| (a) Guaranteed issue.
(1) Eligible persons are those individuals described
in subsection (b) of this section who seek to enroll under the Medicare
supplement policy during the period specified in subsection (d) of
this section, and who 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 persons, an issuer must
not deny or condition the issuance or effectiveness of a Medicare
supplement policy described in subsection (c) of this section that
is offered and is available for issuance to newly enrolled individuals
by the issuer, and must not discriminate in the pricing of a Medicare
supplement policy because of health status, claims experience, receipt
of health care, or medical condition, and must not impose an exclusion
of benefits based on a preexisting condition under a Medicare supplement
policy.
(b) Eligible persons. An eligible person is an individual
described in any of the following paragraphs:
(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
supplemental health benefits to the individual; or the individual
is enrolled under an employee welfare benefit plan that is primary
to Medicare and the plan terminates or the plan ceases to provide
all 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
65 years of age 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 the following
that would permit discontinuance of the individual's enrollment with
the provider if the individual were enrolled in a Medicare Advantage
plan:
(A) the certification of the organization or plan has
been terminated; or
(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 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 §1851(g)(3)(B) of the 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 §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
42 U.S.C. Chapter 7, Subchapter XVIII, Part D in relation to the individual,
including the failure to provide an individual on a timely basis medically
necessary care for which benefits are available under the plan or
the failure to provide the covered care in accord 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 other exceptional conditions
as the Secretary may provide.
(3) The individual is enrolled with an entity listed
in subparagraphs (A) - (D) of this paragraph and enrollment ceases
under the same circumstances that would permit discontinuance of an
individual's election of coverage under paragraph (2) of this subsection:
(A) an eligible organization under a contract under
§1876 of the Social Security Act (Medicare cost);
(B) a similar organization operating under demonstration
project authority, effective for periods before April 1, 1999;
(C) an organization under an agreement under §1833(a)(1)(A)
of the Social Security Act (health care prepayment plan); or
(D) an organization under a Medicare Select policy;
and
(4) the individual is enrolled under a Medicare supplement
policy and the enrollment ceases because:
(A) of the insolvency of the issuer or bankruptcy of
the nonissuer organization; or 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, 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) 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 §1876 of the Social Security Act (Medicare
cost), any similar organization operating under demonstration project
authority, any PACE provider under §1894 of the Social Security
Act, or a Medicare Select policy; and the subsequent enrollment is
terminated by the individual during any period within the first 12
months of the subsequent enrollment (during which time the individual
is permitted to terminate the subsequent enrollment under §1851(e)
of the Social Security Act); or
(6) the individual, on 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, or with a PACE provider under §1894
of the Social Security Act, and disenrolls from the plan or program
no later than 12 months after the effective date of enrollment.
(7) 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 subsection (c)(4) of this section.
(8) The individual loses eligibility for health benefits
under Title XIX of the Social Security Act (Medicaid).
(9) The individual meets the following requirements:
(A) the individual was enrolled in both the federal
Medicare program and the Texas Health Insurance Pool on December 31,
2013; and
(B) the individual's Pool coverage terminated on or
after December 31, 2013.
(c) Products to which eligible persons are entitled.
(1) Persons described by subsection (b)(1), (2), (3),
(4), (8), and (9) of this section are entitled to a Medicare supplement
policy that has a benefit package classified as follows:
(A) Plan A, B, C, F (including F with a High Deductible),
K, or L offered by any issuer, for an individual 65 years of age or
older who first became eligible for Medicare before January 1, 2020,
except that for persons under 65 years of age, it is a policy that
has a benefit package classified as Plan A; or
(B) Plan A, B, D, G (including G with a High Deductible),
K, or L offered by any issuer, for a 2020 newly eligible individual
who is 65 years of age or older, except that for persons under 65
years of age, it is a policy that has a benefit package classified
as Plan A.
(2) Persons described by subsection (b)(5) of this
section are entitled to the same 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 paragraph (1) of
this subsection. If the individual was most recently enrolled in a
Medicare supplement policy with an outpatient prescription drug benefit,
the Medicare supplement policy described in this paragraph is the
policy available from the same issuer but modified to remove outpatient
prescription drug coverage, or at the election of the policyholder,
a policy described in paragraph (1) of this subsection.
(3) Persons described by subsection (b)(6) of this
section are entitled to any Medicare supplement policy offered by
any issuer, with the exception of plans C or F (including F with a
High Deductible) for a 2020 newly eligible individual.
(4) Persons described by subsection (b)(7) of this
section are entitled to a Medicare supplement policy that has a benefit
package classified as follows:
Cont'd... |
