Section 0780-01-58-.15 - GUARANTEED ISSUE FOR ELIGIBLE PERSONS(1) Guaranteed Issue.(a) Eligible persons are those individuals described in Paragraph (2) who seek to enroll under the policy during the period specified in Paragraph (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 Paragraph (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 subparagraphs:(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 sixty-five (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; or5. 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; and2. The enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under subparagraph (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 non-issuer 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; or3. 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; and2. The subsequent enrollment under part 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).(f) The individual, upon first becoming eligible for benefits under part A of Medicare at age sixty-five (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 subparagraph (5)(d).(h) The individual is enrolled under Title XIX of the Social Security Act (Medicaid) and the enrollment involuntarily ceases after the individual is sixty-five (65) years of age or older and eligible for and enrolled in Medicare Part B.(3) Guaranteed Issue Time Periods.(a) In the case of an individual described in subparagraph (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 a 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 subparagraphs (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 subparagraph (2)(d), part 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 subparagraph (2)(b), subparagraph (2)(d), part 2., subparagraph (2)(d), part 3., and subparagraphs (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;(e) In the case of an individual described in subparagraph (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 (60) 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;(f) In the case of an individual described in subparagraph (2)(h), the guaranteed issue period begins on the date that the individual receives notice of the involuntary disenrollment and ends on the date that is sixty-three (63) days after the date the coverage is terminated. The appropriate state disenrolling agency shall notify the individual no later than eight (8) calendar days after the effective date of involuntary disenrollment of his or her rights under this Rule and of the obligations of issuers of Medicare supplement policies under this Rule;(g) Those individuals who were involuntarily disenrolled from Medicaid in the period of June 1, 2009, through September 18, 2009, will have an open enrollment period of six (6) months after September 18, 2009, in which to purchase coverage; further, the issuer shall not consider the period of time between the date of involuntary disenrollment and September 18, 2009, to be a break in the period of continuous creditable coverage, and shall calculate the period of creditable coverage as though the individual were submitting an application on the actual date of disenrollment for purposes of excluding benefits on the basis of a preexisting condition. Those individuals who are involuntarily disenrolled after September 18, 2009, but before March 3, 2010, will have an open enrollment period of six (6) months after the effective date the applicable coverage terminated; and(h) In the case of an individual described in Paragraph (2) but not described in the preceding provisions of this Paragraph 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 subparagraph (2)(e) or deemed to be so described, pursuant to this subparagraph, whose enrollment with an organization or provider described in subparagraph (2)(e), part 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 subparagraph (2)(e);(b) In the case of an individual described in subparagraph (2)(f) or deemed to be so described, pursuant to this subparagraph whose enrollment with a plan or in a program described in subparagraph (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 subparagraph (2)(f); and(c) For purposes of subparagraphs (2)(e) and (2)(f), no enrollment of an individual with an organization or provider described in subparagraph (2)(e), part 1., or with a plan or in a program described in subparagraph (2)(f), may be deemed to be an initial enrollment under this subparagraph after the two (2) 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 Persons are Entitled. The Medicare supplement policy to which eligible persons are entitled under:(a) Subparagraphs (2)(a), (b), (c), (d), and (h) are Medicare supplement policies which have a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L offered by any issuer, after January 1, 2020, Plan A, B, D, G (including G with a high deductible), K, or L offered by any issuer;(b)1. Subject to subparagraph (2)(e), part 2. 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 subparagraph (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) Subparagraph (2)(f) shall include any Medicare supplement policy offered by any issuer;(d) Subparagraph (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, after January 1, 2020, 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.(6) Notification provisions.(a) At the time of an event described in Paragraph (2) 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 Paragraph (1). Such notice shall be communicated contemporaneously with the notification of termination.(b) At the time of an event described in Paragraph (2) 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 Paragraph (1). Such notice shall be communicated within ten (10) working days of the issuer receiving notification of disenrollment.(c) At the time of an event described in subparagraph (2)(h), no later than eight (8) calendar days after the effective date of involuntary disenrollment, the appropriate state disenrolling agency shall notify the individual of his or her rights under this Rule and of the obligations of issuers of Medicare supplement policies under this Rule.Tenn. Comp. R. & Regs. 0780-01-58-.15
Original rule filed August 14, 1989; effective September 28, 1989. Repealed and new rule filed November 26, 1990; effective January 10, 1991. Repealed and new rule filed September 16, 1992; effective November 1, 1992. Amendment filed August 15, 1996; effective October 29, 1996. (Formerly 0780-01-58-.13 ) Amendment filed October 25, 1999; effective January 3, 2000. Public necessity rule filed September 1, 2005; effective through February 13, 2006. Public necessity rule filed September 1, 2005; expired on February 13, 2006. On February 14, 2006, reverted to rule in effect on August 31, 2005. Repeal and new rule filed October 13, 2006; effective December 27, 2006. Public necessity rule filed June 30, 2009; effective through December 12, 2009. Emergency rule filed December 9, 2009; effective through June 7, 2010. Amendment filed December 3, 2009; effective March 3, 2010. Administrative changes made to the authority of this chapter due to revisions in the 2016 Tennessee Code Annotated. Rule was previously numbered 0780-01-58-.14 but was renumbered 0780-01-58-.15 with the addition of a new rule 0780-01-58-.12 filed November 20, 2018; effective February 18, 2019. Amendments filed November 20, 2018; effective 2/18/2019.Authority: T.C.A. §§ 56-1-701; 56-2-301; 56-6-112; 56-6-124(a); 56-7-1401, et seq.; 56-7-1453; 56-7-1454; 56-7-1455; 56-7-1457; 56-7-1501, et seq.; 56-7-1503; 56-7-1504; 56-7-1505; 56-7-1507; and 56-32-118(a); Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, (1990); Genetic Information Non Discrimination Act, Pub. L. No. 110-233 (2008); Medicare Improvements for Patients and Providers Act, Pub. L. No. 110-275 (2008); and Medicare Access and CHIP Reauthorization Act, Pub. L. No. 114-10 (2015).