Current through Register Vol. 56, No. 24, December 18, 2024
(a) Eligible
persons are those individuals described in (c) below who seek to enroll under
the policy during the period specified in (d) below, and who submit evidence of
the date of termination, disenrollment, or Medicare Part D enrollment with the
application for a Medicare supplement policy.
(b) With respect to eligible persons, a
carrier shall not deny or condition the issuance or effectiveness of a Medicare
supplement policy described in (f) below that is offered and is available for
issuance to new enrollees by the carrier, 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.
(c) 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
all such supplemental health benefits to the individual;
2. The individual is enrolled under an
employee welfare benefit plan that is primary to Medicare and the plan
terminates, the plan ceases to provide all health benefits to the individual or
the individual leaves the plan;
3.
The individual is enrolled with a Medicare Advantage organization under a
Medicare Advantage Plan under Part C of Medicare, and any of the circumstances
described in (c)3i through iv below 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:
i. 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;
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 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 (42 U.S.C. §
1395w-21) (where the individual has not paid
premiums on a timely basis or has engaged in disruptive behavior as specified
in standards under Section 1856 (42 U.S.C. §
1395w-26)), or the plan is terminated for
all individuals within a residence area;
iii. The individual demonstrates, in
accordance with guidelines established by the Secretary, that:
(1) 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 such covered
care in accordance with applicable quality standards; or
(2) 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
iv. The individual meets such
other exceptional conditions as the Secretary may provide;
4. The individual is enrolled with any of the
following, and the enrollment ceases under the same circumstances that would
permit discontinuance of an individual's election of coverage under (c)3 above:
i. An eligible organization under a contract
under Section 1876 (42
U.S.C. §
1395mm) 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) (42 U.S.C. §
1395) of the Social Security Act (health
care prepayment plan); or
iv. An
organization under a Medicare Select policy;
5. The individual is enrolled under a
Medicare supplement policy and the enrollment ceases because of the following:
i. Either the insolvency of the carrier or
bankruptcy of the noncarrier organization, or other involuntary termination of
coverage or enrollment under the policy;
ii. The carrier substantially violated a
material provision of the policy; or
iii. The carrier, or an agent or other entity
acting on the carrier's behalf, materially misrepresented the policy's
provisions in marketing the policy to the individual;
6. 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 Medicare
Advantage plan under Part C of Medicare, any eligible organization under a
contract under Section 1876 (42
U.S.C. §
1395mm) 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 (42
U.S.C. §
1395ee e), or a Medicare
Select policy; and the subsequent enrollment 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) (42
U.S.C. §
1395w-2) of the Federal Social
Security Act);
7. The individual,
upon first becoming eligible for benefits under Medicare Part A at age 65 or
older, enrolls in a Medicare Advantage plan under Part C of Medicare, or with a
PACE provider under Section 1894 of the Social Security Act (42
U.S.C. §
1395ee e), and disenrolls from
the plan by not later than 12 months after the effective date of enrollment;
or
8. 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 terminated enrollment
in the Medicare supplement policy and submits evidence of enrollment in
Medicare Part D along with the application for a policy described in (f)
below.
(d) The
guaranteed issue time periods shall be:
1. In
the case of an individual described in (c)1 above, the guaranteed issue period
begins on the date the individual receives a notice of termination or cessation
of all supplemental health benefits or, in the absence of the receipt of such
notice, the individual receives notice that a claim has been denied because of
such a termination or cessation and ends 63 days after the date of the
applicable notice; or
2. In the
case of an individual described in (c)3, 4, 6 or 7 above whose enrollment is
terminated involuntarily, the guaranteed issue period begins on the date that
the individual receives a notice of such termination and ends 63 days after the
date the applicable coverage is terminated;
3. In the case of an individual described in
(c)5i above, the guaranteed issue period begins on the earlier of 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 the date
that the applicable coverage is terminated. The guaranteed issue period ends on
the date that is 63 days after the date the coverage is terminated;
4. In the case of an individual described in
(c)3, 5ii or iii, or (c)6 or 7 above 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 (c)8 above, 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 carrier during the 60-day
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 (c) above but not described in the
preceding paragraphs 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.
(e)
The following shall apply to extended Medicare Supplement access for
interrupted trial periods:
1. In the case of
an individual described in (c)6 above (or deemed to be so described, pursuant
to this paragraph) whose enrollment with an organization or provider described
in (c)6 above 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 (c)6 above;
2. In the case of an individual described in
(c)7 above (or deemed to be so described, pursuant to this paragraph) whose
enrollment with a plan or in a program described in (c)7 above 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 (c)7 above;
and
3. For purposes of (c)6 and 7
above, no enrollment of an individual with an organization or provider
described in (c)6 above, or with a plan or in a program described in (c)7
above, 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.
(f) The Medicare supplement policy to which
eligible persons are entitled under (c)1, 2, 3, 4 and 5 above 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 carrier. The
Medicare supplement policy to which eligible persons are entitled under (c)6
above is the same Medicare supplement policy in which the individual was most
recently previously enrolled, if available from the same carrier, or, if not so
available, a policy described in the preceding sentence. However, after
December 31, 2005, if the Medicare supplement policy, under which an eligible
person entitled under (c)6 above was most recently enrolled, is a Medicare
supplement policy with an outpatient prescription drug benefit, the eligible
person described in (c)6 above will be entitled to the same policy from the
same carrier but modified to remove outpatient prescription drug coverage, or
the eligible person may elect 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 carrier. The Medicare supplement policy to which eligible
persons are entitled under (c)7 above shall include any Medicare supplement
policy offered by any carrier. The Medicare supplement policy to which eligible
persons are entitled under (c)8 above 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 that is offered and is available for issuance to new
enrollees by the same carrier that issued the eligible person's Medicare
supplement policy with outpatient prescription drug coverage.
(g) At the time of an event described in (c)
above 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 carrier 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
carriers issuing Medicare supplement policies under (a) and (b) above. Such
notice shall be communicated contemporaneously with the notification of
termination.
(h) At the time of an
event described in (c) above 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 carrier 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 carriers issuing Medicare supplement
policies under (a) and (b) above. Such notice shall be communicated within 10
working days of the issuer receiving notification of disenrollment.
