Idaho Administrative Code
Title IDAPA 18 - Insurance, Department of
Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS
Section 18.04.10.041 - GUARANTEED ISSUE FOR ELIGIBLE PERSONS
Universal Citation: ID Admin Code 18.04.10.041
Current through August 31, 2023
01. Guaranteed Issue. (3-31-22)
a.
Eligible persons are those individuals described in Subsection
041.02 who seek to enroll under
the policy during the period specified in Subsection
041.03, and who submit evidence
of the date of termination or disenrollment or Medicare Part D enrollment with
the application for a Medicare supplement policy. (3-31-22)
b. With respect to eligible persons, an
issuer cannot deny or condition the issuance or effectiveness of a Medicare
supplement policy described in Subsection
041.05 that is offered and is
available for issuance to new enrollees by the issuer, cannot discriminate in
the pricing of such a Medicare supplement policy because of health status,
claims experience, receipt of health care, or medical condition, and will not
impose an exclusion of benefits based on a preexisting condition under such a
Medicare supplement policy. (3-31-22)
02. Eligible Persons. An eligible person is an individual described here in any part of Subsection 041.02: (3-31-22)
a. The individual is enrolled under an
employee welfare benefit plan that provides health benefits that supplement the
benefits under Medicare; and the plan terminates, or the plan ceases to provide
all such supplemental health benefits to the individual; or the individual is
enrolled under an employee welfare benefits plan that is primary to Medicare
and the plan terminates or the plan ceases to provide all health benefits to
the individual because the individual leaves the plan; (3-31-22)
b. The individual is enrolled with a Medicare
Advantage organization under a Medicare Advantage plan under Part C of
Medicare, and any of the following circumstances apply, or the individual is
sixty-five (65) years of age or older and is enrolled with a Program of
All-Inclusive Care for the Elderly (PACE) provider under Section
1894 of the Social Security Act,
and there are circumstances similar to those described below that would permit
discontinuance of the individual's enrollment with such provider if such
individual were enrolled in a Medicare Advantage plan: (3-31-22)
i. The certification of the organization or
plan under this part has been terminated; (3-31-22)
ii. The organization has terminated or
discontinued providing the plan in the area in which the individual resides;
(3-31-22)
iii. 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, but
not including termination of the individual's enrollment on the basis described
in Section 1851(g)(3)(B) of
the federal Social Security Act (where the individual has not paid premiums on
a timely basis or has engaged in disruptive behavior as specified in standards
under Section 1856), or
the plan is terminated for all individuals within a residence area;
(3-31-22)
iv. The individual
demonstrates, in accordance with guidelines established by the Secretary:
(3-31-22)
(a) That the organization offering
the plan substantially violated a material provision of the organization's
contract under this part 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 such covered
care in accordance with applicable quality standards; or (3-31-22)
(b) The organization, or agent, or other
entity acting on the organization's behalf, materially misrepresented the
plan's provisions in marketing the plan to the individual; or
(3-31-22)
(c) The individual meets
such other exceptional conditions as the Secretary may provide.
(3-31-22)
c. The
individual is enrolled with: (3-31-22)
i. An
eligible organization under a contract under Section
1876 of the Social Security Act
(Medicare cost); (3-31-22)
ii. A
similar organization operating under demonstration project authority, effective
for periods before April 1, 1999; (3-31-22)
iii. An organization under an agreement under
Section 1833(a)(1)(A)
of the Social Security Act (health care
prepayment plan); or (3-31-22)
iv.
An organization under a Medicare Select policy; and
(3-31-22)
d. The
enrollment ceases under the same circumstances that would permit discontinuance
of an individual's election of coverage under Paragraph 041.02.b.
(3-31-22)
e. The individual is
enrolled under a Medicare supplement policy and the enrollment ceases because:
(3-31-22)
i. Of the insolvency of the issuer
or bankruptcy of the non-issuer organization; or (3-31-22)
ii. Of other involuntary termination of
coverage or enrollment under the policy; (3-31-22)
iii. The issuer of the policy substantially
violated a material provision of the policy; or (3-31-22)
iv. 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.
(3-31-22)
f. The
individual 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 Section
1876 of the Social Security Act
(Medicare cost), any similar organization operating under demonstration project
authority, any PACE provider under Section
1894 of the Social Security Act,
or a Medicare Select policy; and (3-31-22)
g. The subsequent enrollment under Paragraph
041.02.f. is terminated by the enrollee during any period within the first
twelve (12) months of such subsequent enrollment (during which the enrollee is
permitted to terminate such subsequent enrollment under Section
1851(e) of the
federal Social Security Act); or (3-31-22)
h. The individual, upon first becoming
eligible for benefits under Part A of Medicare, enrolls in a Medicare Advantage
plan under Part C of Medicare, or with a PACE provider under Section
1894 of the Social Security Act,
and disenrolls from the plan or program by not later than twelve (12) months
after the effective date of enrollment. (3-31-22)
i. The individual enrolls in a Medicare Part
D plan during the initial enrollment period and at the time of enrollment in
Part D, was enrolled under Medicare supplement policy that covers outpatient
prescription drugs and the individual terminates enrollment in the Medicare
supplement policy and submits evidence of enrollment in Medicare Part D along
with the application for a policy described in Paragraph 041.05.e.
(3-31-22)
j. The individual is
enrolled in a Medicare Supplement policy, and, on or after March 1, 2022,
voluntarily terminates enrollment and enrolls in another Medicare Supplement
policy. (3-31-22)
03. Guaranteed Issue Time Periods. (3-31-22)
a. In the case of an individual described in
Paragraph 041.02.a., the guaranteed issue period begins on the later of the
date the individual receives a notice of termination or cessation of all
supplemental health benefits (or, if a notice is not received, notice that a
claim has been denied because of a termination or cessation); or the date that
the applicable coverage terminates or ceases; and ends sixty-three (63) days
thereafter; (3-31-22)
b. In the
case of an individual described in Paragraphs 041.02.b., 041.02.c., 041.02.f.,
or 041.02.h., whose enrollment is terminated involuntarily, the guaranteed
issue period begins on the date that the individual receives a notice of
termination and ends sixty-three (63) days after the date the applicable
coverage is terminated; (3-31-22)
c. In the case of an individual described in
Paragraph 041.02.e., the guaranteed issue period begins on the earlier of:
(3-31-22)
i. The date that the individual
receives a notice of termination, a notice of the issuer's bankruptcy or
insolvency, or other such similar notice if any; and (3-31-22)
ii. The date that the applicable coverage is
terminated, and ends on the date that is sixty-three (63) days after the date
the coverage is terminated; (3-31-22)
d. In the case of an individual described in
Paragraph 041.02.b. and Subparagraph 041.02.e.iii., and Subparagraph
041.02.e.iv., Paragraph 041.02.f., or 041.02.h., who disenrolls voluntarily,
the guaranteed issue period begins on the date that is sixty (60) days before
the effective date of the disenrollment and ends on the date that is
sixty-three (63) days after the effective date; and (3-31-22)
e. In the case of an individual described in
Paragraph 041.02.i., the guaranteed issue period begins on the date the
individual receives notice pursuant to Section
1882(v)(2)(B) of
the Social Security Act from the Medicare supplement issuer during the
sixty-day (60) period immediately preceding the initial Part D enrollment
period and ends on the date that is sixty-three (63) days after the effective
date of the individual's coverage under Medicare Part D; and
(3-31-22)
f. In the case of an
individual described in Subsection
041.02 but not described in the
preceding provisions of Subsection
041.03, the guaranteed issue
period begins on the effective date of disenrollment and ends on the date that
is sixty-three (63) days after the effective date. (3-31-22)
g. In the case of an individual described in
Paragraph 041.02.j., the guaranteed issue period begins on the individual's
birthday and ends sixty-three (63) days thereafter.
(3-31-22)
04. Extended Medigap Access for Interrupted Trial Periods. (3-31-22)
a. In the case of an individual described in
Paragraph 041.02.f. (or so described, pursuant to this paragraph) whose
enrollment with an organization or provider described in Paragraph 041.02.f. is
involuntarily terminated within the first twelve (12) months of enrollment, and
who, without an intervening enrollment, enrolls with another such organization
or provider, the subsequent enrollment is deemed an initial enrollment
described in Paragraph 041.02.f.; (3-31-22)
b. In the case of an individual described in
Paragraph 041.02.h. (or so described, pursuant to this paragraph) whose
enrollment with a plan or in a program described in Paragraph 041.02.h. is
involuntarily terminated within the first twelve (12) months of enrollment, and
who, without an intervening enrollment, enrolls in another such plan or
program, the subsequent enrollment is deemed an initial enrollment described in
Paragraph 041.02.h.; and (3-31-22)
c. For purposes of Paragraphs 041.02.f. and
041.02.h., no enrollment of an individual with an organization or provider
described in Paragraph 041.02.f. or with a plan or in a program described in
Paragraph 041.02.h. may be deemed an initial enrollment under this paragraph
after the two-year period beginning on the date on which the individual first
enrolled with such an organization, provider, plan or program.
(3-31-22)
05. Products to Which Eligible Persons are Entitled. The Medicare supplement policy to which eligible persons are entitled under: (3-31-22)
a. Paragraphs 041.02.a. through 041.02.e. is
a Medicare supplement policy which has a benefit package classified as Plan A,
B, C, or F (including F with a high deductible), K or L offered by any issuer.
(3-31-22)
b. Subject to Paragraph
041.05.c., Paragraph 041.02.g. is the same Medicare supplement policy in which
the individual was most recently previously enrolled, if available from the
same issuer, or, if not so available, a policy described in Paragraph 041.05.a.
(3-31-22)
c. After December 31,
2005, if the individual was most recently enrolled in a Medicare supplement
policy with an outpatient prescription drug benefit, a Medicare supplement
policy described in Subsection
041.05 is: (3-31-22)
i. The policy available from the same issuer
but modified to remove outpatient prescription drug coverage; or
(3-31-22)
ii. At the election of
the policyholder, an A, B, C, F (including F with a high deductible), K or L
policy that is offered by any issuer; (3-31-22)
d. Paragraph 041.02.h. includes any Medicare
supplement policy offered by any issuer. (3-31-22)
e. Paragraph 041.02.i. is a Medicare
supplement policy that has a benefit package classified as Plan A, B, C, F
(including F with a high deductible), K, or L and that is offered and is
available for issuance to new enrollees by the same issuer that issued the
individual's Medicare supplement policy with outpatient prescription drug
coverage. (3-31-22)
f. Paragraph
041.02.j. includes any comparable or lesser Medicare policy offered by any
issuer. For the purposes of this Paragraph, a Medicare supplement policy or
certificate will be considered to have comparable or lesser benefits unless it
contains one (1) or more significant benefits not included in the Medicare
Supplement policy or certificate being replaced. (3-31-22)
06. Notification Provisions. (3-31-22)
a. At the time of an event described
in Subsection 041.02
because of which an individual loses coverage or benefits due to the
termination of a contract or agreement, policy, or plan, the organization that
terminates the contract or agreement, the issuer terminating the policy, or the
administrator of the plan being terminated, respectively, notifies the
individual of the individual's rights under this Section, and of the
obligations of issuers of Medicare supplement policies under Subsection
041.01. Such notice is
communicated contemporaneously with the notification of termination.
(3-31-22)
b. At the time of an
event described in Subsection
041.02 because of which an
individual ceases enrollment under a contract or agreement, policy, or plan,
the organization that offers the contract or agreement, regardless of the basis
for the cessation of enrollment, the issuer offering the policy, or the
administrator of the plan, respectively, notifies the individual of the
individual's rights under this section, and of the obligations of issuers of
Medicare supplement policies under Subsection
041.01. Such notice is
communicated within ten (10) working days of the issuer receiving notification
of disenrollment. (3-31-22)
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