28 Tex. Admin. Code § 3.3324 - Open Enrollment
(a) No issuer may
deny or condition the issuance or effectiveness of any Medicare supplement
policy or certificate available for sale in this state, nor discriminate in the
pricing of a policy or certificate because of the health status, claims
experience, receipt of health care, or medical condition of an applicant where
an application for a policy or certificate is submitted before or during the
six-month period beginning with the first day of the first month in which an
individual is first enrolled for benefits under Medicare Part B. No issuer may
engage in a premium rating practice that results in higher premiums for any
policy solely because the policy is issued under the provisions of this
section. For individuals 65 years of age or older when first enrolled for
benefits under Medicare Part B who apply for Medicare supplement coverage under
this subsection, each Medicare supplement policy and certificate currently
available from an issuer must be made available to all applicants without
regard to age.
(b) The provisions
of paragraphs (1) and (2) of this subsection apply to Medicare supplement
issuers with respect to persons who qualify for Medicare before attaining 65
years of age.
(1) An issuer must comply with
the first two sentences of subsection (a) of this section with respect to a
person who:
(A) qualifies for Medicare before
attaining 65 years of age, who first enrolls for benefits under Medicare Part B
on or after January 1, 1997, and who applies for a Medicare supplement policy
or certificate during the period of eligibility described in subsection (a) of
this section; or
(B) enrolled in
Medicare Part B before attaining 65 years of age, who applies for a Medicare
supplement policy or certificate upon attaining 65 years of age, during the
period of eligibility described in subsection (a) of this section that would
apply if the person first enrolled in Medicare Part B on attaining 65 years of
age.
(2) An issuer must
make available, at a minimum, Plan A of the standard Medicare supplement plans
to individuals who qualify under this subsection.
(c) If an applicant qualifies under
subsection (a) of this section, is 65 years of age or older, and submits an
application during the period referenced in subsection (a) of this section and,
as of the date of application:
(1) has had a
continuous period of creditable coverage of at least six months, the issuer may
not exclude benefits based on a preexisting condition; or
(2) has had a continuous period of creditable
coverage that is less than six months, the issuer must reduce the period of any
preexisting condition exclusion by the aggregate of the period of creditable
coverage applicable to the applicant as of the enrollment date.
(d) Except as provided in
subsection (c) of this section, §
3.3312 of this title (relating to
Guaranteed Issue for Eligible Persons), and §
3.3306(b)(1)(A)
of this title (relating to Minimum Benefit Standards), subsection (a) of this
section may not be construed as preventing the exclusion of benefits under a
policy during the first six months based on a preexisting condition for which
the policyholder or certificate holder received treatment or was otherwise
diagnosed during the six months before the coverage became effective.
(e) The following examples illustrate the
application of subsection (c)(1) and (2) of this section, as prescribed by the
Secretary:
(1) Individual A--" No preexisting
condition exclusion period. Relevant creditable coverage history: Individual A
had coverage under an individual policy for four months beginning on May 1,
1998, through August 31, 1998, followed by a gap in coverage of 61 days until
October 31, 1998. Individual A had coverage under an individual health plan
beginning on November 1, 1998, for three months through January 31, 1999,
followed by a gap in coverage of 59 days or until March 31, 1999, on which date
Individual A submitted an application for a Medicare supplement policy. Under
this example, the Medicare supplement issuer may not apply a preexisting
condition exclusion period because Individual A has seven months of creditable
coverage without a gap in coverage greater than 63 days.
(2) Individual B--" Subject to a three-month
preexisting condition exclusion period. Relevant creditable coverage history:
Individual B is covered under an individual health insurance policy for one
month beginning May 1, 1998, through May 31, 1998, followed by a gap in
coverage of 61 days from June 1, 1998, through July 31, 1998. On August 1,
1998, Individual B is covered under an association health plan for two months
through September 30, 1998, followed by a gap in coverage of 31 days or until
October 31, 1998, on which date Individual B submitted an application for
Medicare supplement coverage. Individual B has three months of creditable
coverage. Under this example, the issuer of a Medicare supplement policy must
give Individual B a three-month credit against any preexisting condition
exclusion period.
(3) Individual
C--" Subject to a six-month preexisting condition exclusion period. Relevant
creditable coverage history: Individual C is covered under an individual health
insurance policy for one month beginning May 1, 1998, through May 31, 1998,
followed by a gap in coverage of 61 days from June 1, 1998, through July 31,
1998. On August 1, 1998, Individual C is covered under an association health
plan for two months through September 30, 1998, followed by a gap in coverage
of 64 days or until November 4, 1998, on which date Individual C submitted an
application for Medicare supplement coverage. Individual C has a gap in
coverage of greater than 63 days. As a result, under this example, the Medicare
supplement issuer can fully apply the preexisting condition exclusion provision
to Individual C.
(f)
Invitation to contract advertisements, as defined in §
21.113(b) of
this title (relating to Rules Pertaining Specifically to Accident and Health
Insurance Advertising and Health Maintenance Organization Advertising), must
include the following statement: "Benefits and premiums under this policy may
be suspended for up to 24 months if you become entitled to benefits under
Medicaid. You must request that your policy be suspended within 90 days of
becoming entitled to Medicaid. If you lose (are no longer entitled to) benefits
from Medicaid, this policy can be reinstated if you request reinstatement
within 90 days of the loss of such benefits and pay the required
premium."
Notes
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