N.J. Admin. Code § 11:4-23.12

Current through Register Vol. 56, No. 8, April 15, 2024

Section 11:4-23.12 - Guaranteed issue for eligible persons

(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.

(d) The guaranteed issue time periods shall be:

1. In the case of an individual described in (c)1 above, the guaranteed issue period begins on the date the individual receives a notice of termination or cessation of all supplemental health benefits or, in the absence of the receipt of such notice, the individual receives notice that a claim has been denied because of such a termination or cessation and ends 63 days after the date of the applicable notice; or

2. In the case of an individual described in (c)3, 4, 6 or 7 above whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of such termination and ends 63 days after the date the applicable coverage is terminated;

3. In the case of an individual described in (c)5i above, the guaranteed issue period begins on the earlier of the date that the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other such similar notice if any, and the date that the applicable coverage is terminated. The guaranteed issue period ends on the date that is 63 days after the date the coverage is terminated;

4. In the case of an individual described in (c)3, 5ii or iii, or (c)6 or 7 above who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date;

5. In the case of an individual described in (c)8 above, 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 carrier during the 60-day period immediately preceding the initial Part D enrollment period and ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D; and

6. In the case of an individual described in (c) above but not described in the preceding paragraphs of this subsection, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date.

(e) The following shall apply to extended Medicare Supplement access for interrupted trial periods:

1. In the case of an individual described in (c)6 above (or deemed to be so described, pursuant to this paragraph) whose enrollment with an organization or provider described in (c)6 above is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment described in (c)6 above;

2. In the case of an individual described in (c)7 above (or deemed to be so described, pursuant to this paragraph) whose enrollment with a plan or in a program described in (c)7 above is involuntarily terminated within the first 12 months of enrollment, and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in (c)7 above; and

3. For purposes of (c)6 and 7 above, no enrollment of an individual with an organization or provider described in (c)6 above, or with a plan or in a program described in (c)7 above, 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 such an organization, provider, plan or program.

(f) The Medicare supplement policy to which eligible persons are entitled under (c)1, 2, 3, 4 and 5 above 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 carrier. The Medicare supplement policy to which eligible persons are entitled under (c)6 above is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same carrier, or, if not so available, a policy described in the preceding sentence. However, after December 31, 2005, if the Medicare supplement policy, under which an eligible person entitled under (c)6 above was most recently enrolled, is a Medicare supplement policy with an outpatient prescription drug benefit, the eligible person described in (c)6 above will be entitled to the same policy from the same carrier but modified to remove outpatient prescription drug coverage, or the eligible person may elect 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 carrier. The Medicare supplement policy to which eligible persons are entitled under (c)7 above shall include any Medicare supplement policy offered by any carrier. The Medicare supplement policy to which eligible persons are entitled under (c)8 above 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 that is offered and is available for issuance to new enrollees by the same carrier that issued the eligible person's Medicare supplement policy with outpatient prescription drug coverage.

(g) At the time of an event described in (c) above 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 carrier terminating the policy, or the administrator of the plan being terminated, respectively, shall notify the individual of his or her rights under this section, and of the obligations of carriers issuing Medicare supplement policies under (a) and (b) above. Such notice shall be communicated contemporaneously with the notification of termination.

(h) At the time of an event described in (c) above 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 carrier 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 carriers issuing Medicare supplement policies under (a) and (b) above. Such notice shall be communicated within 10 working days of the issuer receiving notification of disenrollment.

N.J. Admin. Code § 11:4-23.12

Emergency Rule, R.1999 d.38, effective 12/28/1998 (to expire February 26, 1999).
See: 31 N.J.R. 181(a).
Former N.J.A.C. 11:4-23.12, Filing requirements for policies, certificates and premium rates, recodified to N.J.A.C. 11:4-23.13.
Adopted concurrent proposal, R.1999 d.100, effective 2/26/1999.
See: 31 N.J.R. 181(a), 31 N.J.R. 876(a).
Amended by R.2001 d.7, effective 1/2/2001.
See: 32 N.J.R. 3546(a), 33 N.J.R. 101(a).
Amended by R.2003 d.220, effective 5/19/2003.
See: 35 N.J.R. 71(a), 35 N.J.R. 2184(a).
Rewrote the section.
Amended by R.2005 d.291, effective 9/6/2005.
See: 37 N.J.R. 1428(a), 37 N.J.R. 3376(a).
In (a), substituted "," for "or" following "termination" and added ", or Medicare Part D enrollment" following "disenrollment"; rewrote (c); in (d), deleted "or" following "date;" in 4, added 5, recodified former 5 as 6; rewrote (f).