Attestation

We need a little more information about your current & prior coverage (s). Your answers will help determine if you are eligible to enroll for you've selected.

Do you have another Medicare supplement or Medicare Select policy or certificate in force?

Since you answered 'Yes', we need some more information.

If so, do you intend to replace your current Medicare supplement or Medicare Select policy or certificate with this policy or certificate?

Yes No

Have you had coverage under any other health insurance policy or certificate within the past 63 days? (For example, an employer, or individual plan)

Since you answered 'Yes', we need some more information.

Start Date

End Date

Are you covered for medical assistance through the state Medicaid program? (Important: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer NO to this question.)

Since you answered 'Yes', we need some more information.

Will Medicaid pay your premiums for this Medicare supplement policy?

Yes No

Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

Yes No

If you had coverage from any Medicare Advantage plan other than original Medicare within the past 63 days (for example, a Medicare HMO, PPO or PFFS), fill in your start and end dates to the right. If you are still covered under the Medicare Advantage plan, leave END DATE blank.

Yes, I am a resident in a long-term care facility.

Since you answered 'Yes', we need some more information.

Start Date

End Date

If you are still covered under the Medicare Advantage plan, do you intend to replace your current coverage with this new Medicare supplement policy?

Yes No

To complete your enrollment, please sign your application electronically, then click on 'Agree and Submit'. Thanks for choosing HealthGen !

Enter you first and last name to electronically sign and complete your enrollment application.

*First Name

*Last Name

I understand that I am enrolling into a HealthGen Medicare Advantage Plan or a HealthGen Medicare Prescription Drug Plan and not a Medicare Supplement, Medigap, Medicare Select or Medicaid Plan.

To request any of the above documents in fully accessible format, please contact us by email at accessibilty@hgen.com.

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Plans are insured through HealthGen Insurance Company or one of its affiliated companies. For Medicare Advantage and Prescription Drug Plans: A Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan's contract renewal with Medicare.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year.

HealthGen Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Acknowledgement & Attestations

To complete your enrollment, please sign your application electronically, then click on 'Agree and Submit'. Thanks for choosing HealthGen !

Enter you first and last name to electronically sign and complete your enrollment application.

To request any of the above documents in fully accessible format, please contact us by email at accessibilty@hgen.com.

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APPLICATION SUMMARY