Okla. Admin. Code § 365:10-5-129

Current through Vol. 42, No. 7, December 16, 2024

Section 365:10-5-129 - Open enrollment

(a) An issuer shall not 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 such 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 (6) month period beginning with the first day of the first month in which an individual is both sixty-five (65) years of age or older and 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) If an applicant qualifies under subsection (a) or subsection (d) of this Section and submits an application during the time period referenced in said subsection (a) or subsection (d), and

(1) as of the date of application, has had a continuous period of creditable coverage of at least six (6) months, the issuer shall not exclude benefits based on a preexisting condition; or

(2) as of the date of application, has had a continuous period of creditable coverage that is less than six (6) 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 in Subsection (b) and Section 365:10-5-140, subsection (a) and subsection (d) of this Section shall not be construed as preventing the exclusion of benefits under a policy, during the first six (6) months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the six (6) months before the coverage became effective.

(d) At least one (1) of the ten (10) standardized Medicare supplement plans currently available from an issuer shall be made available to all applicants who qualify under this subsection by reason of disability. The issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State because of the health status, claims experience, receipt of health care, or medical condition of an applicant where an application for such policy or certificate is submitted during the six (6) month period beginning with the first month in which an individual first enrolled for benefits under Medicare Part B. The premium rate charged for such disabled person may not exceed the lowest available aged premium rate for such plan.

(e) In the event Social Security backdates the Medicare enrollment date, the six-month enrollment period shall be calculated from the date the individual first receives notification of approval of Medicare coverage.

(f) A person who has a Medicare supplement policy, including a person entitled to Medicare benefits due to a disability, and has been covered by that policy with no gap in coverage greater than ninety (90) days beginning from the person's open enrollment period shall be provided continuity of coverage under a new supplement policy with the same or lesser benefits issued by the same or different issuer.

(1) The issuer of a new Medicare supplement policy for any person described in subsection (f) shall waive any medical underwriting or preexisting conditions exclusion to the extent benefits would have been payable under the prior Medicare supplement policy and any earlier Medicare supplement policy if those policies were still in effect. The subsection does not require the succeeding insurer to pay any benefits that are not within the terms of coverage of the succeeding policy solely because they would have been paid by the prior policy.

(2) When a determination of benefits under the prior policy is required, the issuer of the prior policy shall, at the request of the issuer of the succeeding policy, furnish a statement of benefits available or pertinent information sufficient to permit verification of the benefit determination or the determination itself by the issuer of the succeeding policy. For purposes of this subsection, benefits of the prior policy are determined in accordance with the definitions, conditions, and covered expense provisions of that policy rather than those of the succeeding policy. The benefit determination must be made as if coverage had not been replaced.

(g) In the case that an individual enrolled in a Medicare supplement policy by reason of disability becomes eligible for open enrollment under subsection (a) of this Section, the issuer of the Medicare supplement policy shall provide notice of such rights no sooner than ninety (90) days and no later than sixty (60) days prior to the first day of the first month in which the individual becomes sixty-five (65) years of age.

Okla. Admin. Code § 365:10-5-129

Added at 9 Ok Reg 549, eff 12-13-91 (emergency); Added at 9 Ok Reg 2499, eff 6-26-92; Amended at 9 Ok Reg 3899, eff 8-24-92 (emergency); Amended at 10 Ok Reg 1475, eff 5-1-93; Amended at 11 Ok Reg 3297, eff 7-1-94; Amended at 14 Ok Reg 2292, eff 7-1-97; Amended at 15 Ok Reg 3569, eff 5-29-98 (emergency); Amended at 16 Ok Reg 1088, eff 4-26-99; Amended at 26 Ok Reg 1551, eff 7-1-09

Amended by Oklahoma Register, Volume 34, Issue 24, September 1, 2017, eff. 9/15/2017

Amended by Oklahoma Register, Volume 40, Issue 23, August 15, 2023, eff. 9/1/2023