemic lupus, Parkinson\'s disease; hepatitis B/C or other liver disease (not hep A); dementia or senility; PSA > 6.0
Q16: List all medications taken in last 2 years — check against Healthspring declinable drug list

⚖ Build Chart — Rate Class Impact

Healthspring uses a build chart with two max weight columns:
• Without selected conditions: Standard max weight column
• With selected conditions (tobacco, diabetes, or heart/vascular maintenance meds): Lower max weight column

If weight is below minimum or above maximum for client's condition profile → client does NOT qualify for Preferred or Standard; may qualify for Standard II or Standard III only.

✓ Forms Required — Return ALL to Company

Application (Pages 1–7) Supplementary application (OE/GI definitions) Electronic Funds Transfer agreement (if EFT payment) HIPAA authorization form(s) (one per applicant) Replacement notice — if replacing existing coverage (leave copy with applicant too) Anti-Discrimination disclosure Phone Verification case # recorded on application (call 866-825-4822, 7am–7pm CT)

🔗 Open Cigna/Healthspring Agent Portal

Humana — Application Guide (ID85030V20-1)

Plans A, F* (pre-2020), G, HD-F*, HD-G, K, N — submit via HEP (Real-Time UW) or paper.

✓ Info to Collect — Section 1: Applicant Information

Full legal name (Last, First, MI) — exactly as on Medicare card Residential address (street, apt, city, county, state, zip) Mailing address (if different) Phone number Date of birth (MMDDYYYY format) Gender Email address (optional) Emergency contact: name, relationship, phone (optional)

✓ Info to Collect — Section 1 (continued): Plan & Medicare

Plan selected: A / F* / HD-F* / G / HD-G / K / N Proposed effective date (auto-fills MM/01/20YY) Medicare Number (from Medicare card — exactly as shown) Medicare Part A effective date (MM/DD/YYYY) Medicare Part B effective date (MM/DD/YYYY) Note: Plan F/HD-F only available to clients eligible for Medicare before 1/1/2020

✓ Info to Collect — Section 2: Other Coverage (ALL applicants)

Ask every client — Yes/No required on all questions:
1. Turned 65 in the last 6 months? Enrolled in Part B in last 6 months?
2. On Medicaid? Will Medicaid pay premiums? Any Medicaid benefits besides Part B?
3. Had Medicare Advantage, HMO, or PPO in last 63 days? (Start/End dates required) Still covered? First time in this type of plan? Dropped a Medigap to enroll?
4. Have another Medicare Supplement currently? Which company/plan? Intend to replace? (Replacement form required)
5. Any other health insurance in last 63 days (employer, union, individual)? Which company/plan? Dates of coverage? Intend to replace?

✓ Info to Collect — Section 3: Guaranteed Acceptance

Two qualifying scenarios — if YES, skip Section 4 (Medical Questions) and go directly to Section 5:
• Applying during Medicare Supplement Open Enrollment Period?
• Lost/losing/replacing coverage that qualifies for Guaranteed Issue? (If YES and submitting Replacement Notice, indicate the specific reason — e.g., "MA plan exiting market")

🚫 Section 4: Medical Questions — Auto-Decline Conditions (Underwritten ONLY)

Required ONLY if NOT in Open Enrollment or Guaranteed Issue. Height, weight, and YES/NO to all questions required.

Any YES to Q1–Q3 = automatic decline:
• Q1: Hospitalized, confined to nursing facility, bedridden, or confined to wheelchair in the last year
• Q2: Received home health care in the past 90 days
• Q3: Used supplementary oxygen in the last year

Q4a–Q4l: Any treatment, medication, or advice for these in the last 2 years = likely decline:
• Q4a: Heart/coronary/carotid artery disease, high blood pressure, high cholesterol, PVD, CHF, stroke, TIA, heart rhythm disorders
• Q4b: Emphysema, COPD, or other chronic pulmonary disorders
• Q4c: Parkinson\'s, MS, Huntington\'s, muscular dystrophy, lupus, hepatitis (non-A/E), ALS
• Q4d: Inflammatory bowel disease, Crohn\'s, ulcerative colitis, Barrett\'s esophagus
• Q4e: Alzheimer\'s, dementia, seizures, epilepsy, schizophrenia, major depression, other mental/nervous disorders, liver disease, cirrhosis, alcoholism, drug abuse
• Q4f: AIDS, ARC, or HIV
• Q4g: Kidney disease requiring dialysis or kidney failure
• Q4h: Diabetes
• Q4i: Internal cancer, leukemia, or melanoma
• Q4j: Amputation by disease/trauma; poor circulation causing skin ulcer; paralytic conditions
• Q4k: Rheumatoid arthritis, Paget\'s, osteoporosis, degenerative bone/joint disorder, crippling arthritis, vertebral or hip fractures, spinal cord disorders, chronic pain
• Q4l: Organ, bone marrow, or stem cell transplant (excluding corneas)

Q5: List all Rx drugs taken in last 12 months (full medication name required)

⚠ Conditions That MAY Be Approved (Controlled)

Per Humana's underwriting guide, these are NOT automatic declines if controlled and compliant:
• Hypertension — not automatically denied; underwriting validates if controlled
• High cholesterol — not automatically denied; underwriting validates if controlled
• Depression — considered if controlled on medications
• Asthma — will be considered for approval
• Blood thinner (one-time fill) — one-time fill for surgery with full recovery may be considered

Top reasons for decline: Alzheimer\'s, COPD, dementia, diabetic neuropathy, chronic kidney disease; and blood thinners (ongoing).

⚖ Build Chart — BMI Limits

Humana uses BMI-based build thresholds:
• Deniable BMI ≤ 14 (severely underweight)
• Deniable BMI ≥ 40.5 (severely obese)
The underwriting tool above applies the exact weight-per-height table from Humana's UW reference guide.

✓ Section 5: Premium Determination & Payment

Tobacco use in last 12 months? (No = Preferred rate; non-tobacco during OE/GI = Preferred rate) Premium quote (from Outline of Coverage) Initial payment amount (minimum: first month's premium) Payment method: Check / Money Order / ACH (bank draft) If ACH: bank name, routing number, account number, account type If credit card: MasterCard / Visa / Discover, card number & expiration Future payment option: same / auto withdrawal / coupon book / auto credit card

✓ Section 7: Signatures & Additional Forms

Applicant signature & date Agent signature & date Agent: list all health insurance policies sold to applicant (current or past 5 years) Medical Records Release Authorization Form (required if Section 4 medical questions were answered) Replacement Form (required if replacing existing Medigap or Medicare Advantage) Writing agent number (SAN), commission level, MGA code

🔗 Open Humana Vantage Portal

UnitedHealthcare (AARP) — Application Guide (S39J49MNAGGA01)

Plans A, B, C*, F*, G, K, L, N, Select G, Select N — 10-page application. Submit online or via paper. *C and F for pre-1/1/2020 Medicare eligibles only.

✓ Info to Collect — Section 1: Applicant Information

AARP Membership Number (required to enroll — join at aarp.org for $20/yr) Full name (First, MI, Last) Permanent home address (no P.O. Box) + mailing address if different Phone number & email address (optional) Date of birth & gender Medicare Number (from Medicare card) Medicare Part A start date (month/year) Medicare Part B start date (month/year) Will Medicare Parts A and B be active on plan start date?

✓ Section 2: Plan Choice & Start Date

Plan selected (A, B, C*, F*, G, K, L, N, Select G, Select N) Desired plan start date (must be the 1st of a future month) Age 50+ and enrolled in Medicare Parts A and B? (required) Not currently enrolled in more than one Medicare Supplement?

✓ Section 3: Guaranteed Acceptance Check

3A: Will plan start date be within 6 months after age 65 or Part B enrollment? → YES = Guaranteed acceptance. Skip Sections 4–7.
3B: Lost/losing coverage or Medicare Advantage "trial right" with GI notice? → YES = Guaranteed acceptance. Attach notice/disenrollment letter. Skip to Section 8.
If NO to both: Age 65+ must answer Sections 4–7. Age 50–64 with disability/ESRD only eligible if Part B enrolled in last 6 months.

✓ Section 4: Medical Providers (Underwritten Only)

Primary physician name & phone Up to 2 specialists seen in last 2 years — name, specialty, phone, diagnosis/condition

✓ Section 5: Kidney Question (Follow-Up Trigger)

5A (2-year lookback): Did a medical professional provide treatment or advice for kidney problems OTHER than kidney stones?
YES or NOT SURE = UHC may follow up for more info. Does NOT automatically decline — but CKD, ESRD, or dialysis history triggers Level 2 rate (Section 7) or hard decline (Section 6D).

🚫 Section 6: Hard Decline Conditions (YES = NOT Eligible for Coverage)

Any YES = application cannot be accepted at ANY rate:
• 6A: Hospitalized as inpatient within the past 90 days — OR hospitalized 3+ times within the past 2 years
• 6B: Currently confined to bed, receiving home health care, or in a nursing facility
• 6C: Received IV infusions or injections for Primary Immunodeficiency Syndrome within the past 2 years
• 6D: Ever told by a medical professional you have End-Stage Renal Disease (ESRD) or may require dialysis
• 6E: Leukemia, Lymphoma, or Multiple Myeloma — diagnosed/treated/medicated within the past 5 years
• 6F: Cancer (other than leukemia/lymphoma/myeloma), Melanoma, or Metastatic Merkel Cell — within past 3 years
• 6G: A medical professional told you that you may need surgery, biopsy, further evaluation, treatment, or diagnostic testing that has NOT been completed
• 6H: Currently awaiting any diagnostic test results

⚠ Section 7: Level 2 Rate Triggers (YES = Higher Premium, NOT a Decline)

UHC does NOT decline most conditions — they charge the Level 2 rate instead (≈50% higher than Standard).

7A — 5-Year Lookback:
• Pulmonary Heart Disease, Heart Failure, Ventricular Tachycardia, or cardiac defibrillator
• Diabetes with Neuropathy, Retinopathy, kidney problems, proteinuria, or circulation problems
• Liver Fibrosis, Cirrhosis, Liver Failure, or Chronic Kidney Disease (CKD)
• ALS or Multiple Sclerosis
• Alzheimer\'s Disease, Dementia, or Parkinson\'s Disease
• Any condition requiring bone marrow, stem cell, or organ transplant

7B — 2-Year Lookback:
• Artery blockage; bypass surgery, stents, or balloon angioplasty
• Heart Attack, Cardiomyopathy, Enlarged Heart, or Atrial Fibrillation
• Carotid Artery Disease, Stroke, TIA, or Mini-Stroke
• Peripheral Vascular Disease (PVD) or Amputation due to disease
• COPD, Emphysema, or Cystic Fibrosis
• Lung/respiratory disorder requiring nebulizer or oxygen, on 3+ meds, or currently using tobacco
• Hemophilia, Hepatitis (other than A), or Pancreatitis
• Osteoporosis with injections or fractures
• Spinal Stenosis, Quadriplegia, Paraplegia, or Hemiplegia
• Psoriatic Arthritis or Rheumatoid Arthritis
• Systemic Lupus Erythematosus (SLE) or Myasthenia Gravis
• Wet Macular Degeneration
• Bipolar Disorder or Schizophrenia
• Alcoholism or Drug Abuse

7C — 2-Year Lookback (IV/Injection-Based Treatment):
• Received blood transfusions, IV infusions, or injections (not vaccines or B12) for: Asthma, Autoimmune disorders, Blood disorders, Cognitive impairment, Connective tissue disorders, Eye disorders, Genetic/Hereditary disorders, Migraine headaches, or Osteoarthritis
• Received skin grafts

⚖ Key UHC Underwriting Notes

• No build chart — UHC does NOT decline based on height or weight.
• Tobacco (Section 8): Any tobacco use in last 12 months = tobacco rate (separate from Level 2 rate — both can apply simultaneously).
• Level 2 rates are approximately 50% higher than Standard rates — still insurable, just at a higher cost.
• NOT SURE answers may trigger follow-up from UHC — treat as a potential flag during intake.
• Plans C and F only available to clients who turned 65 or enrolled in Medicare Part A before 1/1/2020.

✓ Sections 8–9: Tobacco & Prior Coverage

Section 8: Tobacco use in last 12 months? (Yes = tobacco rate) Section 9: On Medicaid? Will Medicaid pay premiums? Medicare Advantage or other Medicare plan in last 63 days? (Start/end dates) Intend to replace current Medicare Supplement? (Replacement Notice required) Other health insurance in last 63 days (employer, union, individual)?

✓ Section 10: Signature & Payment

Applicant signature & date Initial premium payment (check or EFT — $2/month discount for EFT) $24/year discount for Annual Payer option (cannot combine with EFT discount) 10% Multi-Insured Discount — if two insureds on same AARP membership number Replacement Notice enclosed if replacing existing Medigap or Medicare Advantage

🔗 myAARPMedicare Member Portal 🔗 UHC Agent Resources

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Step 1

Client Information

Basic details, height, weight, and tobacco use

First Name

Last Name

State of Residence

Tobacco Use in Last 12 Months?

Height

Weight (lbs)

Enter height & weight above to see instant build chart results

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Step 2

Health Conditions

List all diagnosed conditions with date or number of years

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Step 3

Current Medications

Type any part of the name to search — click a suggestion to select it

Checks Bankers Fidelity, Aetna, Medico/Wellabe, Heartland, Mutual of Omaha, Healthspring, Humana, and UnitedHealthcare simultaneously

💾 Save This Client

Save all info & medications — load instantly next time

✓ Saved!

Medicare Supplement Underwriting