02-031-275 Me. Code R. § 12

Current through 2024-52, December 25, 2024

Section 031-275-12 - Guaranteed Issue for Eligible Persons

A. Guaranteed Issue

(1) Eligible persons are those individuals described in Subsection B who apply to enroll under the policy not later than ninety (90) days after the date of the termination of enrollment described in Subsection B, and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy, or within a reasonable time after the date of the application. In case of an individual described in Subsection 12(B)(1), the guaranteed issue period begins on the later of:

(i) the date the individual receives a notice of termination or cessation of some or all supplemental health benefits (or if a notice is not received, notice that a claim has been denied because of such a termination or cessation); or

(ii) the date that the applicable coverage terminates or ceases; and ends 90 days thereafter.

(2) With respect to eligible persons, an issuer shall not 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, 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. In the case of an individual applying for such a Medicare supplement policy within the 60 days before the anticipated date of termination of prior coverage, the issuer involved shall accept the application, but the coverage shall only become effective upon termination of the prior coverage. In the case of an individual applying for such a Medicare supplement policy who is not enrolled in Medicare Part B, the issuer may defer the effective date of the Medicare supplement policy until such time as the individual is enrolled in Medicare Part B.

B. Eligible Persons

An eligible person is an individual described in any of the following paragraphs:

(1) The individual is eligible for Medicare Part B and is enrolled under an employee welfare benefit plan and the plan terminates, or the plan ceases to provide some or all benefits that supplement the benefits under Medicare to the individual, or the plan ceases to provide 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 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 the individual were enrolled in a Medicare Advantage plan:

a. The certification of the organization or plan under Part C 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 has voluntarily disenrolled after receiving notice from the organization or plan or from the federal Health Care Finance Administration that the organization's or plan's certification will be terminated or the organization will terminate or discontinue 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 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;

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 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 producer 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 such other exceptional conditions as the Secretary may provide.

(3)

a. The individual is enrolled with:

i. An eligible organization under a contract under Section 1876 of the Federal Social Security Act ( 42 U.S.C. §§ 1395et seq.) (Medicare risk or 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 Federal Social Security Act ( 42 U.S.C. §§ 1395et seq.) (health care prepayment plan); or

iv. An organization under a Medicare Select policy; and

b. The enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under Section 12(B)(2) of this Rule.

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

i. Of the insolvency of the issuer or bankruptcy of the nonissuer organization; or

ii. 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, or a producer or other entity acting on the issuer's behalf, materially misrepresented the policy's provisions in marketing the policy to the individual;

(5)

a. 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 Federal Social Security Act ( 42 U.S.C. §§ 1395et seq.) (Medicare risk or cost), any similar organization operating under demonstration project authority, any PACE program under Section 1894 of the Social Security Act, an organization under an agreement under Section 1833(a)(1)(A) of the Federal Social Security Act ( 42 U.S.C. §§ 1395et seq.) (health care prepayment plan), or a Medicare Select policy; and

b. The subsequent enrollment in one of the programs described in subparagraph (a) is terminated by the enrollee at any time within the first thirty-six (36) 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);

c. For purposes of this paragraph and paragraph (6), an enrollee who changes plans within a program described in subparagraph (a) is not considered to have terminated enrollment in the program, or to have reenrolled in the program.

(6) The individual, within six (6) months after becoming enrolled in Part B of Medicare, enrolls in a Medicare Advantage plan under part C of Medicare, or in a PACE program under Section 1894, or in a program described in section 12(B)(5)(a) and disenrolls from the Medicare Advantage program or from the PACE program, or from a program described in section 12(B)(5)(a) not later than thirty-six (36) months after the effective date of enrollment;

Individuals who enroll in Medicare Advantage under Part C, or in the PACE program, or in a program described in section 12(B)(5)(a) and change plans within a program without returning to coverage under Part A and Part B of Medicare are considered to have met the requirements of this paragraph 6 upon returning to Medicare Part A and Part B within 36 months.

(7) The individual is eligible for Medicare Part B and is enrolled in an individual health plan as defined by Title 24-A M.R.S.A. §2736-C and the individual's coverage under the individual health plan terminates or is expected to terminate for any reason except for fraud or nonpayment of premium. An individual whose coverage has been terminated for nonpayment of premium or who has received a notice of termination for nonpayment of premium is an eligible person if he or she provides proof that the outstanding premium debt has been paid, that he or she has entered into a payment agreement with the issuer of the individual plan, or that he or she has sought or received bankruptcy protection with respect to the debt.

(8) The individual is eligible for Medicare Part B and is enrolled in a program providing coverage for medical benefits under Title XIX of the Social Security Act (Medicaid), and enrollment in the Medicaid program providing medical benefits ceases because the individual is no longer eligible. For the purpose of this paragraph 8 programs providing coverage for medical benefits include programs that reimburse for medical expenses or Medicare copayments, coinsurance, and deductibles. Programs that provide only premium assistance or limited benefits such as vision or immunization are not considered programs that provide coverage for medical benefits.

C.Products to Which Eligible Persons are Entitled

Eligible persons described in Section 12(B) are entitled to any Medicare supplement policy offered by any issuer, except that if the Medicare supplement policy in which an eligible person described in Section 12(B)(5) was most recently enrolled did not have an outpatient prescription drug benefit, guaranteed issue is limited to plans with equivalent or lesser benefits as determined by the table in Subsection D.

D. Continuity Rights

The issuer shall waive any medical underwriting for an individual replacing another Medicare supplement policy, whether from the same issuer or another issuer, if the individual meets the requirement to have continuous coverage since the end of the open enrollment period as specified in 24-A M.R.S.A. §5002-B(1)(A), and the replacement plan satisfies the following criteria:

(1) The plan applied for is currently offered by the issuer and is one of the replacement plans indicated in the table below for all of the applicant's prior plans. Issuers may allow transfers to additional plans not noted below.

(2) The 1990 and 2010 standardized Medicare supplement benefit plans of the same letter are considered comparable for continuity purposes.

Replacing Plan

Prior

Plan

High Deductible

F High Deductible

G High Deductible

J* High Deductible

J High Deductible

* Excluding prescription drugs

E. Notification provisions

(1) At the time of an event described in Subsection B of this section because of which an individual involuntarily 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 Subsection A. Such notice shall be communicated at the same time as the required advance notice of termination, if any. If no advance notice of the termination is otherwise required by law, the notice of rights under this section shall be given at least 30 days before the event or as soon as possible thereafter.

(2) At the time of an event described in Subsection B of this section because of which an individual voluntarily 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 Section 12(A). Such notice shall be communicated within ten working days of the issuer receiving notification of disenrollment.

The notice shall include a statement advising that if the individual is terminating the Medicare supplement policy to enroll in a Medicare Advantage plan for the first time, the individual may be entitled to obtain a Medicare supplement policy in the state of Maine if he or she returns to original Medicare Part A and Part B within three years. The notice shall specifically advise that the right to return to original Medicare Part A and Part B is governed by federal law and that for many enrollees federal law only permits Medicare beneficiaries to return to original Medicare Part A and Part B during an annual enrollment period. The notice shall specifically advise that Medicare Advantage enrollees may therefore need to return to original Medicare Part A and Part B in less than three years in order to obtain a Medicare supplement policy on a guaranteed issue basis.

02-031 C.M.R. ch. 275, § 12