Division of Insurance Division of Insurance en espanol State of Colorado DORA
MEDICARE SUPPLEMENT INSURANCE PLANS IN COLORADO 2014 QUESTIONNAIRE

Company Information

Only submit for multiple companies at the same time if all answers are uniform for all insurers included.
Company Name:

Please provide your company's toll-free number for prospective clients looking for Medicare Supplement Plans information:

NAIC #(s) of companies included:

URL for Consumer page:

Respondent contact information
Name of the person completing this form (Respondent):

Address:

City:

State:

Zip Code:

Phone:

Extension:

Fax:
Extension:

Email:

Is your company marketing Medicare Supplement Insurance Plans in the State of Colorado in 2014?
Yes
No

Which Medicare Supplement insurance plan(s) does your company market in the State of Colorado? (Select all that apply.)
For consumers age 65 & older.
A
B
C
D
F
F-High Deductible
G
K
L
M
N

Which Medicare Supplement insurance plan(s) does your company market in the State of Colorado? (Select all that apply.)
For consumers under age 65 (disabled)
A
B
C
D
F
F-High Deductible
G
K
L
M
N

Do you require membership in any kind of association to sell your Medicare Supplement to an individual?
Yes, please list in which association or association's membership is required: 
No

How many consumers does your company currently cover under age 65?
A
B
C
D
F
F-High Deductible
G
K
L
M
N
Please provide monthly rates for each Medicare Supplement plan your company markets in Colorado according to the following criteria:
Male, non-smoking, age 65, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N


Female, non-smoking, age 65, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N

Male, non-smoking, age 70, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N

Female, non-smoking, age 70, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N


Male, non-smoking, age 75, resides in zip code 80202:
A

B
C

D

F

F-High Deductible

G

K

L

M

N

Female, non-smoking, age 75, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N



Male, non-smoking, age 80, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N


Female, non-smoking, age 80, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N

Male, non-smoking, under 65, with disability, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N

Female non-smoking, under 65, with disability, resides in zip code 80202:
A

B

C

D

F

F-High Deductible

G

K

L

M

N

What are the minimum and maximum ages imposed by your company at which a Colorado consumer may purchase a Medicare Supplement insurance plan outside his/her guaranteed enrollment period?
a. Male Minimum Age (Enter age, if applicable) 
b. Female Minimum Age (Enter age, if applicable) 
c. Male Maximum Age (Enter age, if applicable) 
d. Female Maximum Age (Enter age, if applicable) 
e. Other underwriting characteristics exist 
f. Not applicable

How are your Medicare Supplement insurance plan premiums calculated/rated?
a. Attained Age
b. Issue Age
c. Community
d. Other or a combination of the above methods, if so please describe: 

Which Medicare Supplement plans does your company have an agreement with Medicare for automatic crossover of unassigned claims that Medicare does not already crossover (please check all that apply)?
A
B
C
D
F
F-High Deductible
G
K
L
M
N

Has your company filed rate changes (increases/decreases) with the State of Colorado for Medicare Supplement plans that are awaiting approval?
Yes
No
Please provide the commissions paid on the Medicare Supplement plans your company offers.
Under Age 65 Open Enrollment
Under Age 65 Outside Open Enrollment
All Others Open Enrollment
All Others Outside Open Enrollment

Does your company differentiate rates based on tobacco use?
Yes
No

Does your company differentiate rates based on geographic area?
Yes
No

Does your company provide a household or marital discount?
Yes
No

Does your company impose a limitation for pre-existing conditions outside of the guarantee issue period?
Yes, How many months? 
No

Does your company assess a policy fee?
Yes, What is it? 
No

Please provide any additional comments you may have related to this survey and its process. This includes any clarifying statements related to information entered above, or any possible improvements you feel should be made.



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