Md. Code Regs. 31.10.06.09-1

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.10.06.09-1 - Guaranteed Issue for Eligible Individuals

A. Guaranteed Issue.

(1) Eligible individuals are those individuals described in §B of this regulation who:

(a) Seek to enroll under the policy during the period specified in §C of this regulation; and

(b) 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 individuals, an issuer may not:

(a) Deny or condition the issuance or effectiveness of a Medicare supplement policy described in §E of this regulation that is offered and is available for issuance to new enrollees by the issuer;

(b) Discriminate in the pricing of a Medicare supplement policy described in §E of this regulation because of health status, claims experience, receipt of health care, or medical condition; and

(c) Impose an exclusion of benefits based on a preexisting condition under a Medicare supplement policy described in §E of this regulation.

B. An eligible individual is an individual described in any of the following:

(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 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:

(a) The certification of the organization or plan under the federal Social Security Act 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:

(i) Of a change in the individual's place of residence,

(ii) Of another 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 federal Social Security Act (when the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under § 1856 of the federal Social Security Act), or

(iii) 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 Part C of Medicare 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 medically necessary 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 any other exceptional conditions as the Secretary may provide;

(3) The individual is 65 years old 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 those described in §B(2) of this regulation that would permit discontinuance of the individual's enrollment with the PACE provider if the individual were enrolled in a Medicare Advantage plan;

(4) The individual:

(a) Is enrolled with:

(i) An eligible organization under a contract under § 1876 of the federal Social Security Act (Medicare cost),

(ii) A similar organization to the organization described in §B(4)(a)(i) of this regulation operating under demonstration project authority, effective for periods before April 1, 1999,

(iii) An organization under an agreement under § 1833(a)(1)(A) of the federal Social Security Act (health care prepayment plan), or

(iv) An organization under a Medicare Select policy; and

(b) Ceases to be enrolled under the same circumstances that would permit discontinuance of an individual's election of coverage under §B(2) of this regulation;

(5) The individual is enrolled under a Medicare supplement policy and the enrollment ceases because of:

(a) The insolvency of the issuer or bankruptcy of the nonissuer organization or 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;

(6) The individual:

(a) Was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time with:

(i) Any Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare,

(ii) Any eligible organization under a contract under § 1876 of the federal Social Security Act (Medicare cost),

(iii) Any similar organization operating under demonstration project authority,

(iv) A Medicare Select policy, or

(v) Any Program of All-Inclusive Care for the Elderly (PACE) provider under § 1894 of the Social Security Act; and

(b) Terminates the subsequent enrollment under §B(6)(a) of this regulation during any period within the first 12 months of the subsequent enrollment (during which the enrollee is permitted to terminate the subsequent enrollment under § 1851(e) of the federal Social Security Act);

(7) The individual, upon first becoming enrolled in Part B of Medicare at 65 years old 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 by not later than 12 months after the effective date of enrollment; or

(8) The individual:

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

(b) At the time of enrollment in Part D:

(i) Was enrolled under a Medicare supplement policy that covers outpatient prescription drugs; and

(ii) Terminates enrollment in the Medicare supplement policy described in §B(8)(b)(i) of this regulation; and

(c) Submits evidence of enrollment in Medicare Part D with the application for a policy described in §E(5) of this regulation.

C. Guaranteed Issue Time Periods.

(1) The guaranteed issue period for an individual described in §B(1) of this regulation:

(a) Begins on the later of the date:

(i) The individual receives a notice of termination or cessation of all supplemental health benefits, or, if the individual does not receive the notice, the date the individual receives notice that a claim has been denied because of a termination or cessation of all supplemental health benefits; or

(ii) The applicable coverage terminates or ceases; and

(b) Ends 63 days after the beginning of the period described in §C(1)(a) of this regulation.

(2) The guaranteed issue period for an individual described in §B(2)-(4), (6), or (7) of this regulation whose enrollment is terminated involuntarily:

(a) Begins on the date that the individual receives a notice of termination; and

(b) Ends 63 days after the date the applicable coverage is terminated.

(3) The guaranteed issue period for an individual described in §B(5)(a) of this regulation:

(a) 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 similar notice, if any; or

(ii) The date that the applicable coverage is terminated; and

(b) Ends on the date that is 63 days after the date the coverage is terminated.

(4) The guaranteed issue period for an individual described in §B(2), (3), (5)(b), (5)(c), (6), or (7) of this regulation, who disenrolls voluntarily:

(a) Begins on the date that is 60 days before the effective date of the disenrollment; and

(b) Ends on the date that is 63 days after the effective date.

(5) The guaranteed issue period for an individual described in §B(8) of this regulation:

(a) Begins on the date the individual receives notice pursuant to § 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

(b) Ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D.

(6) The guaranteed issue period for an individual described in §B of this regulation but not described in §C(1)-(5) of this regulation:

(a) Begins on the effective date of disenrollment; and

(b) Ends on the date that is 63 days after the effective date of disenrollment.

D. Extended Medigap Access for Interrupted Trial Periods.

(1) A subsequent enrollment of an individual described in §B(6) of this regulation shall be deemed to be a first time enrollment described in §B(6) of this regulation if both of the following are satisfied:

(a) The individual's enrollment with an organization or provider described in §B(6)(a) of this regulation is involuntarily terminated within the first 12 months of enrollment; and

(b) The individual enrolls with another organization or provider described in §B(6)(a) of this regulation without an intervening enrollment.

(2) A subsequent enrollment of an individual described in §B(7) of this regulation shall be deemed to be a first time enrollment described in §B(7) of this regulation if both of the following are satisfied:

(a) The individual's enrollment with a plan or in a program described in §B(7) of this regulation is involuntarily terminated within the first 12 months of enrollment; and

(b) The individual enrolls in another plan or program described in §B(7) of this regulation, without an intervening enrollment.

(3) For purposes of §B(6) and (7) of this regulation, an enrollment of an individual with an organization or provider described in §B(6)(a) of this regulation, or with a plan or in a program described in §B(7) of this regulation, may not be deemed to be a first time enrollment under this section after the 2-year period beginning on the date on which the individual first enrolled with the organization, provider, plan, or program.

E. Products to Which Eligible Individuals Are Entitled. The Medicare supplement policy to which eligible individuals are entitled under:

(1) §B(1)-(5) of this regulation is a Medicare supplement policy which has a benefit package classified as plan A, B, C, F, including F with a high deductible, K, or L offered by any issuer;

(2) Subject to §E(3) of this regulation, §B(6) of this regulation 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 §E(1) of this regulation;

(3) §B(6) of this regulation 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 subsection is:

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

(b) 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;

(4) §B(7) of this regulation shall include any Medicare supplement policy offered by any issuer; and

(5) §B(8) of this regulation 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 §B of this regulation 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 the individual's rights under this section, and of the obligations of issuers of Medicare supplement policies under §A of this regulation.

(2) The notice required by §F(1) of this regulation shall be communicated contemporaneously with the notification of termination.

(3) At the time of an event described in §B of this regulation 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 the individual's rights under this section, and of the obligations of issuers of Medicare supplement policies under §A of this regulation.

(4) The notice required by §F(3) of this regulation shall be communicated within 10 working days of the issuer receiving notification of disenrollment.

Md. Code Regs. 31.10.06.09-1

Regulation .09-1 adopted as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); adopted permanently effective March 22, 1999 (26:6 Md. R. 489)
Regulation .09-1 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061)
Regulation .09-1 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570)