Ins 3.39(34)(34)Guaranteed issue for eligible persons.
Ins 3.39(34)(a)(a) Guaranteed issue.
Ins 3.39(34)(a)1.1. Persons eligible for guarantee issue are those individuals described in par. (b) who seek to enroll under the policy during the period specified in par. (c), and who submit evidence of the date of termination or disenrollment with the application for a Medicare supplement policy, Medicare select policy or Medicare cost policy, and where applicable, evidence of enrollment in Medicare Part D.
Ins 3.39(34)(a)2.2. With respect to an eligible person, an issuer may not deny or condition the issuance or effectiveness of a Medicare supplement policy, Medicare select policy, or Medicare cost policy described in par. (e) that is offered and is available for issuance to new enrollees by the issuer, and shall not discriminate in the pricing of such a Medicare supplement, Medicare select, or Medicare cost 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, Medicare select policy, or Medicare cost policy.
Ins 3.39(34)(b)(b) Eligible persons. An eligible person for guarantee issue is an individual described in any of the following subdivisions:
Ins 3.39(34)(b)1.1. The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare and the plan does any of the following:
Ins 3.39(34)(b)1.a.a. Terminates.
Ins 3.39(34)(b)1.b.b. Ceases to provide some or all such supplemental health benefits to the individual.
Ins 3.39(34)(b)1.c.c. The amount the individual pays for coverage under the plan increases from one 12-month period to the subsequent 12-month period by more than 25% and the new payment for the employer-sponsored coverage is greater than the premium charged under the Medicare supplement plan for which the individual is applying. An issuer may require reasonable documentation to substantiate the increase of the cost of coverage to the individual. Reasonable documentation that issuers may request includes premium billing statements and notices of premiums from employers for the most recent 12 month period.
Ins 3.39(34)(b)1m.1m. 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 some or all health benefits to the individual because the individual leaves the plan.
Ins 3.39(34)(b)1r.1r. The individual is covered by an employee welfare benefit plan that is either primary to Medicare or provides health benefits that supplement the benefits of Medicare and the individual terminates coverage under the employee welfare benefit plan to enroll in a Medicare Advantage plan, but disenrolls from the Medicare Advantage plan by not later than 12 months after the effective date of enrollment.
Ins 3.39(34)(b)1s.1s. The individual is enrolled in a Medicare select policy and is notified by the issuer, as required in par. (f) 3. and s. Ins 9.35, as applicable, that a hospital is leaving the Medicare select policy network and that there is no other network provider hospital within a 30 minute or 30 mile radius of the policyholder.
Ins 3.39(34)(b)2.2. 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 PACE provider, and there are circumstances similar to those described below that would permit discontinuance of the individual’s enrollment with the PACE provider if the individual were enrolled in a Medicare Advantage plan including any of the following:
Ins 3.39(34)(b)2.a.a. The certification of the organization or plan under Medicare Part C has been terminated; or
Ins 3.39(34)(b)2.b.b. The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides.
Ins 3.39(34)(b)2.c.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.
Ins 3.39(34)(b)2.d.d. The individual demonstrates, in accordance with guidelines established by the secretary that, at least one of the following has occurred; 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 such covered care in accordance with applicable quality standards, or 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.
Ins 3.39(34)(b)2.e.e. The individual meets such other exceptional conditions as the secretary may provide.
Ins 3.39(34)(b)3.3. The individual is enrolled with any of the following:
Ins 3.39(34)(b)3.a.a. An eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost);
Ins 3.39(34)(b)3.b.b. A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;
Ins 3.39(34)(b)3.c.c. An organization under an agreement under Section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan); or
Ins 3.39(34)(b)3.d.d. An organization under a Medicare select policy; and
Ins 3.39(34)(b)3m.3m. The enrollment ceases under the same circumstances that would permit discontinuance of an individual’s election of coverage under subd. 2.
Ins 3.39(34)(b)4.4. The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:
Ins 3.39(34)(b)4.a.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;
Ins 3.39(34)(b)4.b.b. The issuer of the policy substantially violated a material provision of the policy; or
Ins 3.39(34)(b)4.c.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;
Ins 3.39(34)(b)5.5.