| (a) No issuer may deny or condition the issuance or
effectiveness of any Medicare supplement policy or certificate available
for sale in this state, nor discriminate in the pricing of a policy
or certificate because of the health status, claims experience, receipt
of health care, or medical condition of an applicant where an application
for a policy or certificate is submitted before or during the six-month
period beginning with the first day of the first month in which an
individual is first enrolled for benefits under Medicare Part B. No
issuer may engage in a premium rating practice that results in higher
premiums for any policy solely because the policy is issued under
the provisions of this section. For individuals 65 years of age or
older when first enrolled for benefits under Medicare Part B who apply
for Medicare supplement coverage under this subsection, each Medicare
supplement policy and certificate currently available from an issuer
must be made available to all applicants without regard to age.
(b) The provisions of paragraphs (1) and (2) of this
subsection apply to Medicare supplement issuers with respect to persons
who qualify for Medicare before attaining 65 years of age.
(1) An issuer must comply with the first two sentences
of subsection (a) of this section with respect to a person who:
(A) qualifies for Medicare before attaining 65 years
of age, who first enrolls for benefits under Medicare Part B on or
after January 1, 1997, and who applies for a Medicare supplement policy
or certificate during the period of eligibility described in subsection
(a) of this section; or
(B) enrolled in Medicare Part B before attaining 65
years of age, who applies for a Medicare supplement policy or certificate
upon attaining 65 years of age, during the period of eligibility described
in subsection (a) of this section that would apply if the person first
enrolled in Medicare Part B on attaining 65 years of age.
(2) An issuer must make available, at a minimum, Plan
A of the standard Medicare supplement plans to individuals who qualify
under this subsection.
(c) If an applicant qualifies under subsection (a)
of this section, is 65 years of age or older, and submits an application
during the period referenced in subsection (a) of this section and,
as of the date of application:
(1) has had a continuous period of creditable coverage
of at least six months, the issuer may not exclude benefits based
on a preexisting condition; or
(2) has had a continuous period of creditable coverage
that is less than six months, the issuer must reduce the period of
any preexisting condition exclusion by the aggregate of the period
of creditable coverage applicable to the applicant as of the enrollment
date.
(d) Except as provided in subsection (c) of this section,
§3.3312 of this title (relating to Guaranteed Issue for Eligible
Persons), and §3.3306(b)(1)(A) of this title (relating to Minimum
Benefit Standards), subsection (a) of this section may not be construed
as preventing the exclusion of benefits under a policy during the
first six months based on a preexisting condition for which the policyholder
or certificate holder received treatment or was otherwise diagnosed
during the six months before the coverage became effective.
(e) The following examples illustrate the application
of subsection (c)(1) and (2) of this section, as prescribed by the
Secretary:
(1) Individual A--" No preexisting condition exclusion
period. Relevant creditable coverage history: Individual A had coverage
under an individual policy for four months beginning on May 1, 1998,
through August 31, 1998, followed by a gap in coverage of 61 days
until October 31, 1998. Individual A had coverage under an individual
health plan beginning on November 1, 1998, for three months through
January 31, 1999, followed by a gap in coverage of 59 days or until
March 31, 1999, on which date Individual A submitted an application
for a Medicare supplement policy. Under this example, the Medicare
supplement issuer may not apply a preexisting condition exclusion
period because Individual A has seven months of creditable coverage
without a gap in coverage greater than 63 days.
(2) Individual B--" Subject to a three-month preexisting
condition exclusion period. Relevant creditable coverage history:
Individual B is covered under an individual health insurance policy
for one month beginning May 1, 1998, through May 31, 1998, followed
by a gap in coverage of 61 days from June 1, 1998, through July 31,
1998. On August 1, 1998, Individual B is covered under an association
health plan for two months through September 30, 1998, followed by
a gap in coverage of 31 days or until October 31, 1998, on which date
Individual B submitted an application for Medicare supplement coverage.
Individual B has three months of creditable coverage. Under this example,
the issuer of a Medicare supplement policy must give Individual B
a three-month credit against any preexisting condition exclusion period.
(3) Individual C--" Subject to a six-month preexisting
condition exclusion period. Relevant creditable coverage history:
Individual C is covered under an individual health insurance policy
for one month beginning May 1, 1998, through May 31, 1998, followed
by a gap in coverage of 61 days from June 1, 1998, through July 31,
1998. On August 1, 1998, Individual C is covered under an association
health plan for two months through September 30, 1998, followed by
a gap in coverage of 64 days or until November 4, 1998, on which date
Individual C submitted an application for Medicare supplement coverage.
Individual C has a gap in coverage of greater than 63 days. As a result,
under this example, the Medicare supplement issuer can fully apply
the preexisting condition exclusion provision to Individual C.
(f) Invitation to contract advertisements, as defined
in §21.113(b) of this title (relating to Rules Pertaining Specifically
to Accident and Health Insurance Advertising and Health Maintenance
Organization Advertising), must include the following statement: "Benefits
and premiums under this policy may be suspended for up to 24 months
if you become entitled to benefits under Medicaid. You must request
that your policy be suspended within 90 days of becoming entitled
to Medicaid. If you lose (are no longer entitled to) benefits from
Medicaid, this policy can be reinstated if you request reinstatement
within 90 days of the loss of such benefits and pay the required premium."
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| Source Note: The provisions of this §3.3324 adopted to be effective April 15, 1992, 17 TexReg 2238; amended to be effective January 1, 1997, 21 TexReg 10753; amended to be effective April 14, 1999, 24 TexReg 3353; amended to be effective May 10, 2005, 30 TexReg 2669; amended to be effective June 13, 2018, 43 TexReg 3787 |
