31 Pa. Code § 89.790 - 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 may not:
(i) 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.
(ii) Discriminate in
the pricing of such a Medicare supplement policy because of health status,
claims experience, receipt of health care or medical condition.
(iii) 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 paragraphs
(1)-(7):
(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 supplemental Medicare health benefits to the individual; or the
individual is enrolled under an employee welfare benefit plan that is primary
to Medicare and the plan terminates, or the plan ceases to provide health
benefits to the individual because 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
(42 U.S.C.A. §
1395ee e), and there are circumstances
similar to those described as follows that would permit discontinuance of the
individual's enrollment with the provider if the individual were enrolled in a
Medicare Advantage plan:
(i) The certification
of the organization or plan under this part has been terminated.
(ii) The organization has terminated or
otherwise discontinued providing the plan in the area in which the individual
resides.
(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 HHS Secretary,
but not including termination of the individual's enrollment on the basis
described in section 1851(g)(3)(B) of the Social Security Act (42 U.S.C.A. §
1395w-21(g)(3)(B)) (when the individual has
not paid premiums on a timely basis or has engaged in disruptive behavior as
specified in standards under section 1856 of the Social Security Act
(42 U.S.C.A. §
1395w-26), or the plan is terminated for all
individuals within a residence area).
(iv) The individual demonstrates, in
accordance with guidelines established by the HHS Secretary, that one of the
following applies:
(A) 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 the covered care in accordance with applicable quality
standards.
(B) The organization, or
producer or other entity acting on the organization's behalf, materially
misrepresented the plan's provisions in marketing the plan to the
individual.
(v) The
individual meets other exceptional conditions the HHS Secretary may
provide.
(3) The
individual's enrollment ceases under the same circumstances that would permit
discontinuance of an individual's election of coverage under paragraph (2) and
the individual is enrolled with one of the following:
(i) An eligible organization under a contract
under section 1876 of the Social Security Act (42 U.S.C.A. §
1395mm) (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
(42 U.S.C.A. §
1395l(a)(1)(A)) (health care
prepayment plan).
(iv) An
organization under a Medicare Select policy.
(4) The individual is enrolled under a
Medicare supplement policy and the enrollment ceases because one of the
following applies:
(i) The insolvency of the
issuer or bankruptcy of the nonissuer organization or of other involuntary
termination of coverage or enrollment under the policy.
(ii) The issuer of the policy substantially
violated a material provision of the policy.
(iii) The issuer, or a producer or other
entity acting on the issuer's behalf, materially misrepresented the policy's
provisions in marketing the policy to the individual.
(5) 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)
(42 U.S.C.A. §
1395mm), any similar organization operating
under demonstration project authority, any PACE provider under section 1894 of
the Social Security Act, or any Medicare Select policy and the subsequent
enrollment under this paragraph is terminated by the enrollee during the first
12 months of the subsequent enrollment (during which the enrollee is permitted
to terminate the subsequent enrollment under section 1851(e) of the Social
Security Act).
(6) The individual,
upon first becoming eligible for benefits under Part A and enrolled in Part B,
if eligible, 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 within 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 subsection (e)(4).
(c)
Guaranteed issue time periods.
(1) In the case of an individual described in
subsection (b)(1), the guaranteed issue period begins on the later of one of
the following:
(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).
(ii) The date that the applicable coverage
terminates or ceases; and ends 63 days thereafter.
(2) In the case of an individual described in
subsection (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
subsection (b)(4)(i), the guaranteed issue period begins on the earlier of the
following:
(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.
(ii) 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 subsection (b)(2), (4)(ii), (4)(iii), (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
subsection (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-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.
(6) In the case of
an individual described in subsection (b) but not described in subsections
(d)-(f), 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
subsection (b)(5) (or deemed to be so described, under this paragraph) whose
enrollment with an organization or provider described in subsection (b)(5) is
involuntarily terminated within the first 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 subsection (b)(5).
(2)
In the case of an individual described in subsection (b)(6) (or deemed to be so
described, under this paragraph) whose enrollment with a plan or in a program
described in subsection (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 subsection (b)(6).
(3) For the purposes of subsection (b)(5) and
(6), no enrollment of an individual with an organization or provider described
in subsection (b)(5), or with a plan or in a program described in subsection
(b)(6), may be deemed to be an initial enrollment under this paragraph after
the 2-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) Subsection
(b)(1)-(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 an issuer.
(2)
Subsection (b)(5) is one of the following:
(i)
Subject to subparagraph (ii), 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).
(ii) After December 31, 2005, if the
individual was most recently enrolled in a Medicare supplement policy with an
outpatient prescription drug benefit, one of the following:
(A) The policy available from the same issuer
but modified to remove outpatient prescription drug coverage.
(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.
(3) Subsection (b)(6) includes any Medicare
supplement policy offered by an issuer.
(4) Subsection (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) 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 individuals of their rights under
this section, and of the obligations of issuers of Medicare supplement policies
under subsection (a). The notice shall be communicated contemporaneously with
the notification of termination.
(2) At the time of an event described in
subsection (b) 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 individuals of their rights under this section, and of the
obligations of issuers of Medicare supplement policies under subsection (a).
The notice shall be communicated within 10 working days of the issuer receiving
notification of disenrollment.
Notes
The provisions of this § 89.790 amended under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. §§ 66, 186, 411 and 412).
This section cited in 31 Pa. Code § 89.777c (relating to Standard Medicare supplement benefit plans for 2020 Standardized Medicare supplement benefit plans issued or delivered to individuals newly eligible for Medicare on or after January 1, 2020); and 31 Pa. Code § 89.778 (relating to open enrollment).
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