Current through February 24, 2025
(a) Except as
provided in (h) of this section, an eligible person is an individual described
in (c) of this section who seeks to enroll under the policy during the period
specified in (d) of this section, and who submits evidence of the date of the
termination, date of withdrawal from enrollment, date of enrollment in medicare
Part D, or date of substantial reduction of supplemental health benefits with
the application for a medicare supplement policy.
(b) With respect to an eligible person, an
issuer
(1) may not deny or condition the
issuance or effectiveness of a medicare supplement policy that is offered and
is available for issuance to a new enrollee by the issuer;
(2) may not discriminate in the pricing of
that medicare supplement policy because of health status, claims experience,
receipt of health care, or medical condition; and
(3) may not impose an exclusion of benefits
based on a preexisting condition under that medicare supplement
policy.
(c) For purposes
of this section, an eligible person is
(1) an
individual who is enrolled under an employee welfare benefit plan that provides
health benefits that supplement the benefits provided under medicare and whose
plan terminates or ceases to provide substantially all of the supplemental
health benefits to the individual, or an individual who is enrolled under an
employee welfare benefit plan that is primary to medicare and whose plan
terminates or ceases to provide all health benefits to the individual because
the individual leaves the plan;
(2)
an individual who is enrolled with a medicare advantage organization under a
medicare advantage plan under Part C of medicare if any of the following
circumstances apply:
(A) the organization's
or plan's certification under Part C of medicare has been terminated or the
organization has terminated or otherwise discontinued providing the plan in the
area in which the individual resides;
(B) the individual is no longer eligible to
elect the plan because of a change in the individual's place of residence or
other change in circumstances specified by the secretary, excluding termination
of the individual's enrollment on the basis described in
42 U.S.C.
1395w-21 (sec. 1851(g)(3)(B) of the Social
Security Act), if the individual has not paid premiums on a timely basis or has
engaged in disruptive behavior as specified in standards under
42 U.S.C.
1395w-26 (sec. 1856 of the Social Security
Act), or if the plan is terminated for all individuals within a residence
area;
(C) the individual
demonstrates under guidelines established by the secretary that
(i) the organization offering the plan
substantially violated a material provision of the organization's contract
under Part C of medicare in relation to the individual, including the failure
to provide an enrollee on a timely basis medically necessary care for which
benefits are available under the plan or the failure to provide covered care in
accordance with applicable quality standards; or
(ii) the organization, its agent, or another
entity acting on the organization's behalf, materially misrepresented the
plan's provisions in marketing the plan to the individual;
(D) the individual meets other exceptional
conditions that the secretary may provide;
(3) an individual who is enrolled with any of
the following and whose enrollment ceases under any of the circumstances that
would permit discontinuance of an individual's election of coverage under (2)
of this subsection:
(A) an eligible
organization under a contract under
42 U.S.C.
1395 mm (sec. 1876 of the Social Security
Act);
(B) a similar organization
operating under demonstration project authority, effective for periods before
April 1, 1999;
(C) an organization
under an agreement under
42 U.S.C.
1395
l(a)(1)(A) (sec.
1833(a)(1)(A) of the Social Security Act);
(D) an organization under a medicare select
policy as defined in
42 U.S.C.
1395 ss(t) (sec. 1882(t) of the Social
Security Act);
(4) an
individual who is enrolled under a medicare supplement policy and whose
enrollment ceases because
(A) of the
insolvency of the issuer or bankruptcy of the nonissuer organization or other
involuntary termination of coverage or enrollment under the policy;
(B) the issuer of the policy substantially
violated a material provision of the policy; or
(C) the issuer or an agent or other entity
acting on the issuer's behalf materially misrepresented the policy's provisions
in marketing the policy to the individual;
(5) an individual
(A) who was enrolled under a medicare
supplement policy and terminates enrollment and subsequently enrolls, for the
first time, with any medicare advantage organization under a medicare advantage
plan under Part C of medicare, any eligible organization under a contract under
42 U.S.C.
1395 mm (sec. 1876 of the Social Security
Act), any similar organization operating under demonstration project authority,
or a medicare select policy; and
(B) whose subsequent enrollment is terminated
by the enrollee within the first 12 months of this subsequent enrollment,
during which the enrollee is permitted to terminate this subsequent enrollment
under
42 U.S.C.
1395 w - 21(e) (sec. 1851(e) of the Social
Security Act);
(6) an
individual who, upon first becoming enrolled in medicare Part B for benefits at
age 65 or older, enrolls in a medicare advantage plan under Part C of medicare
and who withdraws from the plan not later than 12 months after the effective
date of enrollment; or
(7) an
individual who enrolls in a medicare Part D plan during the initial enrollment
period, and who
(A) at the time of enrollment
in the medicare Part D plan, was enrolled under a medicare supplement policy
that covers outpatient prescription drugs;
(B) terminates enrollment in the medicare
supplement policy; and
(C) provides
evidence of enrollment in the medicare Part D plan along with the application
for a policy described in (d) of this section.
(d) A guaranteed issue time period in the
case of an individual described
(1) in (c)(1)
of this section, begins on the later of the following dates and ends 63 days
after that date:
(A) the date the individual
receives a notice of termination or cessation of all supplemental health
benefits or, if the individual does not receive that notice, a notice that a
claim has been denied because of a termination or cessation;
(B) the date that the applicable coverage
terminates or ceases;
(2) in (c)(2), (c)(3), (c)(5), or (c)(6) of
this section, whose enrollment is terminated involuntarily, begins on the date
that the individual receives a notice of termination and ends 63 days after the
date the coverage is terminated;
(3) in (c)(4)(A) of this section, begins on
the earlier of the following dates and ends 63 days after that date:
(A) the date the individual receives a notice
of termination, a notice of the issuer's bankruptcy or insolvency, or other
similar notice;
(B) the date that
the applicable coverage terminates or ceases;
(4) in (c)(2), (c)(4)(B), (c)(4)(C), (c)(5),
or (c)(6) of this section, who voluntarily withdraws from the plan, begins on
the date that is 60 days before the effective date of the withdrawal and ends
63 days after the effective date;
(5) in (c) of this section, but not described
in (1),(2),(3), or (4) of this subsection, begins on the effective date of an
individual's withdrawal and ends 63 days after the effective date; or
(6) in (c)(7) of this section,
(A) begins on the date the individual
receives notice under
42 U.S.C.
1395 ss(v)(2)(B) (sec. 1882(v)(2)(B) of the
Social Security Act) from the medicare supplement issuer during the 60-day
period immediately preceding the initial Part D enrollment period;
and
(B) ends 63 days after the
effective date of the individual's coverage under medicare Part D.
(e) Access to
enrollment for a medicare supplement policy may be extended for an interrupted
trial period. For purposes of (c)(5) and (c)(6) of this section, an enrollment
of an individual with an organization or provider described in (c)(5)(A) of
this section or with a plan or in a program described in (c)(6) of this
section, may not be deemed to be an initial enrollment under this subsection
after the two-year period beginning on the date on which the individual first
enrolled with the organization, provider, or plan, or in the program. A
subsequent enrollment may be deemed to be an initial enrollment as follows:
(1) in the case of an individual described in
(c)(5) of this section, whose enrollment with an organization or provider
described in (c)(5)(A) of this section is involuntarily terminated within the
first 12 months of enrollment and who, without an intervening enrollment,
enrolls with another organization or provider, the subsequent enrollment is
deemed to be an initial enrollment as described in (c)(5) of this
section;
(2) in the case of an
individual described in (c)(6) of this section, whose enrollment with a plan or
in a program described in (c)(6) of this section is involuntarily terminated
within the first 12 months of enrollment, and who enrolls with another plan or
in another program, the subsequent enrollment is deemed to be an initial
enrollment as described in (c)(6) of this section.
(f) The medicare supplement policy to which
an eligible person is entitled
(1) for
individuals eligible for medicare on or before December 31, 2019, under (c)(1)
- (4) of this section is a medicare supplement policy that has a benefit
package classified as plan "A," "B," "C," "F" high deductible "F," high
deductible "G," "K," or "L," offered by any issuer;
(2) under (c)(5) of this section is the same
medicare supplement policy in which the individual was most recently previously
enrolled if available from the same issuer, or if that policy is not available,
a policy described in (1) of this subsection;
(3) under (c)(6) of this section is any
medicare supplement policy offered by any issuer;
(4) after December 31, 2005, if the
individual was most recently enrolled in a medicare supplement policy with an
outpatient prescription drug benefit, is
(A) a
medicare supplement policy available from the same issuer but modified to
remove outpatient prescription drug coverage; or
(B) at the election of the individual, a
medicare supplement policy that has a benefit package classified as plan "A,"
"B," "C," "F," high deductible "F," high deductible "G," "K," or "L" and that
is offered by any issuer;
(5) for individuals eligible for medicare on
or before December 31, 2019, under (c)(7) of this section is a medicare
supplement policy that has a benefit package classified as plan "A," "B," "C,"
"F," high deductible "F," high deductible "G," "K," or "L" and that is offered
and available for issue to new enrollees by the same issuer that issued the
individual's medicare supplement policy with outpatient prescription drug
coverage;
(6) for individuals newly
eligible for medicare on or after January 1, 2020, under (c)(1) - (4) of this
section is a medicare supplement policy that has a benefit package classified
as plan "A," "B," "D," "G" high deductible "G." "K." or "L." offered by any
issuer; and
(7) for individuals
newly eligible for medicare on or after January 1, 2020, under (c)(7) of this
section is a medicare supplement policy that has a benefit package classified
as plan "A," "B," "D," "G." high deductible "G." "K," or "L" and that is
offered and available for issue to new enrollees by the same issuer that issued
the individual's medicare supplement policy with outpatient prescription drug
coverage.
(g) When an
individual becomes an eligible person under (c) of this section because the
individual loses coverage or benefits due to the termination of a contract or
agreement, policy, or plan, the organization terminating the contract or
agreement, the issuer terminating the policy, or the administrator of the
terminated plan, respectively, shall, contemporaneously with the notification
of termination, notify the eligible person of the eligible person's rights
under this section and of the obligations of issuers of medicare supplement
policies under (b) of this section.
(h) When an individual becomes an eligible
person under (c) of this section because the individual loses coverage or
benefits due to the cessation of substantially all of the supplemental health
benefits under an employee welfare health benefit contract or agreement,
policy, or plan, the organization that substantially reduced the contract or
agreement, the issuer that substantially reduced the policy, or the
administrator of the substantially reduced plan, respectively, shall,
contemporaneously with the notification of the substantial cessation of
benefits, notify the eligible person of the eligible person's rights under this
section and of the obligations of issuers of medicare supplement policies under
(b) of this section.
(i) When an
individual becomes an eligible person under (c) of this section because the
individual withdraws enrollment under a contract or agreement, policy, or plan,
the organization offering the contract or agreement, regardless of the basis
for the withdrawal of enrollment, the issuer offering the policy, or the
administrator of the plan, respectively, shall, within 10 working days of the
date that the issuer receives notification of the withdrawal, notify the
eligible person of the eligible person's rights under this section and of the
obligations of issuers of medicare supplement policies under (b) of this
section.
Authority:AS
21.06.090
AS 21.42.130
AS
21.96.060
