760 Ind. Admin. Code 3-9-2

Current through October 31, 2024

Section 760 IAC 3-9-2 - Guaranteed issue for eligible persons

Authority: IC 27-8-13-9; IC 27-8-13-10; IC 27-8-13-10.1

Affected: IC 27-8-13-1

Sec. 2.

(a) As used in this section, "eligible person" means an individual described in any of the following:

(1) An individual enrolled under an employee welfare benefit plan that:

(A) provides health benefits that supplement the benefits under Medicare and the plan:

(i) terminates; or

(ii) implements a material reduction of supplemental health benefits to the individual; or

(B) is primary to Medicare and the plan:

(i) terminates; or

(ii) ceases to provide health benefits to the individual because the individual leaves the plan.

(2) An individual enrolled with a Medicare Advantage organization under a Medicare Advantage plan and any of the following circumstances apply:

(A) The organization's or plan's certification has been terminated or the organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides.

(B) 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:

(i) not paid premiums on a timely basis; or

(ii) engaged in disruptive behavior as specified in standards under Section 1856; or the plan is terminated for all individuals within a residence area.

(C) 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:

(AA) an enrollee on a timely basis medically necessary care for which benefits are available under the plan; or

(BB) 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.

(D) The individual meets other exceptional conditions as the Secretary may provide.

(3) An individual enrolled in:

(A) an eligible organization under a contract under Section 1876 (Medicare risk or cost);

(B) a similar organization operating under demonstration project authority, effective for periods before April 1, 1999; or

(C) an organization under:

(i) an agreement under Section 1833(a)(1)(A) (health care prepayment plan); or

(ii) a Medicare Select policy; and the enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under subdivision (2).

(4) An individual enrolled under a Medicare supplement policy and the enrollment ceases due to one (1) of the following:

(A) Insolvency of the issuer.

(B) Bankruptcy of the organization.

(C) Other involuntary termination of coverage or enrollment under the policy.

(D) The issuer of the policy substantially violated a material provision of the policy.

(E) 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) An individual enrolled under a Medicare supplement policy who:

(A) terminates enrollment and subsequently enrolls with:

(i) any Medicare Advantage organization under Medicare Advantage plans;

(ii) any:

(AA) eligible organization under a contract under Section 1876 (Medicare risk or cost); or

(BB) similar organization operating under demonstration project authority;

(iii) an organization under an agreement under Section 1833(a)(1)(A) (health care prepayment plan); or

(iv) a Medicare Select policy; and

(B) during the first twelve (12) months after the initial termination of enrollment from the Medicare supplement policy under clause (A), the individual:

(i) terminates any subsequent enrollments in any plans or organizations described in clause (A); and

(ii) applies to enroll with a Medicare supplement policy.

(6) An individual who, upon first enrolling in Medicare Part B:

(A) enrolls in any Medicare Advantage plans; and

(B) disenrolls from the plans not later than twelve (12) months after the effective date of the individual's first enrollment.

(7) An individual who:

(A) enrolls in a Medicare Part D plan during the initial enrollment period;

(B) at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs;

(C) terminates enrollment in the Medicare supplement policy; and

(D) submits evidence of enrollment in Medicare Part D along with the application for a policy described in subsection (d).

(b) With respect to eligible persons who apply to enroll under the policy not later than sixty-three (63) days after the date of the termination of enrollment described in subsection (a) and who submit evidence of the date of termination or disenrollment with the application for a Medicare supplement policy, an issuer shall not:

(1) deny or condition the issuance or effectiveness of a Medicare supplement policy described in subsection (c) that is offered and is available for issuance to new enrollees by the issuer;

(2) discriminate in the pricing of such a Medicare supplement policy because of:

(A) health status;

(B) claims experience;

(C) receipt of health care; or

(D) medical condition; and

(3) impose an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy.

(c) An eligible person as defined by subsection (a)(1), (a)(2), (a)(3), or (a)(4) is guaranteed issuance of a standardized Medicare supplement benefit:

(1) Plan A;

(2) Plan B;

(3) Plan C;

(4) Plan F (including Plan F with a high deductible);

(5) Plan K; or

(6) Plan L; offered by any issuer.

(d) An eligible person as defined by subsection (a)(5) is guaranteed issuance of the same standardized 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 subsection (c). 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 referenced above is:

(1) the policy available from the same issuer but modified to remove outpatient prescription drug coverage; or

(2) at the election of the policyholder, a:

(A) Plan A;

(B) Plan B;

(C) Plan C;

(D) Plan F (including Plan with a high deductible);

(E) Plan K; or

(F) Plan L; policy that is offered by any issuer.

(e) In the case of an individual described in subsection (a)(7), the guaranteed issue period:

(1) begins on the date the individual receives notice under Section 1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the sixty (60) day period immediately preceding the initial Part D enrollment period; and

(2) ends on the date that is sixty-three (63) days after the effective date of the individual's coverage under Medicare Part D. An eligible person as defined by subsection (a)(7) is guaranteed issuance of a Medicare supplement Plan A, B, C, F (including F with a high deductible), K, or L 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) An eligible person as defined by subsection (a)(6) is guaranteed issuance of any standardized Medicare supplement policy offered by any issuer.

(g) At the time of an event described in subsection (a), either the:

(1) organization that terminates the contract or agreement;

(2) employee welfare benefit plan;

(3) issuer of the policy; or

(4) administrator of the plan being terminated; shall notify the individual of his or her rights under this section.

(h) At the time of an event described in subsection (a), because of which an individual ceases enrollment under a contract or agreement, policy, or plan, either the:

(1) organization that offers the contract or agreement;

(2) issuer offering the policy; or

(3) administrator of the plan; shall notify the individual of his or her rights under this section. The notice shall be communicated to the individual within ten (10) working days of the issuer receiving notification of disenrollment.

760 IAC 3-9-2

Department of Insurance; 760 IAC 3-9-2; filed Feb 1, 1999, 10:45 a.m.: 22 IR 1976; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; filed Sep 14, 2005, 3:00 p.m.: 29 IR 528; readopted filed Nov 29, 2011, 9:14 a.m.: 20111228-IR-760110553RFA

Readopted filed 11/20/2015, 9:25 a.m.: 20151216-IR-760150341RFA

Readopted filed 11/15/2021, 8:32 a.m.: 20211215-IR-760210419RFA