28 Tex. Admin. Code § 3.3312 - 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
Medicare supplement policy during the period specified in subsection (d) 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 must not deny or condition the
issuance or effectiveness of a Medicare supplement policy described in
subsection (c) of this section that is offered and is available for issuance to
newly enrolled individuals by the issuer, and must not discriminate in the
pricing of a Medicare supplement policy because of health status, claims
experience, receipt of health care, or medical condition, and must not impose
an exclusion of benefits based on a preexisting condition under a Medicare
supplement policy.
(b)
Eligible persons. An eligible person is an individual described in any of the
following paragraphs:
(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 supplemental health benefits to the individual; or the
individual is enrolled under an employee welfare benefit plan that is primary
to Medicare and the plan terminates or the plan ceases to provide all health
benefits to the individual because the individual leaves the plan.
(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 §1894 of the Social Security Act, and there
are circumstances similar to the following that would permit discontinuance of
the individual's enrollment with the provider if the individual were enrolled
in a Medicare Advantage plan:
(A) the
certification of the organization or plan has been terminated; or
(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 §1851(g)(3)(B) of the 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 §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 42 U.S.C. Chapter 7, Subchapter XVIII, Part D in
relation to the individual, including the failure to provide an individual on a
timely basis medically necessary care for which benefits are available under
the plan or the failure to provide the covered care in accord 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 other exceptional conditions as the Secretary may
provide.
(3) The
individual is enrolled with an entity listed in subparagraphs (A) - (D) of this
paragraph and enrollment ceases under the same circumstances that would permit
discontinuance of an individual's election of coverage under paragraph (2) of
this subsection:
(A) an eligible organization
under a contract under §1876 of the Social Security Act (Medicare
cost);
(B) a similar organization
operating under demonstration project authority, effective for periods before
April 1, 1999;
(C) an organization
under an agreement under §1833(a)(1)(A) of the Social Security Act (health care
prepayment plan); or
(D) an
organization under a Medicare Select policy; and
(4) the individual is enrolled under a
Medicare supplement policy and the enrollment ceases because:
(A) of the insolvency of the issuer or
bankruptcy of the nonissuer organization; or 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, 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) 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 §1876 of the Social Security Act (Medicare cost), any similar
organization operating under demonstration project authority, any PACE provider
under §1894 of the Social Security Act, or a Medicare Select policy; and the
subsequent enrollment is terminated by the individual during any period within
the first 12 months of the subsequent enrollment (during which time the
individual is permitted to terminate the subsequent enrollment under §1851(e)
of the Social Security Act); or
(6)
the individual, on first becoming enrolled in Medicare Part B for benefits at
age 65 or older, enrolls in a Medicare Advantage plan under Part C of Medicare,
or with a PACE provider under §1894 of the Social Security Act, and disenrolls
from the plan or program no later than 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 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 (c)(4) of this section.
(8) The individual loses eligibility for
health benefits under Title XIX of the Social Security Act
(Medicaid).
(9) The individual
meets the following requirements:
(A) the
individual was enrolled in both the federal Medicare program and the Texas
Health Insurance Pool on December 31, 2013; and
(B) the individual's Pool coverage terminated
on or after December 31, 2013.
(c) Products to which eligible persons are
entitled.
(1) Persons described by subsection
(b)(1), (2), (3), (4), (8), and (9) of this section are entitled to a Medicare
supplement policy that has a benefit package classified as follows:
(A) Plan A, B, C, F (including F with a High
Deductible), K, or L offered by any issuer, for an individual 65 years of age
or older who first became eligible for Medicare before January 1, 2020, except
that for persons under 65 years of age, it is a policy that has a benefit
package classified as Plan A; or
(B) Plan A, B, D, G (including G with a High
Deductible), K, or L offered by any issuer, for a 2020 newly eligible
individual who is 65 years of age or older, except that for persons under 65
years of age, it is a policy that has a benefit package classified as Plan
A.
(2) Persons described
by subsection (b)(5) of this section are entitled to the same Medicare
supplement policy in which the individual was most recently enrolled, if
available from the same issuer or, if not available, a policy described in
paragraph (1) of this subsection. If the individual was most recently enrolled
in a Medicare supplement policy with an outpatient prescription drug benefit,
the Medicare supplement policy described in this paragraph is the policy
available from the same issuer but modified to remove outpatient prescription
drug coverage, or at the election of the policyholder, a policy described in
paragraph (1) of this subsection.
(3) Persons described by subsection (b)(6) of
this section are entitled to any Medicare supplement policy offered by any
issuer, with the exception of plans C or F (including F with a High Deductible)
for a 2020 newly eligible individual.
(4) Persons described by subsection (b)(7) of
this section are entitled to a Medicare supplement policy that has a benefit
package classified as follows:
(A) 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, for an individual who first became eligible for Medicare before
January 1, 2020; or
(B) Plan A, B,
D, G (including G 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, for a 2020 newly eligible individual.
(d) Guaranteed issue time period.
(1) In the case of an individual described in
subsection (b)(1) of this section:
(A) for a
plan that supplements the benefits under Medicare, 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, the date the individual
receives notice that a claim has been denied because of the termination or
cessation); or
(ii) the date the
applicable coverage terminates or ceases; and ends 63 days later; or
(B) for a plan that is primary to
the benefits under Medicare, the guaranteed issue period begins on the later
of:
(i) the date the individual receives a
notice of termination or cessation of all health benefits (or if a notice is
not received, the date the individual receives notice that a claim has been
denied because of the termination or cessation); or
(ii) the date the applicable coverage
terminates or ceases; and ends 63 days later.
(2) In the case of an individual described in
subsection (b)(2), (3), (5), or (6) 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
subsection (b)(4)(A) of this section, the guaranteed issue period begins on the
earlier of 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 the date that the applicable coverage is terminated, and ends on
the date that is 63 days after the date the coverage is terminated.
(4) In the case of an individual described in
subsection (b)(2), (4)(B) and (C), (5), or (6) 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 of disenrollment.
(5) In the case of an individual described in
subsection (b)(7) of this section, the guaranteed issue period begins on the
date the individual receives notice under §1882(v)(2)(B) of the Social Security
Act from the Medicare supplement issuer during the 60-day period immediately
preceding the initial 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.
(6) In the case of an individual
described in subsection (b) of this section, but not described in paragraphs
(1) - (5) 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 of disenrollment.
(7) In the case of an individual described in
subsection (b)(9) of this section, the guaranteed issue period begins on the
date that the individual's coverage in the Texas Health Insurance Pool
terminates and ends 63 days later.
(e) Extended Medicare supplement access for
interrupted trial periods.
(1) In the case of
an individual described in subsection (b)(5) of this section (or deemed to be
so described under this paragraph), whose enrollment with an organization or
provider described in subsection (b)(5) of this section is involuntarily
terminated within the first 12 months of enrollment, and who, without an
intervening enrollment, enrolls with another organization or provider, the
subsequent enrollment will be deemed to be an initial enrollment as described
in subsection (b)(5) of this section.
(2) In the case of an individual described in
subsection (b)(6) of this section (or deemed to be so described under this
paragraph), whose enrollment with a plan or in a program described in
subsection (b)(6) of this section is involuntarily terminated within the first
12 months of enrollment, and who, without an intervening enrollment, enrolls
with another plan or program, the subsequent enrollment will be deemed to be an
initial enrollment as described in subsection (b)(6) of this section.
(3) For purposes of subsection (b)(5) and (6)
of this section, no enrollment of an individual with an organization or
provider described in subsection (b)(5) of this section, or with a plan or in a
program described in subsection (b)(6) of this section, may be deemed to be an
initial enrollment under this paragraph after the 2-year period beginning on
the date on which the individual first enrolled with the organization,
provider, plan, or program.
Notes
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