West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-24 - Medicare Supplement Insurance
Section 114-24-10 - Guaranteed Issue for Eligible Persons
Universal Citation: 114 WV Code of State Rules 114-24-10
Current through Register Vol. XLI, No. 38, September 20, 2024
10.1.
10.1.a. Eligible persons are those individuals
described in subsection 10.2 of this section who seek to enroll under the policy
during the period specified in subsection 10.3 of this section, and who submit
evidence of the date of termination, disenrollment, or Medicare Part D enrollment
with the application for a Medicare supplement policy.
10.1.b. With respect to eligible persons, an
issuer shall not deny or condition the issuance or effectiveness of a Medicare
supplement policy described in subsection 10.5 of this section that is offered and
is available for issuance to new enrollees by the issuer, shall not discriminate in
the pricing of 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 a Medicare supplement
policy.
10.2. An eligible person is an individual described in any of the following subdivisions:
10.2.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
substantially all supplemental health benefits to the individual;
10.2.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 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 the provider if the individual were enrolled in a
Medicare Advantage plan:
10.2.b.1. The
certification of the organization or plan has been terminated;
10.2.b.2. The organization has terminated or
otherwise discontinued providing the plan in the area in which the individual
resides;
10.2.b.3. 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;
10.2.b.4. The individual demonstrates, in
accordance with guidelines established by the Secretary, that:
10.2.b.4.A. The organization offering the plan
substantially violated a material provision of the organization's contract under
this series 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 the covered care in accordance with
applicable quality standards; or
10.2.b.4.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
10.2.b.5. The individual meets other exceptional
conditions as the Secretary may provide.
10.2.c.
10.2.c.1. The individual is enrolled with:
10.2.c.1.A. An eligible organization under a
contract under Section 1876 of the Social Security Act (Medicare cost);
10.2.c.1.B. A similar organization operating under
demonstration project authority, effective for periods before April 1,
1999;
10.2.c.1.C. An organization under
an agreement under Section 1833(a)(1)(A) of the Social Security Act (health care
prepayment plan); or
10.2.c.1.D. An
organization under a Medicare Select policy; and
10.2.c.2. The enrollment ceases under the same
circumstances that would permit discontinuance of an individual's election of
coverage under subdivision b of subsection 10.2 of this section.
10.2.d. The individual is enrolled under
a Medicare supplement policy and the enrollment ceases because:
10.2.d.1. Of the insolvency of the issuer or
bankruptcy of the non-issuer organization or of other involuntary termination of
coverage or enrollment under the policy;
10.2.d.2. The issuer of the policy substantially
violated a material provision of the policy; or
10.2.d.3. 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.
10.2.e.
10.2.e.1. 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
10.2.e.2. The subsequent enrollment under
paragraph 1 of this subdivision is terminated by the enrollee during any period
within the first twelve (12) months of subsequent enrollment (during which the
enrollee is permitted to terminate subsequent enrollment under Section 1851(e) of
the federal Social Security Act); or
10.2.f. The individual, upon first becoming
eligible for benefits under Part A of Medicare at age 65, 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.
10.2.g. 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 subdivision d, subsection 10.5 of this
section.
10.3. Guaranteed Issue Time Periods
10.3.a. In the case of an
individual described in subdivision a, subsection 10.2 of this section, the
guaranteed issue period begins on the later of:
(i) 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
(ii) the date that the
applicable coverage terminates or ceases; and ends sixty-three (63) days thereafter
;
10.3.b. In the case of an
individual described in subdivisions b, c, e or f, subsection 10.2 of this section
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;
10.3.c. In the case of an individual described in
paragraph 1, subdivision d, subsection 10.2 of this section, the guaranteed issue
period begins on the earlier of:
(i) the date that
the individual receives a notice of termination, a notice of the issuer's bankruptcy
or insolvency, or other similar notice if any, and
(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;
10.3.d. In the case of an individual described in
subdivision b, paragraph 2 of subdivision d, paragraph 3 of subdivision d,
subdivision e or subdivision f of subsection 10.2 of this section 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;
10.3.e. In the case of an individual described in
subdivision g, subsection 10.2 of this section, 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 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
10.3.f. In the case
of an individual described in subsection 10.2 of this section 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 sixty-three (63)
days after the effective date.
10.4. Extended Medigap Access for Interrupted Trial Periods
10.4.a. In the case of an individual
described in subdivision e, subsection 10.2 of this section (or deemed to be so
described, pursuant to this paragraph) whose enrollment with an organization or
provider described in paragraph 1, subdivision e, subsection 10.2 of this section is
involuntarily terminated within the first twelve (12) months of enrollment, and who,
without an intervening enrollment, enrolls with another organization or provider,
the subsequent enrollment shall be deemed to be an initial enrollment described in
subdivision e, subsection 10.2 of this section;
10.4.b. In the case of an individual described in
subdivision f, subsection 10.2 of this section (or deemed to be so described,
pursuant to this paragraph) whose enrollment with a plan or in a program described
in subdivision f, subsection 10.2 of this section is involuntarily terminated within
the first twelve (12) months of enrollment, and who, without an intervening
enrollment, enrolls in another plan or program, the subsequent enrollment shall be
deemed to be an initial enrollment described in subdivision f, subsection 10.2 of
this section; and
10.4.c. For purposes
of subdivisions e and f, subsection 10.2 of this section, no enrollment of an
individual with an organization or provider described in paragraph 1, subdivision e,
subsection 10.2 of this section, or with a plan or in a program described in
subdivision f, subsection 10.2 of this section, 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 an organization, provider, plan or
program.
10.5. The Medicare supplement policy to which eligible persons are entitled under:
10.5.a. Subdivisions a, b, c, and d, subsection
10.2 of this section 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 insurer.
10.5.b.
10.5.b.1. Subject to paragraph 2 of this
subdivision, subdivision e, subsection 10.2 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 not so available, a policy described in
subdivision a of this subsection.
10.5.b.2. 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
paragraph is:
10.5.b.2.A. The policy available from
the same issuer but modified to remove outpatient prescription drug coverage;
or
10.5.b.2.B. 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;
10.5.c. Subdivision f, subsection 10.2 of this
section shall include any Medicare supplement policy offer by any issuer;
10.5.d. Subdivision g, subsection 10.2 of this
section 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.
10.6. Notification provisions are as follows:
10.6.a. At the time of
an event described in subsection 10.2 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
10.1 of this section. The notice shall be communicated contemporaneously with the
notification of termination.
10.6.b. At
the time of an event described in subsection 10.2 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
subsection 10.1 of this section. The notice shall be communicated within ten (10)
working days of the issuer receiving notification of disenrollment.
Disclaimer: These regulations may not be the most recent version. West Virginia 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.
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