Title 3 . Commerce, Community, and Economic Development

Chapter 28 . Miscellaneous

Section 462. Guaranteed issue for eligible persons

3 AAC 28.462. Guaranteed issue for eligible persons

(a) Except as provided in (h) of this section, an eligible person is an individual described in (c) of this section who seeks to enroll under the policy during the period specified in (d) of this section, and who submits evidence of the date of the termination, date of withdrawal from enrollment, date of enrollment in medicare Part D, or date of substantial reduction of supplemental health benefits with the application for a medicare supplement policy.

(b) With respect to an eligible person, an issuer

(1) may not deny or condition the issuance or effectiveness of a medicare supplement policy that is offered and is available for issuance to a new enrollee by the issuer;

(2) may not discriminate in the pricing of that medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition; and

(3) may not impose an exclusion of benefits based on a preexisting condition under that medicare supplement policy.

(c) For purposes of this section, an eligible person is

(1) an individual who is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits provided under medicare and whose plan terminates or ceases to provide substantially all of the supplemental health benefits to the individual, or an individual who is enrolled under an employee welfare benefit plan that is primary to medicare and whose plan terminates or ceases to provide all health benefits to the individual because the individual leaves the plan;

(2) an individual who is enrolled with a medicare advantage organization under a medicare advantage plan under Part C of medicare if any of the following circumstances apply:

(A) the organization's or plan's certification under Part C of medicare 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, excluding termination of the individual's enrollment on the basis described in 42 U.S.C. 1395w-21 (sec. 1851(g)(3)(B) of the Social Security Act), if the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under 42 U.S.C. 1395w-26 (sec. 1856 of the Social Security Act), or if the plan is terminated for all individuals within a residence area;

(C) the individual demonstrates under 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 covered care in accordance with applicable quality standards; or

(ii) the organization, its agent, or another 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 that the secretary may provide;

(3) an individual who is enrolled with any of the following and whose enrollment ceases under any of the circumstances that would permit discontinuance of an individual's election of coverage under (2) of this subsection:

(A) an eligible organization under a contract under 42 U.S.C. 1395mm (sec. 1876 of the Social Security Act);

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

(C) an organization under an agreement under 42 U.S.C. 1395 l (a)(1)(A) (sec. 1833(a)(1)(A) of the Social Security Act);

(D) an organization under a medicare select policy as defined in 42 U.S.C. 1395ss(t) (sec. 1882(t) of the Social Security Act);

(4) an individual who is enrolled under a medicare supplement policy and whose enrollment ceases because

(A) of 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;

(5) an individual

(A) who 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 42 U.S.C. 1395mm (sec. 1876 of the Social Security Act), any similar organization operating under demonstration project authority, or a medicare select policy; and

(B) whose subsequent enrollment is terminated by the enrollee within the first 12 months of this subsequent enrollment, during which the enrollee is permitted to terminate this subsequent enrollment under 42 U.S.C. 1395w-21(e) (sec. 1851(e) of the Social Security Act);

(6) an individual who, upon 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 and who withdraws from the plan not later than 12 months after the effective date of enrollment; or

(7) an individual who enrolls in a medicare Part D plan during the initial enrollment period, and who

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

(B) terminates enrollment in the medicare supplement policy; and

(C) provides evidence of enrollment in the medicare Part D plan along with the application for a policy described in (d) of this section.

(d) A guaranteed issue time period in the case of an individual described

(1) in (c)(1) of this section, begins on the later of the following dates and ends 63 days after that date:

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

(B) the date that the applicable coverage terminates or ceases;

(2) in (c)(2), (c)(3), (c)(5), or (c)(6) of this section, whose enrollment is terminated involuntarily, begins on the date that the individual receives a notice of termination and ends 63 days after the date the coverage is terminated;

(3) in (c)(4)(A) of this section, begins on the earlier of the following dates and ends 63 days after that date:

(A) the date the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other similar notice;

(B) the date that the applicable coverage terminates or ceases;

(4) in (c)(2), (c)(4)(B), (c)(4)(C), (c)(5), or (c)(6) of this section, who voluntarily withdraws from the plan, begins on the date that is 60 days before the effective date of the withdrawal and ends 63 days after the effective date; or

(5) in (c) of this section, but not described in (1),(2),(3), or (4) of this subsection, begins on the effective date of an individual's withdrawal and ends 63 days after the effective date.

(6) in (c)(7) of this section,

(A) begins on the date the individual receives notice under 42 U.S.C. 1395ss(v)(2)(B) (sec. 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 63 days after the effective date of the individual's coverage under medicare Part D.

(e) Access to enrollment for a medicare supplement policy may be extended for an interrupted trial period. For purposes of (c)(5) and (c)(6) of this section, an enrollment of an individual with an organization or provider described in (c)(5)(A) of this section or with a plan or in a program described in (c)(6) of this section, may not be deemed to be an initial enrollment under this subsection after the two-year period beginning on the date on which the individual first enrolled with the organization, provider, or plan, or in the program. A subsequent enrollment may be deemed to be an initial enrollment as follows:

(1) in the case of an individual described in (c)(5) of this section, whose enrollment with an organization or provider described in (c)(5)(A) 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 is deemed to be an initial enrollment as described in (c)(5) of this section;

(2) in the case of an individual described in (c)(6) of this section, whose enrollment with a plan or in a program described in (c)(6) of this section is involuntarily terminated within the first 12 months of enrollment, and who enrolls with another plan or in another program, the subsequent enrollment is deemed to be an initial enrollment as described in (c)(6) of this section.

(f) The medicare supplement policy to which an eligible person is entitled

(1) under (c)(1) - (4) of this section is a medicare supplement policy that has a benefit package classified as plan "A," "B," "C," "F" high deductible "F," "K," or "L," offered by any issuer;

(2) under (c)(5) of this section is the same medicare supplement policy in which the individual was most recently previously enrolled if available from the same issuer, or if that policy is not available, a policy described in (1) of this subsection;

(3) under (c)(6) of this section is any medicare supplement policy offered by any issuer;

(4) after December 31, 2005, if the individual was most recently enrolled in a medicare supplement policy with an outpatient prescription drug benefit, is

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

(B) at the election of the individual, a medicare supplement policy that has a benefit package classified as plan "A," "B," "C," "F," high deductible "F," "K," or "L" and that is offered by any issuer; and

(5) under (c)(7) of this section is a medicare supplement policy that has a benefit package classified as plan "A," "B," "C," "F," high deductible "F," "K," or "L" and that is offered and available for issue to new enrollees by the same issuer that issued the individual's medicare supplement policy with outpatient prescription drug coverage.

(g) When an individual becomes an eligible person under (c) of this section because the individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization terminating the contract or agreement, the issuer terminating the policy, or the administrator of the terminated plan, respectively, shall, contemporaneously with the notification of termination, notify the eligible person of the eligible person's rights under this section and of the obligations of issuers of medicare supplement policies under (b) of this section.

(h) When an individual becomes an eligible person under (c) of this section because the individual loses coverage or benefits due to the cessation of substantially all of the supplemental health benefits under an employee welfare health benefit contract or agreement, policy, or plan, the organization that substantially reduced the contract or agreement, the issuer that substantially reduced the policy, or the administrator of the substantially reduced plan, respectively, shall, contemporaneously with the notification of the substantial cessation of benefits, notify the eligible person of the eligible person's rights under this section and of the obligations of issuers of medicare supplement policies under (b) of this section.

(i) When an individual becomes an eligible person under (c) of this section because the individual withdraws enrollment under a contract or agreement, policy, or plan, the organization offering the contract or agreement, regardless of the basis for the withdrawal of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall, within 10 working days of the date that the issuer receives notification of the withdrawal, notify the eligible person of the eligible person's rights under this section and of the obligations of issuers of medicare supplement policies under (b) of this section.

History: Eff. 4/21/99, Register 150; am 9/17/2003, Register 167; am 9/4/2005, Register 175

Authority: AS 21.06.090

AS 21.42.130

AS 21.89.060