(a)
Prohibitions regarding denial, issuance and pricing of Medicare
supplement policies or certificates.
(1) An issuer may not deny or condition the
issuance or effectiveness of a Medicare supplement policy or certificate
available for sale in this Commonwealth, 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 in the case of an
application for a policy or certificate that is submitted prior to or during
the 6-month period beginning with the first day of the first month in which
either of the following occurs:
(i) An
individual enrolled for benefits under Medicare Part B.
(ii) An applicant who is retroactively
enrolled in Medicare Part B due to a retroactive eligibility decision made by
the Social Security Administration received notice of retroactive eligibility
to enroll.
(2) Each
Medicare supplement policy and certificate currently available from an issuer
shall be made available to applicants who qualify under this subsection without
regard to age. In the case of group policies, an issuer may condition issuance
on whether an applicant is a member or is eligible for membership in the
insured group.
(b)
Exclusion of benefits based on a pre-existing condition
prohibited. If an applicant qualifies under subsection (a) and submits
an application during the time period referenced in subsection (a) and, as of
the date of application, has had a continuous period of creditable coverage of
at least 6 months, the issuer may not exclude benefits based on a preexisting
condition.
(c)
Reduction of
the period of a pre-existing condition exclusion. If the applicant
qualifies under subsection (a) and submits an application during the time
period referenced in subsection (a) and, as of the date of application, has had
a continuous period of creditable coverage that is less than 6 months, the
issuer shall 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. The HHS Secretary shall specify the manner of the
reduction under this subsection.
(d)
Prevention of the exclusion of
benefits under a policy. Except as provided in subsections (b) and (c)
and §§
89.789 and
89.790 (relating to prohibition
against preexisting conditions, waiting periods, elimination periods and
probationary periods in replacement policies or certificates; and guaranteed
issue for eligible persons), subsection (a) will not be construed as preventing
the exclusion of benefits under a policy, during the first 6 months, based on a
preexisting condition for which the policyholder or certificateholder received
treatment or was otherwise diagnosed during the 6 months before it became
effective.
Notes
The
provisions of this § 89.778 adopted July 24, 1992, effective
7/25/1992, 22 Pa.B. 3841;
amended September 2, 1994, effective 11/2/1994, 24 Pa.B. 4467; amended May 10, 1996,
effective 5/11/1996, 26 Pa.B.
2196; amended January 8, 1999, effective 1/9/1999, 29 Pa.B. 172; amended May 6, 2005,
effective 5/7/2005, 35 Pa.B.
2729; amended September 7, 2018, effective 9/8/2018, 48 Pa.B.
5601.
The provisions of this § 89.778 amended under the
Omnibus Budget Reconciliation Act (OBRA 90) of November 15, 1990,
P. L.
101-508; sections 206, 506, 1501 and 1502 of The
Administrative Code of 1929 (71 P.S. §§
66,
186,
411 and
412); sections 356 and 616 of
The Insurance Company Law of 1921 (40 P.S. §§
477b and
751); sections 5 and 9 of the
Medicare Supplement Insurance Act (40 P.S. §§
3105 and
3109); and section 314 of the
Accident and Health Filing Reform Act (40 P.S. §
3801.314).
