New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.12 - Guaranteed issue for eligible persons

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligible persons are those individuals described in (c) below who seek to enroll under the policy during the period specified in (d) below, and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy.
(b) With respect to eligible persons, a carrier shall not deny or condition the issuance or effectiveness of a Medicare supplement policy described in (f) below that is offered and is available for issuance to new enrollees by the carrier, shall not discriminate in the pricing of such a 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 such a Medicare supplement policy.
(c) 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 all such supplemental health benefits to the individual;
2. The individual is enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates, the plan ceases to provide all health benefits to the individual or the individual leaves the plan;
3. The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage Plan under Part C of Medicare, and any of the circumstances described in (c)3i through iv below 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 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 such provider if such individual were enrolled in a Medicare Advantage plan:
i. The organization's or plan's certification under Part C of Medicare has been terminated or the organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides;
ii. 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 ( 42 U.S.C. §
												1395w-21 ) (where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under Section 1856 ( 42 U.S.C. §
												1395w-26 )), or the plan is terminated for all individuals within a residence area;
iii. The individual demonstrates, in accordance with guidelines established by the Secretary, that:
(1) The organization offering the plan substantially violated a material provision of the organization's contract under Part C of Medicare 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
(2) 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
iv. The individual meets such other exceptional conditions as the Secretary may provide;
4. The individual is enrolled with any of the following, and the enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under (c)3 above:
i. An eligible organization under a contract under Section 1876 ( 42 U.S.C. §
												1395mm ) 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) ( 42 U.S.C. §
												1395 ) of the Social Security Act (health care prepayment plan); or
iv. An organization under a Medicare Select policy;
5. The individual is enrolled under a Medicare supplement policy and the enrollment ceases because of the following:
i. Either the insolvency of the carrier or bankruptcy of the noncarrier organization, or other involuntary termination of coverage or enrollment under the policy;
ii. The carrier substantially violated a material provision of the policy; or
iii. The carrier, or an agent or other entity acting on the carrier's behalf, materially misrepresented the policy's provisions in marketing the policy to the individual;
6. 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 Medicare Advantage plan under Part C of Medicare, any eligible organization under a contract under Section 1876 ( 42 U.S.C. §
											1395mm ) 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 ( 42 U.S.C. §
											1395ee e ), or a Medicare Select policy; 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) ( 42 U.S.C. §
											1395w-2 ) of the Federal Social Security Act);
7. The individual, upon first becoming eligible for benefits under Medicare Part A at age 65 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 ( 42 U.S.C. §
											1395ee e ), and disenrolls from the plan by not later than 12 months after the effective date of enrollment; or
8. 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 terminated enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in (f) below.