NAC687B.2053. Eligible persons: Description; prohibited actions by insurers.

     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. § 1395w-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. § 1395mm (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. § 1395l(a)(1)(A) (health care prepayment plan); or

          (4) An organization under a Medicare Select policy,

Ê 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. § 1395mm (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. § 1395w-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.

     (Added to NAC 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)