044-35 Wyo. Code R. §§ 35-12 - Guaranteed Issue for Eligible Persons
(a) Guaranteed Issue.
(i) 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.
(ii) 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 such 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 such a Medicare
supplement policy.
(b)
Eligible Persons. An eligible person is an individual described in any of the
following paragraphs:
(i) 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;
(ii) 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 such
provider if such individual were enrolled in a Medicare Advantage plan:
(A) The certification of the organization or
plan 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 such 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 such
other exceptional conditions as the Secretary may provide.
(iii) Organization:
(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 Section 12(b)(ii).
(iv) The individual is enrolled under a
Medicare supplement policy and the enrollment ceases because:
(A) Insolvency, bankruptcy, and involuntary
termination.
(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.
(v) Related Enrollments
(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 (12) months of such subsequent enrollment during
which the enrollee is permitted to terminate such subsequent enrollment under
Section 1851(e) of the federal Social Security Act); or
(vi) 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.
(vii) The individual who has postponed
enrollment in Medicare Part B until after age 65 because he is working and
enrolled in a group health insurance plan.
(viii) 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)(iv).
(c) Guaranteed
Issue Time Periods.
(i) In the case of an
individual described in Subsection (b)(i), 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;
(ii) In the case of an individual described
in Subsection (b)(ii), (b)(iii), (b)(v) or (b)(vi) 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;
(iii) In the case of an individual described
in Subsection (b)(iv)(A), 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 such 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;
(iv) In the case of an individual described
in Subsection (b)(ii), (b)(iv), (b)(v) or (b)(vi) 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;
(v) In the case of an individual described in
Subsection (b)(vii), 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
(vi) In the case of an individual described
in Subsection (b) 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.
(d) Extended Medigap Access for Interrupted
Trial Periods.
(i) In the case of an
individual described in Subsection (b)(v) (or deemed to be so described,
pursuant to this paragraph) whose enrollment with an organization or provider
described in Subsection (b)(v)(A) is involuntarily terminated within the first
twelve (12) months of enrollment, and who, without an intervening enrollment,
enrolls with another such organization or provider, the subsequent enrollment
shall be deemed to be an initial enrollment described in Section
12(b)(v);
(ii) In the case of an
individual described in Subsection (b)(vi) (or deemed to be so described,
pursuant to this paragraph) whose enrollment with a plan or in a program
described in Subsection (b)(vi) is involuntarily terminated within the first
twelve (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 Section 12(b)(vi);
and
(iii) For purposes of
Subsections (b)(v) and (b)(vi), no enrollment of an individual with an
organization or provider described in Subsection (b)(v)(A), or with a plan or
in a program described in Subsection (b)(vi), 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 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 the following:
(i) Section 12(b)(i), (ii), (iii) and (iv) 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.
(ii) Other Eligible
Policies.
(A) Subject to Subparagraph (B),
Section 12(b)(v) 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 (i);
(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.
(iii) Section 12(b)(vi) shall include any
Medicare supplement policy offered by any issuer;
(iv) Section 12(b)(vii) 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.
(i) 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). Such notice shall be communicated
contemporaneously with the notification of termination.
(ii) At the time of an event described in
Subsection (a) 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 Section 12(a). Such notice shall be communicated within ten working days
of the issuer receiving notification of disenrollment.
Notes
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