© 2020 Amerigroup Corporation
Non-Discrimination Notice: The plan documents may be available in other languages. Or, if you have special needs, the documents may be available in other formats. Please review the
Notice of Non-Discrimination in Health Programs and Activities
Not connected with or endorsed by the U.S. Government or the federal Medicare program. The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent or insurance company.
Once enrolled in your Medicare Supplement insurance plan, your coverage is guaranteed for the life of the plan with only two exceptions/restrictions: nonpayment of premiums and material misrepresentation.
NOTICE OF THIRD DAY RIGHT TO EXAMINE POLICY: You have 30 days to examine this Policy. If you are not satisfied with this Policy, you may return it to us or the agent who sold it to you within 30 days after your receive it. If you return it to us, you should mail it to P.O. Box 659816, San Antonio, TX 78265-9116. Your premium will be refunded and this Policy will be void from its start.
MEDICARE PART B EXCESS CHARGES: Standardized Medicare Supplement Plan F and G pay for 100% of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.
OPEN ENROLLMENT. If you are in your open enrollment period, you cannot be denied coverage because of health problems. Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, for instance due to disability, you will also have a 6 month open enrollment period when you reach age 65.
If you are outside any open enrollment period, when you fill out the application be sure to answer complete all questions about your medical and health history. If you leave out or falsify important medical information the company may cancel your coverage and refuse to pay any claims.
POLICY FORM NUMBER: AGPLANAM(18)D-TX, AGPLANAM(18)-TX, AGPLANFM(18), AGPLANGM(18) and AGPLANNM(18)-TX
PRE-EXISTING CONDITION LIMITATION: Except as noted below, we do not provide benefits for losses you incur during the first six (6) months after the policy effective date if caused by or resulting from a pre-existing condition.
This pre-existing condition limitation does not apply if:
- The policy effective date is no more than six (6) months after your 65th birth date; or
- You submit an Application prior to or during the six (6) month period beginning with the first day of the month in which you are 65 years or older and enrolled for benefits under Medicare Part B; or
- You are an eligible person coming from a Medicare Advantage, Medicare Select, Medicare Supplement, or an Employee Welfare Benefit Plan as defined in the Employee Retirement Income Security Act of 1974 (29 USC 1003), and you apply to enroll not later than 63 days from the date of the termination of enrollment in the previous plan, and you submit evidence of termination or disenrollment from that plan with your Application (Certificate of Creditable Coverage).
If you had less than six months prior creditable coverage, the pre-existing conditions limitation will be reduced by the aggregate amount of creditable coverage. If the policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.
A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a physician within six months prior to the policy effective date.
MEDICAID ELIGIBILITY: Benefits and premiums under this policy may be suspended for up to 24 months if you become entitled to benefits under Medicaid. You must request that your policy be suspended within 90 days of becoming entitled to Medicaid. If you lose (are no longer entitled to) benefits from Medicaid, this policy can be reinstated if you request reinstatement within 90 days of the loss of such benefits and pay the required premium.
Coverage is provided by Amerigroup Insurance Company.
CMS Accepted 02/21/2020