HAR §16-12-6.2. Open enrollment

(a) No issuer shall 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 in the case of an application for a policy or certificate that is submitted prior to or during the six month period beginning with the first day of the first month in which an individual is enrolled for benefits under Medicare Part B. Each Medicare supplement policy and certificate currently available from an issuer shall be made available to all applicants who qualify under this subsection without regard to age. (b) (1) If an applicant qualifies under subsection (a) and submits an application during the time period referenced in subsection (a) and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer shall not exclude benefits based on a preexisting condition. (2) If the applicant qualifies under subsection (a) and submits an application during the time period referenced in subsection (a) and, as of the date of application, has had a continuous period of creditable coverage that is less than six months, the issuer shall 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. The Secretary shall specify the manner of the reduction under this subsection. (c) Except as provided for in subsection (b) and in sections 16-12-6.3 and 16-12-12.8, subsection (a) shall not be construed as preventing the exclusion of benefits under a policy, during the first six months, §16-12-6.2 12-62 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. [Eff and comp 9/3/92; am, ren §16-12-6.2 and comp 7/6/99; comp 10/15/01; am and comp 12/9/02; am and comp 10/8/05; comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305) §16-12-6.3 Guaranteed issue for eligible persons. (a) Guaranteed issue. (1) Eligible persons are those individuals described in subsection (b) who seek to enroll under the policy during the period specified in subsection (c), 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 shall not deny or condition the issuance or effectiveness of a Medicare supplement policy described in subsection (e) that is offered and is available for issuance to new enrollees by the issuer, shall not discriminate in the pricing of that 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 that 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 §16-12-6.3 12-63 plan ceases to provide all such supplemental health benefits to the individual. (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 sixty-five 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 that provider if the individual were enrolled in a Medicare Advantage plan: (A) The certification of the organization or plan under this part has been terminated; (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 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: §16-12-6.3 12-64 (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 that 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; or (E) The individual meets those 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 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; and (B) The enrollment ceases under the same circumstances that would permit §16-12-6.3 12-65 discontinuance of an individual's election of coverage under paragraph 16-12-6.3(b)(2); (4) The individual is enrolled under a Medicare supplement policy and the enrollment ceases because: (A) (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 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) (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 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; and (B) The subsequent enrollment under subparagraph (A) is terminated by the enrollee during any period within the first twelve months of that subsequent enrollment (during which the enrollee is permitted to terminate that subsequent enrollment under Section §16-12-6.3 12-66 1851(e) of the federal Social Security Act); (6) The individual, upon first becoming enrolled in Medicare Part A for benefits at age sixty-five or older, 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 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 paragraph (e)(4); (c) Guaranteed issue time periods. (1) In the case of an individual described in paragraph (b)(1), the guaranteed issue period begins on the later of: (A) 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 (B) The date that the applicable coverage terminates or ceases; and ends sixty-three days thereafter; (2) In the case of an individual described in paragraphs (b)(2), (b)(3), (b)(5), or (b)(6) 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 days after the date the applicable coverage is terminated; §16-12-6.3 12-67 (3) In the case of an individual described in paragraph (b)(4)(A), the guaranteed issue period begins on the earlier of: (A) The date that the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other similar notice if any; and (B) The date that the applicable coverage is terminated, and ends on the date that is sixty-three days after the date the coverage is terminated; (4) In the case of an individual described in paragraphs (b)(2), (b)(4)(B), (b)(4)(C), (b)(5), or (b)(6) who disenrolls voluntarily, the guaranteed issue period begins on the date that is sixty days before the effective date of the disenrollment and ends on the date that is sixty-three days after the effective date; (5) In the case of an individual described in paragraph (b)(7), 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-day period immediately preceding the initial Part D enrollment period and ends on the date that is sixty-three days after the effective date of the individual's coverage under Medicare Part D; and (6) In the case of an individual described in paragraph (b) 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 days after the effective date. (d) Extended Medigap access from interrupted trial periods. (1) In the case of an individual described in paragraph (b)(5) (or deemed to be so §16-12-6.3 12-68 described, pursuant to this paragraph) whose enrollment with an organization or provider described in paragraph (b)(5)(A) is involuntarily terminated within the first twelve months of enrollment, and who, without an intervening enrollment, enrolls with another organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (b)(5); (2) In the case of an individual described in paragraph (b)(6) (or deemed to be so described, pursuant to this paragraph) whose enrollment with a plan or in a program described in paragraph (b)(6) is involuntarily terminated within the first twelve months of enrollment, and who, without an intervening enrollment, enrolls in another plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (b)(6); and (3) For purposes of paragraphs (b)(5) and (b)(6), no enrollment of an individual with an organization or provider described in paragraph (b)(5)(A), or with a plan or in a program described in paragraph (b)(6), may be deemed to be an initial enrollment under this paragraph after the two-year period beginning on the date on which the individual first enrolled with an organization, provider, plan, or program. (e) Products to which eligible persons are entitled. The Medicare supplement policy to which eligible persons are entitled under: (1) Paragraphs 16-12-6.3(b)(1), (2), (3), and (4), is a Medicare supplement policy which has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L offered by any issuer; (2) (A) Subject to subparagraph (B), paragraph 16-12-6.3(b)(5) is the same Medicare §16-12-6.3 12-69 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 paragraph (1); (B) 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; (3) Paragraph 16-12-6.3(b)(6) shall include any Medicare supplement policy offered by any issuer; and (4) Paragraph 16-12-6.3(b)(7) 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, 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. (f) Notification provisions. (1) At the time of an event described in subsection (b) of this section 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 §16-12-6.3 12-70 this section, and of the obligations of issuers of Medicare supplement policies under subsection (a). That notice shall be communicated contemporaneously with the notification of termination; and (2) At the time of an event described in subsection (b) of this section 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 subsection 16-12-6.3(a). The notice shall be communicated within ten working days of the issuer receiving notification of disenrollment. [Eff and comp 7/6/99; am and comp 10/15/01; am and comp 12/9/02; am and comp 10/8/05; comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305)