Ga. Comp. R. & Regs. R. 120-2-8-.12 - Guaranteed Issue for Eligible Persons
(1) Guaranteed Issue
(a) Eligible persons are those individuals
described in Subsection (2) who seek to enroll under the policy during the
period specified in Subsection (3), and who submit evidence of the date of
termination, disenrollment, or Medicare Part D enrollment with the application
for a Medicare supplement policy.
(b) With respect to eligible persons, an
issuer shall not deny or condition the issuance or effectiveness of a Medicare
supplement policy described in Subsection (5) 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.
(2)
Eligible Persons. An eligible person is an individual described in any of the
following paragraphs:
(a) 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;
(b) 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:
1. The certification of the organization or
plan has been terminated;
2. The
organization has terminated or otherwise discontinued providing the plan in the
area in which the individual resides;
3. 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;
4. 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
5. The individual meets such other
exceptional conditions as the Secretary may provide.
(c)
1. 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
2. The
enrollment ceases under the same circumstances that would permit discontinuance
of an individual's election of coverage under Section
120-2-8-.12(2)(b).
(d) The individual is enrolled under a
Medicare supplement policy and the enrollment ceases because:
1.
(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;
2. The issuer of the policy substantially
violated a material provision of the policy; or
3. 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;
(e)
1. 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
2. The subsequent enrollment under
subparagraph 1. 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
(f) 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.
(g) 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 (5)(d).
(3) Guaranteed Issue Time Periods.
(a) In the case of an individual described in
Subsection (2)(a), 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
termination or cessation); or
(ii)
the date that the applicable coverage terminates or ceases; and ends
sixty-three (63) days thereafter;
(b) In the case of an individual 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 sixty-three (63) days
after the date the applicable coverage is terminated;
(c) In the case of an individual described in
Subsection (2)(d)1., 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;
(d) In the case of an individual described in
Subsection (2)(b), (2)(d)2., (2)(d)3., (2)(e) or (2)(f) 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; and
(e) In the case of an individual described in
Subsection (2)(g), 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
(f) In the case of an individual described in
Subsection (2) 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.
(4)
Extended Medigap Access for Interrupted Trial Periods.
(a) In the case of an individual described in
Subsection (2)(e) (or deemed to be so described, pursuant to this paragraph)
whose enrollment with an organization or provider described in Subsection
(2)(e)1. 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
120-2-8-.12(2)(e);
(b) In the case of an individual described in
Subsection 2(e) (or deemed to be so described, pursuant to this paragraph)
whose enrollment with a plan or in a program described in Subsection (2)(f) 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
120-2-8-.12(2)(f);
and
(c) For purposes of Subsections
(2)(e) and (2)(f), no enrollment of an individual with an organization or
provider described in Subsection (2)(e)1., or with a plan or in a program
described in Subsection (2)(f), 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.
(5) Products to
Which Eligible Person are Entitled. The Medicare supplement policy to which
eligible persons are entitled under:
(a)
Section 120-2-8-.12(2)(a), (b), (c) and
(d) is a Medicare supplement policy that has
a benefit package classified as Plan A, B, C, F (including F with an high
deductible), K or L offered by any issuer.
(b)
1.
Subject to Subparagraph 2., Section
120-2-8-.12(2)(e)
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 (a);
2. 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;
(c) Section
120-2-8-.12(2)(f)
shall include any Medicare supplement policy offered by any issuer.
(d) Section
120-2-8-.12(2)(g)
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.
(6)
Notification provisions.
(a) At the time of an
event described in Subsection (2) 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 (1). Such notice shall be communicated
contemporaneously with the notification of termination.
(b) At the time of an event described in
Subsection (2) 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
120-2-8-.12(1).
Such notice shall be communicated within ten working days of the issuer
receiving notification of disenrollment.
Notes
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