NAC687B.206. Eligibility for policy to supplement Medicare offered to new enrollees or for certificate offered to new enrollees following certain disenrollment; required policy or certificate; outpatient prescription drug coverage.

     1. A person is eligible for a policy to supplement Medicare that is offered to new enrollees or for a certificate that is offered to new enrollees if the person provides evidence that he or she disenrolled within the previous 63 days from:

     (a) An employee welfare benefit plan that:

          (1) Provided health benefits to supplement the benefits provided under Medicare; and

          (2) Discontinued providing substantially all such supplemental health benefits to the person.

     (b) An employee welfare benefit plan that:

          (1) Provided health benefits that were primary to the benefits provided under Medicare; and

          (2) Discontinued providing all such health benefits to the person because the employee welfare benefit plan was terminated or the person disenrolled from the employee welfare benefit plan.

     (c) A Medicare Advantage plan offered by a Medicare Advantage organization pursuant to Medicare Part C, if the person was allowed to disenroll from the Medicare Advantage plan under any of the following circumstances:

          (1) The certification of the organization or the plan has been terminated, or the organization or plan has notified the person of an impending termination of its certification.

          (2) The organization has terminated or otherwise discontinued providing the plan in the area in which the person resides, or has notified the person of an impending termination or discontinuance of the plan.

          (3) The person was no longer eligible to elect a Medicare Advantage plan because:

               (I) His or her residence changed;

               (II) The Medicare Advantage plan was terminated with respect to all persons in the area where the person resided; or

               (III) Other circumstances as specified by the Secretary of Health and Human Services changed. Those circumstances do not include terminating the election of the person pursuant to section 1851(g)(3)(B)(i) or (ii) of the Social Security Act, 42 U.S.C. § 1395w-21(g)(3)(B)(i) or (ii).

          (4) The person demonstrated in accordance with guidelines established by the Secretary of Health and Human Services that:

               (I) The Medicare Advantage organization offering the Medicare Advantage plan substantially violated a material provision of the contract of the Medicare Advantage organization under Medicare Part C with respect to the person, including, without limitation, failing to provide to an enrollee on a timely basis medically necessary care for which benefits are available under the Medicare Advantage plan or failing to provide such care in accordance with applicable quality standards; or

               (II) The Medicare Advantage organization, agent or other person acting on behalf of the Medicare Advantage organization made a material misrepresentation of the provisions of the Medicare Advantage plan.

          (5) The person met such other exceptional condition as provided by the Secretary of Health and Human Services.

     (d) The PACE program if the person is 65 years of age or older and there are circumstances similar to those described in paragraph (c) that would permit discontinuance of the person’s enrollment with the provider if he or she were enrolled in a Medicare Advantage plan.

     (e) If the person disenrolled pursuant to the same circumstances that are required to disenroll from a plan pursuant to paragraph (c), any plan offered by:

          (1) An eligible organization that had a risk-sharing contract or a reasonable cost reimbursement contract with the Secretary of Health and Human Services pursuant to section 1876 of the Social Security Act, 42 U.S.C. § 1395mm;

          (2) For periods before April 1, 1999, an insurer that operated pursuant to the authority of a demonstration project;

          (3) An insurer that had an agreement to provide medical and other health services on a prepaid basis pursuant to section 1833(a)(1)(A) of the Social Security Act, 42 U.S.C. § 1395l(a)(1)(A); or

          (4) A Medicare select issuer that had a Medicare select policy.

     (f) A policy to supplement Medicare or a certificate, if the person disenrolled from that policy or certificate because:

          (1) The insurer filed a voluntary petition in bankruptcy or had an involuntary petition in bankruptcy filed against it and the insurer ceased doing business in this State;

          (2) The issuer was adjudicated insolvent by a court of competent jurisdiction in the state of domicile of the issuer;

          (3) The insurer involuntarily terminated coverage or enrollment;

          (4) The issuer of the policy or certificate substantially violated a material provision of the policy or certificate; or

          (5) The issuer, an agent or other person acting on behalf of the issuer made a material misrepresentation of the provisions of the policy or certificate.

     2. In lieu of using the date of termination of enrollment for purposes of this section, a person described in paragraph (c) or (d) of subsection 1 may substitute the date on which he or she was notified by the Medicare Advantage organization of the impending termination or discontinuance of the Medicare Advantage plan offered by the Medicare Advantage organization in the area in which the person resides, but only if the person disenrolls from the plan as a result of that notification. If a person makes the substitution provided in this subsection, the issuer shall accept the application of the person submitted before the date of termination or enrollment, but the coverage under this subsection must become effective only upon termination of coverage under the Medicare Advantage plan involved.

     3. A person who is eligible for a policy to supplement Medicare or a certificate pursuant to subsection 1 is entitled to obtain from any issuer a policy to supplement Medicare or a certificate that has a benefit plan that is designated as Standardized Benefit Plan A, B, C, F (including F with a high deductible), K or L.

     4. After December 31, 2005, a person currently enrolled in a policy to supplement Medicare with an outpatient prescription drug benefit is eligible to:

     (a) Retain their current plan with outpatient prescription drug coverage;

     (b) Enroll in a plan from the same issuer that is modified to exclude outpatient prescription drug coverage with the option to select Medicare Part D; or

     (c) Enroll in an A, B, C, F (including F with a high deductible), K or L policy that is offered by any issuer with an option to select Medicare Part D.

     5. As used in this section, “Medicare select policy” has the meaning ascribed to it in NAC 687B.348.

     (Added to NAC by Comm’r of Insurance by R110-98, eff. 2-23-99; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)