Louisiana Administrative Code
Title 37 - INSURANCE
Part XIII - Regulations
Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards
Section XIII-535 - Guaranteed Issue for Eligible Persons
Universal Citation: LA Admin Code XIII-535
Current through Register Vol. 50, No. 3, March 20, 2024
A. Guaranteed Issue
1. Eligible persons are those individuals
described in Subsection B who seek to enroll under the policy during the period
specified in Subsection C, and who submit evidence of the date of termination
disenrollment, or Medicare Part D enrollment with the application for a
Medicare supplement policy.
2. With
respect to eligible persons, an issuer shall not deny or condition the issuance
or effectiveness of a Medicare supplement policy described in Subsection E that
is offered and is available for issuance to new enrollees by the issuer, shall
not discriminate in the pricing of such a Medicare supplement policy because of
health status, claims experience, receipt of health care, or medical condition,
and shall not impose an exclusion of benefits based on a preexisting condition
under such a Medicare supplement policy.
B. Eligible Persons. An eligible person is an individual described in any of the following Paragraphs.
1. 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
some or all such supplemental health benefits to the individual; or the
individual is enrolled under an employee welfare benefit plan that is primary
or secondary to Medicare and the plan terminates or the plan ceases to provide
some or all health benefits to the individual or the individual leaves the
plan.
2. 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 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:
a. the certification of the organization or
plan has been terminated, or the organization has terminated or otherwise
discontinued providing the plan in the area in which the individual
resides;
b. t he 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;
c. t he individual demonstrates, in
accordance with guidelines established by the secretary, that:
i. 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
ii. 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
d. the individual meets such other
exceptional conditions as the secretary may provide;
3.
a. the
individual is enrolled with:
i. an eligible
organization under a contract under Section 1876 of the Social Security Act (
Medicare cost);
ii. a similar
organization operating under demonstration project authority, effective for
periods before April 1, 1999;
iii.
an organization under an agreement under Section 1833(a)(1)(A) of the Social
Security Act (health care prepayment plan); or
iv. an organization under a Medicare select
policy; and
b. pursuant
to Subsection B.3.a.i, B.3.a.ii, and B.3.a.iii, the enrollment ceases under the
same circumstances that would permit discontinuance of an individual's election
of coverage under §535. B.2; or pursuant to Subsection B.3.a.iv, the enrollment
ceases and discontinuance of an individual's election of coverage occurs due to
one of the following:
i. the certification of
the organization or plan has been terminated, or the organization has
terminated or otherwise discontinued providing the plan in the area in which
the individual resides;
ii. 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 commissioner, 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;
iii. the individual
demonstrates, in accordance with guidelines established by the commissioner,
that:
(a). the organization offering the plan
substantially violated a material provision of the organization's contract(s)
or plan of operation or the organization offering the plan made a material
change or altered the organization's contract(s) or plan of operation that
potentially impacts the individual under this Part or Regulation 33, 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 or adequacy standards or
failure to provide covered services in accordance with the plan of operation,
including but not limited to the adequacy of a organization's provider
network(s); or
(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
4. the individual is enrolled under a
Medicare supplement policy and the enrollment ceases because:
a.
i. of the
insolvency of the issuer or bankruptcy of the nonissuer organization; or
ii. of 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.
a. 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
b. the subsequent enrollment under
Subparagraph a is terminated by the enrollee during any period within the first
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
6. the individual, upon first becoming
enrolled for benefits under Medicare Part B, 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 by not later 12 months
after the effective date of enrollment;
7. 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 a 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 E.4.
C. Guaranteed Issue Time Periods
1. In the case of an individual described in
Paragraph B.1, the guaranteed issue period begins on the later of:
a. 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
b.
the date that the applicable coverage terminates or ceases; and ends 63 days
thereafter;
2. in the
case of an individual described in Paragraphs B.2, 3, 5 or 6 whose enrollment
is terminated involuntarily, the guaranteed issue period begins on the date
that the individual receives a notice of termination and ends 63 days after the
date the applicable coverage is terminated;
3. in the case of an individual described in
Subparagraph B.4.a, the guaranteed issue period begins on the earlier of:
a. 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
b. the date that the applicable coverage is
terminated, and ends on the date that is 63 days after the date the coverage is
terminated;
4. in the
case of an individual described in Paragraphs B.2, 4.b, 4.c, 5 or 6 who
disenrolls voluntarily, the guaranteed issue period begins on the date that is
60 days before the effective date of the disenrollment and ends on the date
that is 63 days after the effective date;
5. in the case of an individual described in
Paragraph B.7, 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 60 period immediately preceding
the initial Part D enrollment period and ends on the date that is 63 days after
the effective date of the individual's coverage under Medicare Part D;
and
6. in the case of an individual
described in Subsection B but not described in the preceding provisions of this
Subsection, the guaranteed issue period begins on the effective date of
disenrollment and ends on the date that is 63 days after the effective
date.
D. Extended Medigap Access for Interrupted Trial Periods
1. In the case of an individual described in
Paragraph B.5 (or deemed to be so described, pursuant to this Paragraph) whose
enrollment with an organization or provider described in Subparagraph B.5.a is
involuntarily terminated within the first 12 months of enrollment, and who,
without an intervening enrollment, enrolls with another such organization or
provider, the subsequent enrollment shall be deemed to be an initial enrollment
described in §535. B.5;
2. in the
case of an individual described in Paragraph B.6 (or deemed to be so described,
pursuant to this Paragraph) who enrollment with a plan or in a program
described in Paragraph B.6 is involuntarily terminated within the first 12
months of enrollment, and who, without an intervening enrollment, enrolls in
another such plan or program, the subsequent enrollment shall be deemed to be
an initial enrollment described in §535. B.6; and
3. for purposes of Paragraphs B.5 and B.6, no
enrollment of an individual with an organization or provider described in
Subparagraph B.5.a, or with a plan or in a program described in Paragraph B.6,
may be deemed to be 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.
E. Products to Which Eligible Persons Are Entitled. The Medicare supplement policy to which eligible persons are entitled under:
1.§535. B.1.2.3 and 4 is a Medicare
supplement policy which has a benefit package classified as Plan A, B, C, F
(including F with a high deductible), K or L offered by any issuer;
2.
a.
subject to Subparagraph b, §535. B.5 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 §535.
E.1;
b. 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 this Subparagraph is:
i. the policy
available from the same issuer but modified to remove outpatient prescription
drug coverage; or
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.§535. B.6 shall include any
Medicare supplement policy available by any issuer;
4.§535. B.7 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.
F. Notification Provisions
1. At the time of an event described in
Subsection B of this Section 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, shall notify the individual of his or her rights under this
Section, and of the obligations of issuers of Medicare supplement policies
under Subsection A. Such notice shall be communicated contemporaneously with
the notification of termination.
2.
At the time of an event described in Subsection B of this Section 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, shall notify the individual of his or
her rights under this Section, and of the obligations of issuers of Medicare
supplement policies under §535. A. Such notice shall be communicated within 10
working days of the issuer receiving notification of disenrollment.
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:1111 (re-designated from LSA-R.S. 22:224 pursuant to Acts 2008, No. 415, effective January 1, 2009) and 42 U.S.C. 1395 et seq.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
