Haw. Code R. § 16-12-6.3 - Guaranteed issue for eligible persons
(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 that 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 that 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 all such supplemental health benefits to the individual.
(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 sixty-five 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 that
provider if the individual were enrolled in a Medicare Advantage plan:
(A) The certification of the organization or
plan under this part has been terminated;
(B) The organization has terminated or
otherwise discontinued providing the plan in the area in which the individual
resides;
(C) 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;
(D) The 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 that 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
(E) The individual meets those
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) The
enrollment ceases under the same circumstances that would permit discontinuance
of an individual's election of coverage under paragraph
16-12-6.3(b)(2);
(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 twelve months of that subsequent enrollment (during which the enrollee is
permitted to terminate that subsequent enrollment under Section 1851(e) of the
federal Social Security Act);
(6) The individual, upon first becoming
enrolled in Medicare Part A for benefits at age sixty-five 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, and disenrolls from the plan or
program by not later than twelve 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 sixty-three days thereafter;
(2) In the case of an individual
described in paragraphs (b)(2), (b)(3), (b)(5), or (b)(6) 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 days after
the date the applicable coverage is terminated;
(3) In the case of an individual described in
paragraph (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 similar notice if any; and
(B) The date that the applicable coverage is
terminated, and ends on the date that is sixty-three days after the date the
coverage is terminated;
(4) In the case of an individual described in
paragraphs (b)(2), (b)(4)(B), (b)(4)(C), (b)(5), or (b)(6) who disenrolls
voluntarily, the guaranteed issue period begins on the date that is sixty days
before the effective date of the disenrollment and ends on the date that is
sixty-three 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 sixty-day period immediately
preceding the initial Part D enrollment period and ends on the date that is
sixty-three days after the effective date of the individual's coverage under
Medicare Part D; and
(6) In the
case of an individual described in paragraph (b) but not described in the
preceding provisions of this paragraph, the guaranteed issue period begins on
the effective date of disenrollment and ends on the date that is sixty-three
days after the effective date.
(d) Extended Medigap access from 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 paragraph (b)(5)(A) is involuntarily terminated within the first
twelve 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 paragraph (b)(5);
(2) In the case of an individual described in
paragraph (b)(6) (or deemed to be so described, pursuant to this paragraph)
whose enrollment with a plan or in a program described in paragraph (b)(6) is
involuntarily terminated within the first twelve 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
paragraph (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 paragraph (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 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)
Paragraphs 16-12-6.3(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), paragraph 16-12-6.3(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 paragraph (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) Paragraph 16-12-6.3(b)(6) shall include
any Medicare supplement policy offered by any issuer; and
(4) Paragraph 16-12-6.3(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). That notice shall be communicated
contemporaneously with the notification of termination; and
(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 subsection 16-12-6.3(a). The notice shall be communicated within ten
working days of the issuer receiving notification of disenrollment.
Notes
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