Utah Admin. Code R590-146-12 - Guaranteed Issue for Eligible Persons

(1)

(a) An eligible person is an individual described in Subsection (2) who seeks to enroll under a policy or certificate during the period specified in Subsection (3), and who submits evidence of the date of termination, disenrollment, or Medicare Part D enrollment with an application for a policy or certificate.

(b) With respect to an eligible person, an issuer may not:

(i) deny or condition the issuance or effectiveness of a policy or certificate described in Subsection (5) that is offered and is available for issuance to new enrollees by the issuer;

(ii) discriminate in the pricing of a policy because of health status, claims experience, receipt of health care, or medical condition; or

(iii) impose a benefit exclusion based on a preexisting condition.

(2) An eligible person is an individual:

(a) enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates or the plan no longer provides all supplemental health benefits to the individual;

(b) enrolled with a Medicare Advantage organization under a Medicare Advantage plan, and one or more of the circumstances in this subsection 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 in this subsection that would permit discontinuance of the individual's enrollment with such provider if such individual were enrolled in a Medicare Advantage plan:

(i) the certification of the organization or plan has been terminated;

(ii) the organization has terminated or otherwise discontinued providing the plan in the area 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 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, when 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 each individual within a residence area;

(iv) the individual demonstrates, in accordance with guidelines established by the Secretary, that:

(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 such covered care in accordance with applicable quality standards; or

(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; or

(v) the individual meets such other exceptional conditions the Secretary may provide;

(c)

(i) enrolled with:

(A) an eligible organization under a contract under Section 1876 of the Social Security Act;

(B) a similar organization operating under demonstration project authority, effective before April 1, 1999;

(C) an organization under an agreement under Section 1833(a)(1)(A) of the Social Security Act; or

(D) an organization under a Medicare Select policy; and

(ii) enrollment ends under circumstances that would permit discontinuance of an individual's election of coverage under Subsection (2)(b);

(d) enrolled under a policy and the enrollment ends because of:

(i)

(A) the insolvency of the issuer or bankruptcy of the non-issuer organization; or

(B) other involuntary termination of coverage or enrollment under the policy;

(ii) the issuer of the policy substantially violated a material provision of the policy; or

(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;

(e)

(i) enrolled under a policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan, any eligible organization under a contract under Section 1876 of the Social Security Act, 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

(ii) subsequent enrollment under Subsection (2)(e)(i) 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) of the Social Security Act;

(f) upon first becoming eligible for benefits under Medicare Part A at age 65, enrolls in a Medicare Advantage plan, 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;

(g) enrolled in a Medicare Part D plan during the initial enrollment period and was enrolled under a policy that covers outpatient prescription drugs and the individual terminates enrollment in the policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in Subsection (5)(d); or

(h) enrolled under medical assistance under Title XIX of the Social Security Act, Medicaid, and is involuntarily terminated outside of requirements of Subsection R590-146-8(1)(g)(i) or R590-146-8a(1)(g)(i) and R590-146-8a(1)(g)(ii).

(3)

(a) For an eligible person described in Subsection (2)(a), the guaranteed issue period extends for 63 days beginning 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 ends.

(b) For an eligible person described in Subsection (2)(b), (2)(c), (2)(e), or (2)(f), 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 applicable coverage is terminated.

(c) For an eligible person described in Subsection (2)(d)(i), the guaranteed issue period extends for 63 days beginning on the later of:

(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; or

(ii) the date that the applicable coverage is terminated.

(d) For an eligible person described in Subsection (2)(b), (2)(d)(ii), (2)(d)(iii), (2)(e), or (2)(f) 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.

(e) For an eligible person described in Subsection (2)(g), the guaranteed issue period begins on the date the individual receives notice under Section 1882(v)(2)(B) of the Social Security Act from the issuer during the 60-day period immediately preceding the initial Medicare 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.

(f) For an eligible person described in Subsection (2) but not described in Subsections (3)(a) through (e), the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date.

(4)

(a) An eligible person described in Subsection (2)(e), or who is considered to be an eligible person under this subsection, whose enrollment with an organization or provider described in Subsection (2)(e)(i) 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 is considered to be an initial enrollment.

(b) An eligible person described in Subsection (2)(f), or who is considered to be an eligible person under this subsection, whose enrollment with a plan or in a program described in Subsection (2)(f) 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 is considered to be an initial enrollment.

(c) For the purposes of Subsections (2)(e) and (2)(f), enrollment of an individual with an organization or provider described in Subsection (2)(e)(i) or with a plan or in a program described in Subsection (2)(f), may not be considered to be an initial enrollment under this subsection after the two-year period beginning on the date on which the individual first enrolled with the organization, provider, plan, or program.

(5)

(a) An eligible person who is entitled to an open enrollment period under Subsection (2)(a), (2)(b), (2)(c), or (2)(d) may select Plan A, B, C, F, High Deductible F, K, or L if offered by any insurer.

(b)

(i) Subject to Subsection (5)(b)(ii), the policy an eligible person is entitled to under Subsection (2)(e) is the same policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not available, a policy described in Subsection (5)(a).

(ii) After December 31, 2005, if the individual was most recently enrolled in a policy with an outpatient prescription drug benefit, a policy described in this subsection is:

(A) the policy available from the same issuer but modified to remove outpatient prescription drug coverage; or

(B) at the election of the policyholder, Plan A, B, C, F, High Deductible F, K, or L that is offered by any issuer.

(c) The policy an eligible person is entitled to under Subsection (2)(f) includes any policy offered by any issuer.

(d) The policy an eligible person is entitled to under Subsection (2)(g) is Plan A, B, C, F, High Deductible F, K, or L, and is offered and available for issuance to new enrollees by the same issuer that issued the individual's policy with outpatient prescription drug coverage.

(6)

(a) At the time of an event described in Subsection (2) because an individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization, issuer, or administrator terminating the contract, agreement, policy, or plan, shall notify the individual of their rights under this section, and of the obligations of issuers of Medicare supplement insurance policies under Subsection (1). The notice shall be communicated with the notification of termination.

(b) At the time of an event described in Subsection (2) because an individual ends enrollment under a contract, agreement, policy, or plan, the organization, issuer, or administrator offering the contract, agreement, policy, or plan, regardless of the basis for ending enrollment, shall notify the individual of their rights under this section, and of the obligations of issuers of Medicare supplement insurance policies under Subsection (1). The notice shall be provided within ten working days of the issuer receiving notification of disenrollment.

Notes

Utah Admin. Code R590-146-12

Amended by Utah State Bulletin Number 2019-13, effective 6/7/2019 Adopted by Utah State Bulletin Number 2024-16, effective 8/7/2024