Nevada Administrative Code › Chapter 687B - Contracts of Insurance › POLICIES SUPPLEMENTARY TO MEDICARE › General Provisions › Section 687B.2053 - Eligible persons: Description; prohibited actions by insurers

Current through June 11, 2024
1. Eligible persons are those persons
				described in subsection 3 who seek to enroll under the policy during the period
				specified in NAC 687B.2056, and who submit evidence of the date of termination,
				disenrollment or Medicare Part D enrollment with the application for a policy
				to supplement Medicare.
2. With
				respect to eligible persons, an issuer shall not deny or condition the issuance
				or effectiveness of a policy to supplement Medicare described in NAC 687B.2057
				that is offered and is available for issuance to new enrollees by the issuer,
				shall not discriminate in the pricing of such a policy to supplement Medicare
				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 policy to supplement Medicare.
3. An eligible person is a person described
				in any of the following paragraphs:
(a) The
				person 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 all such supplemental health benefits to the
				person;
(b) The person is enrolled
				with a Medicare Advantage organization under a Medicare Advantage plan under
				Medicare Part C, and any of the following circumstances apply, or the person is
				65 years of age or older and is enrolled with a PACE program, and there are
				circumstances similar to those described below that would permit discontinuance
				of the person's enrollment with such provider if such person was enrolled in a
				Medicare Advantage plan:
(1) The certification
				of the organization or plan has been terminated;
(2) The organization has terminated or
				otherwise discontinued providing the plan in the area in which the person
				resides;
(3) The person is no
				longer eligible to elect the plan because of a change in the person's place of
				residence or other change in circumstances specified by the Secretary of Health
				and Human Services, but not including termination of the person's enrollment on
				the basis described in section 1851(g)(3)(B) of the Social Security Act,
				42 U.S.C. §
												1395 w - 21(g)(3)(B), where the person has
				not paid premiums on a timely basis or has engaged in disruptive behavior as
				specified in standards under section 1856 of the Social Security Act,
				42 U.S.C. §
												1395w-26, or the plan is terminated for all
				persons within a residence area;
(4) The person demonstrates, in accordance
				with guidelines established by the Secretary of Health and Human Services,
				that:
(I) The organization offering the plan
				substantially violated a material provision of the organization's contract
				under Medicare Part C in relation to the person, 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
(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 person; or
(5) The person meets such other exceptional
				conditions as the Secretary of Health and Human Services may provide;
(c) The person is enrolled with:
(1) An eligible organization under a contract
				under section 1876 of the Social Security Act,
				42 U.S.C. §
												1395 mm (Medicare cost);
(2) A similar organization operating under
				demonstration project authority, effective for periods before April 1,
				1999;
(3) An organization under an
				agreement under section 1833(a)(1)(A) of the Social Security Act,
				42 U.S.C. §
												1395 l(a)(1)(A) (health care prepayment
				plan); or
(4) An organization under
				a Medicare Select policy, and the enrollment ceases under the same
				circumstances that would permit discontinuance of a person's election of
				coverage under paragraph (b);
(d) The person is enrolled under a policy to
				supplement Medicare and the enrollment ceases because:
(1) Of the insolvency of the issuer or
				bankruptcy of the nonissuer organization;
(2) Of other involuntary termination of
				coverage or enrollment under the policy;
(3) The issuer of the policy substantially
				violated a material provision of the policy; or
(4) 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 person;
(e) The person was enrolled under a policy to
				supplement Medicare and terminates enrollment and subsequently enrolls, for the
				first time, with any Medicare Advantage organization under a Medicare Advantage
				plan under Medicare Part C, any eligible organization under a contract under
				section 1876 of the Social Security Act,
				42 U.S.C. §
											1395 mm (Medicare cost), any similar
				organization operating under demonstration project authority or any PACE
				program, and the subsequent enrollment is terminated by the enrollee during any
				period within the first 12 months of such subsequent enrollment, during which
				the enrollee is permitted to terminate such subsequent enrollment under section
				1851(e) of the Social Security Act,
				42 U.S.C. §
											1395 w - 21(e);
(f) The person, upon first becoming eligible
				for benefits under Medicare Part A at the age of 65 years, enrolls in a
				Medicare Advantage plan under Medicare Part C or with a PACE program, and
				disenrolls from the plan or program by not later than 12 months after the
				effective date of enrollment; or
(g) The person 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 policy to supplement Medicare that covers
				outpatient prescription drugs, and the person terminates enrollment in the
				policy to supplement Medicare and submits evidence of enrollment in Medicare
				Part D along with the application for a policy described in subsection 5 of NAC
				687B.2057.