Conn. Agencies Regs. § 38a-495a-8a - Guaranteed issue for eligible persons
(a)
Guaranteed Issue
(1) Eligible
persons are those individuals described in subsection (b) of this section who
seek to enroll under the policy during the period specified in subsection (c)
of this section, 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) of this section 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 subdivisions:
(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 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.
(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 subdivision (2) of this
subsection.
(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 described in
subparagraph (A) of this subdivision 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
(6) 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.
(7) The individual
enrolls in a Medicare Part D plan during the initial enrollment period and, at
the time of enrollment in Medicare 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) of this section.
(c)
Guaranteed issue time
periods
(1) In the case of an
individual described in subdivision (1) of subsection (b) of this section, the
guaranteed issue period:
(A) Begins on the
later of (i) the date the individual receives a notice of termination or
cessation of all supplemental health benefits (or, if such notice is not
received, notice that a claim has been denied because of such a termination or
cessation) or (ii) the date the applicable coverage terminates or ceases; and
(B) ends 63 days after the date of the applicable notice;
(2) In the case of an individual described in
subdivisions (2), (3), (5) or (6) of subsection (b) of this section 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
subparagraph (A) of subdivision (4) of subsection (b) of this section, 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 63 days after the date the coverage is
terminated;
(4) In the
case of an individual described in subdivision (2), (5) or (6) of subsection
(b) of this section or subparagraph (B) or (C) of subdivision (4) of subsection
(b) of this section 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;
and
(5) In the case of an
individual described in subdivision (7) of subsection (b) of this section, 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
Medicare 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
(6) In the case of an
individual described in subsection (b) but not described in the preceding
subdivisions of this subsection, 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
subdivision (5) of subsection (b) of this section (or deemed to be so
described, pursuant to this subdivision) whose enrollment with an organization
or provider described in subparagraph (A) of subdivision (5) of subsection (b)
of this section 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 shall be deemed to be
an initial enrollment described in subdivision (5) of subsection (b) of this
section;
(2) In the case of an
individual described in subdivision (6) of subsection (b) of this section (or
deemed to be so described, pursuant to this subdivision) whose enrollment with
a plan or in a program described in subdivision (6) of subsection (b) of this
section 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 subdivision (6) of subsection (b) of this section; and
(3) For purposes of subdivisions (5) and (6)
of subsection (b) of this section no enrollment of an individual with an
organization or provider described in subparagraph (A) of subdivision (5) of
subsection (b) of this section, or with a plan or in a program described in
subdivision (6) of subsection (b) of this section, may be deemed to be an
initial enrollment under subdivisions (1) and (2) of this subsection 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) Subdivisions (1), (2),
(3) and (4) of subsection (b) of this section is a Medicare supplement policy
which has a benefit package classified as Plan A, B, C, or F (including F with
a high deductible), K or L offered by any issuer.
(2)
(A)
Subject to subdivision (5) of subsection (b) of this section is (A) 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 subdivision (1) of this subsection ;
(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 subdivision 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) Subdivision (6) of subsection (b) of this
section shall include any Medicare supplement policy offered by any
issuer.
(4) Subsection (b) (7) of
this section 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) of this section. Such notice shall be communicated
contemporaneously with the notification of termination.
(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 (a) of this section. Such notice shall be communicated within
ten working days of the issuer receiving notification of
disenrollment.
Notes
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