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Ins 3.39(34)(b)2. 2. The individual 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 individual is 65 years of age or older and is enrolled with a PACE provider under section 1894 of the Social Security Act, and there are circumstances similar to those described in subd. 2. a. to e. that would permit discontinuance of the individual's enrollment and such provider if such individual were enrolled in a Medicare Advantage plan:
Ins 3.39(34)(b)2.a. a. The certification of the organization or plan under Medicare Part C has been terminated; or
Ins 3.39(34)(b)2.b. b. The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides.
Ins 3.39(34)(b)2.c. c. 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 (where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under section 1856), or the plan is terminated for all individuals within a residence area.
Ins 3.39(34)(b)2.d. d. The individual demonstrates, in accordance with guidelines established by the secretary that, at least one of the following has occurred; the organization offering the plan substantially violated a material provision of the organization's contract under this part 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 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.
Ins 3.39(34)(b)2.e. e. The individual meets such other exceptional conditions as the secretary may provide.
Ins 3.39(34)(b)3. 3. The individual is enrolled with any of the following:
Ins 3.39(34)(b)3.a. a. An eligible organization under a contract under Section 1876 of the Social Security Act (Medicare cost);
Ins 3.39(34)(b)3.b. b. A similar organization operating under demonstration project authority, effective for periods before April 1, 1999;
Ins 3.39(34)(b)3.c. c. An organization under an agreement under Section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan); or
Ins 3.39(34)(b)3.d. d. An organization under a Medicare select policy; and
Ins 3.39(34)(b)3m. 3m. The enrollment ceases under the same circumstances that would permit discontinuance of an individual's election of coverage under subd. 2.
Ins 3.39(34)(b)4. 4. The individual is enrolled under a Medicare supplement policy and the enrollment ceases because:
Ins 3.39(34)(b)4.a. a. Of the insolvency of the issuer or bankruptcy of the nonissuer organization or of other involuntary termination of coverage or enrollment under the policy;
Ins 3.39(34)(b)4.b. b. The issuer of the policy substantially violated a material provision of the policy; or
Ins 3.39(34)(b)4.c. c. 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 individual;
Ins 3.39(34)(b)5.a.a. 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 a Medicare Advantage plan under Medicare Part C, any eligible organization under a contract under section 1876 of the Social Security Act, Medicare cost, any similar organization operating demonstration project authority, any PACE provider under section 1894 of the Social Security Act, or a Medicare select policy; and
Ins 3.39(34)(b)5.b. b. The subsequent enrollment under subd. 5. a. 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 federal Social Security Act); or
Ins 3.39(34)(b)6. 6. The individual, upon first becoming eligible for benefits under Medicare Parts A and B at age 65, enrolls in a Medicare Advantage plan under Medicare Part C, or with a PACE provider under section 1894 of the Social Security Act, and disenrolls from the plan or program by not later than 12 months after the effective date of enrollment.
Ins 3.39(34)(b)7. 7. The individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Medicare Part D, was enrolled under a Medicare supplement, Medicare replacement, Medicare cost or Medicare select policy that covered outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement, Medicare replacement Medicare cost or Medicare select policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in par. (e) 4.
Ins 3.39(34)(b)8. 8. The individual is eligible for benefits under Medicare Parts A and B and is covered under the medical assistance program and subsequently loses eligibility in the medical assistance program.
Ins 3.39(34)(c) (c) Guaranteed issue time periods.
Ins 3.39(34)(c)1.1. In the case of an individual described in par. (b) 1., 1m., or 1s., the guaranteed issue period begins on the later of the following dates:
Ins 3.39(34)(c)1.a. a. The date the individual receives a notice of termination or cessation of some or all supplemental health benefits, or, if a notice is not received, notice that a claim has been denied because of a termination or cessation, and ends 63 days after the date the applicable coverage is terminated.
Ins 3.39(34)(c)1.b. b. The date the individual receives notice that a claim has been denied because of such a termination or cessation, if the individual did not receive notice of the plan's termination or cessation, and ends 63 days after the date of notice of the claim denial.
Ins 3.39(34)(c)2. 2. In the case of an individual described in par. (b) 2., 3., 5., 6. or 8., whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends on the date that is 63 days after the date the applicable coverage is terminated.
Ins 3.39(34)(c)3. 3. In the case of an individual described in par. (b) 4. a., the guaranteed issue period begins on the earlier of either: 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; or the date that the applicable coverage is terminated. The guaranteed issue period ends on the date that is 63 days after the date such coverage is terminated.
Ins 3.39(34)(c)4. 4. In the case of an individual described in par. (b) 1r., 2., 4. b. or c., 5., or 6. 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.
Ins 3.39(34)(c)5. 5. In the case of an individual described in par. (b) 7., 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 issuer during the 60-day period immediately preceding the initial Medicare 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.
Ins 3.39(34)(c)6. 6. In the case of an individual described in par. (b) but not described in the preceding provisions of this paragraph, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date.
Ins 3.39(34)(d) (d) Extended Medigap access for interrupted trial periods.
Ins 3.39(34)(d)1.1. In the case of an individual described in par. (b) 5., or deemed to be so described pursuant to this subdivision, whose enrollment with an organization or provider described in par. (b) 5. a. 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 par. (b) 5.
Ins 3.39(34)(d)2. 2. In the case of an individual described in par. (b) 6., or deemed to be so described pursuant to this paragraph, whose enrollment with a plan or in a program described in par. (b) 6. 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 par. (b) 6.
Ins 3.39(34)(d)3. 3. For purposes of par. (b) 5. and 6., no enrollment of an individual with an organization or provider described in par. (b) 5. a., or with a plan or in a program described in par. (b) 6., may be deemed to be an initial enrollment under this paragraph after the 2-year period beginning on the date on which the individual first enrolled with such an organization, provider, plan or program.
Ins 3.39(34)(e) (e) Products to which eligible persons are entitled prior to June 1, 2010. The Medicare supplement or Medicare cost policy to which eligible persons are entitled under:
Ins 3.39(34)(e)1. 1. Paragraph (b) 1., 1m., 1r., 2., 3., and 4., is a Medicare supplement policy as defined in sub. (5) along with any riders available or a Medicare select policy as defined in sub. (30). except the Outpatient Prescription Drug Rider defined in sub. (5) (i) 7.
Ins 3.39(34)(e)2. 2. Paragraph (b) 5. is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy as described in subd. 1.
Ins 3.39(34)(e)3. 3. Paragraph (b) 6. and 8. is a Medicare supplement policy as described in sub. (5) along with any riders available or a Medicare select policy as defined in sub. (30).
Ins 3.39(34)(e)4. 4. Paragraph (b) 7., is a Medicare supplement policy as described in sub. (5) along with any riders available or a Medicare select policy as defined in sub. (30), that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with the outpatient prescription drug coverage.
Ins 3.39(34)(e)5. 5. Paragraph (b) 3., is a Medicare cost policy as described in sub. (7) along with any enhancements and riders, that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare cost policy.
Ins 3.39(34)(e)6. 6. The Outpatient Prescription Drug Rider referenced in sub. (5) (i) 7. may only be issued through December 31, 2005.
Ins 3.39(34)(ez) (ez) Products to which eligible persons are entitled on or after June 1, 2010. The Medicare supplement or Medicare cost policy or certificate to which eligible persons are entitled under:
Ins 3.39(34)(ez)1. 1. Paragraph (b) 1., 1m., 1r., 1s., 2., 3. and 4., is a Medicare supplement policy or certificate as defined in sub. (5m) along with any riders available or a Medicare select policy or certificate as defined in sub. (30m).
Ins 3.39(34)(ez)2. 2. Paragraph (b) 5. is the same Medicare supplement policy or certificate in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy or certificate as described in subd. 1.
Ins 3.39(34)(ez)3. 3. Paragraph (b) 6. and 8. is a Medicare supplement policy or certificate as described in sub. (5m) along with any riders available or a Medicare select policy or certificate as defined in sub. (30m).
Ins 3.39(34)(ez)4. 4. Paragraph (b) 7., is a Medicare supplement policy or certificate as described in sub. (5m) along with any riders available or a Medicare select policy or certificate as defined in sub. (30m), that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy or certificate with the outpatient prescription drug coverage.
Ins 3.39(34)(f) (f) Notification provisions.
Ins 3.39(34)(f)1.1. At the time of an event described in par. (b) 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 issuer 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 issuers of Medicare supplement or Medicare cost policies under par. (a). The notice shall be communicated contemporaneously with the notification of termination.
Ins 3.39(34)(f)2. 2. At the time of an event described in par. (b) 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 issuer 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 issuers of Medicare supplement or Medicare cost policies under par. (a). Such notice shall be communicated within 10 working days of the issuer receiving notification of disenrollment.
Ins 3.39(34)(f)3. 3. At the time of an event described in par. (b) because of which a hospital in a Medicare select network leaves the network the issuer shall notify the insured of his or her rights under this section, and of the obligations of issuers of Medicare supplement or Medicare cost policies under par. (a). The notice to insureds shall be communicated within 10 business days of the issuer receiving notification of the hospital's notice of leaving the network.
Ins 3.39(35) (35)Exchange of Medicare supplement policy. An issuer that submits and receives approval to offer a Medicare supplement insurance policy that is effective or issued on or after June 1, 2010, may offer an exchange subject to the following requirements:
Ins 3.39(35)(a) (a) By or before May 31, 2011, on a one-time basis in writing, an issuer may offer to all of its existing Medicare supplement policyholders or certificateholders covered by a policy with an effective prior to June 1, 2010, the option to exchange the existing policy to a different policy that complies with subs. (4s), (5m) and (30m), as applicable.
Ins 3.39(35)(b) (b) The offer shall be made on a nondiscriminatory basis without regard to the age or health status of the insured unless such offer or issue would be in violation of state or federal law.
Ins 3.39(35)(c) (c) The offer shall remain open for a minimum of 120 days from the date of the mailing by the issuer.
Ins 3.39(35)(d) (d) In the event of an exchange, if the replaced policy is priced on an issue age rate schedule, the rate charged to the insured for the newly exchanged policy shall recognize the policy reserve buildup, due to the pre-funding inherent in the use of an issue age rate basis, for the benefit of the insured.
Ins 3.39(35)(e) (e) The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage.
Ins 3.39(35)(f) (f) The issuer may not apply new preexisting condition limitations or a new incontestability period to the newly issued policy for those benefits that were contained in the exchanged policy or certificate of the insured but may apply a preexisting condition limitation of no more than 6 months to any added benefits contained in the newly issued policy or certificate that were not present in the exchanged policy or certificate.
Ins 3.39(36) (36)Genetic information. In addition to compliance with ss. 631.89 and 632.748, Stats., beginning on May 21, 2009, an issuer of a Medicare supplement policy or certificate may not deny or condition the issuance or effectiveness of the policy or certificate, including the imposition of any exclusion of benefits under the policy based on a preexisting condition, on the basis of the genetic information with respect to such individual. The issuer may not discriminate in the pricing of the policy or certificate, including the adjustment of rates of an individual on the basis of the genetic information with respect to such individual.
Ins 3.39(36)(a) (a) In this subsection and for use in policies or certificates:
Ins 3.39(36)(a)1. 1. "Family member" means, with respect to an individual, any other individual who is a first through fourth degree relative of the individual.
Ins 3.39(36)(a)2. 2. "Genetic information" means, with respect to any individual, information about such individual's genetic tests, the genetic tests of family members of such individual, and the manifestation of a disease or disorder in family members of such individual. Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research that includes genetic services, by such individual or any family member of such individual. Any reference to genetic information concerning an individual or family member of an individual who is a pregnant woman includes genetic information of any fetus carried by such pregnant woman, or with respect to an individual or family member utilizing reproductive technology, includes genetic information of any embryo legally held by an individual or family member. The term "genetic information" does not include information about the sex or age of any individual.
Ins 3.39(36)(a)3. 3. "Genetic services" means a genetic test, genetic counseling including, obtaining, interpreting, or assessing genetic information, or genetic education.
Ins 3.39(36)(a)4. 4. "Genetic test" means an analysis of human deoxyribonucleic acid, ribonucleic acid or chromosomes, proteins, or metabolites that detect genotypes, mutations, or chromosomal changes. The term "genetic test" does not mean an analysis of proteins or metabolites that does not detect genotypes, mutation, or chromosomal changes; or an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved.
Ins 3.39(36)(a)5. 5. "Issuer of a Medicare supplement policy or certificate" includes third-party administrators, or other person acting for or on behalf of such issuer.
Ins 3.39(36)(a)6. 6. "Underwriting purposes," means all of the following:
Ins 3.39(36)(a)6.a. a. Rules for, or determinations of, eligibility including enrollment and continued eligibility for benefits under the policy.
Ins 3.39(36)(a)6.b. b. The computation of premium or contribution amounts under the policy.
Ins 3.39(36)(a)6.c. c. The application of any preexisting condition exclusions under the policy.
Ins 3.39(36)(a)6.d. d. Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.
Ins 3.39(36)(b) (b) An issuer of a Medicare supplement policy or certificate may not request or require an individual or a family member of such individual to undergo a genetic test. An issuer may not request, require or purchase genetic information for use in underwriting. An issuer may not request, require or purchase genetic information with respect to any individual prior to such individual's enrollment under the policy in connection with such enrollment.
Ins 3.39(36)(c) (c) Nothing in par. (b) shall be construed to limit the ability of an issuer, to the extent otherwise permitted by law, from any of the following;
Ins 3.39(36)(c)1. 1. Denying or conditioning the issuance or effectiveness of a policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant.
Ins 3.39(36)(c)2. 2. Increasing the premium for any policy issued to an individual based on the manifestation of a disease or disorder of an individual who is covered under the policy.
Ins 3.39(36)(d) (d) Notwithstanding par. (b), the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members to further increase the premium for the group.
Ins 3.39(36)(e) (e) An issuer of a Medicare supplement policy or certificate may not request or require an individual or a family member of such individual to undergo a genetic test. Nothing in this paragraph shall be construed to preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a payment determination when consistent with the requirements of par. (b). If genetic information is obtained, the request may only include the minimum amount necessary to accomplish the intended purpose.
Ins 3.39(36)(f) (f) If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring or purchasing of other information concerning any individual, such request, requirement or purchase may not be considered a violation of this section.
Ins 3.39 Note Note: This rule requires the use of a rate change transmittal form which may be obtained from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, WI 53707-7873.
Ins 3.39 Note Note: The rule revisions published in June, 1994 first apply to any policy issued, renewed or solicited on or after September 1, 1994.
Ins 3.39 Note Note: For a complete history of s. Ins 3.39 from July 1977 to October 31, 2001, see the History note following s. Ins 3.39 as published in Register October 2001 No. 550.
Ins 3.39 History History: CR 00-133: am (2) (a) (intro.), (3) (cm), (4) (intro.), (a), (b) 2., (34) (b) 5. a., 6., (c) 1. and Appendix 1, cr. (4) (a) 18p., (34) (b) 2. b., 2. f. and (c) 3., r. (7) (b),(c), (7) (g), (21) (f), r. and recr. (7) (d), (13) and (34) (b) 2.a., renum (7) (e) to be (7) (c) and am., renum. (7) (f) to be (7) (d), (34) (b) 2. b. to be 2. c., 2. c. to be 2. d and 2. d. to be 2. e.,Register October 2001 No. 550, eff. 11-1-01; corrections in (34) (b) 2. and 3., made under s. 13.93 (2m) (b) 1., Stats., Register October 2001 No. 550; emerg. am. eff. 12-16-02; corrections in (2) (a), (4), (7) (b) and (c), (13) and (33) made under s. 13.93 (2m) (b) 7., Stats., Register December 2002 No. 564; CR 02-118: am. (4) (a) 18p., (5) (c) 4., (34) (a) 1. and 2., (b) (intro.), 2. (intro.), a., b., 3. (intro.), a. and c., 4. (intro.), 5. a. and 6., r. (34) (b) 2. f. and fm., renum. (34) (c) and (d) to be (34) (e) and (f), cr. (34) (c) and (d) Register April 2003 No. 568, eff. 5-1-03; CR 04-121: am. (1) (c), (4) (intro.), (a) 1. to 3., 6., 12., 18m. and 18r. b., (4m) (a), (b) and (d), (5) (c) 6., 12. to 15., (i) (intro.) and 7., (j), (k) (intro.), (m) (intro.), (14) (a), (c) 6., (j), (m), (15), (16) (a), (c) (intro.), 1., 3. and (e), (21) (a) and (e), (22) (a), (b), (d), (e), (f) (intro.) and 1., (23) (a) (intro.), 1., 3., 4. and (c), (25) (a) to (c), (26) (a) (intro.), (27), (29), (30) (a), (b) 1. to 7., (c), (d), (e) (intro.) and 1. e., (f) 1., (g) (intro.), (h), (i) (intro.), 1. (intro.) and b., 3., 7., and 9., (j), (k) (intro.), (L) to (o), (p) (intro.) and 8., (34) (a), (b) 1., 1m., 2. (intro.) and a., 3. d., 4. (intro.), 5. a., 6., (c) 1. (intro.) and a., 2., 4., (e) and (f), and Appendices 5 and 8, cr. (2) (f), (4) (a) 20., 21., (5) (n), (o), (23) (a) 5., (30) (q), (r), (34) (b) 1r., 7., 8., and (c) 5., r. and recr. (3), (7), (22) (i) and Appendices 1, 3, 4, and 6, renum. (23) (a) 5., (30) (q) and (r) and (34) (c) 5. to be (23) (a) 6, (30) (s) and (t) and (34) (c) 6. and am. (23) (a) 6., (30) (s) and (t), r. (33) Register June 2005 No. 594, eff. 7-1-05; CR 08-112: am. (1) (a), (b), (3) (q), (v), (w), (4) (intro.), (a) 3., 8., 17., (5) (title), (intro.), (6) (intro.), (7) (a), (d), (8) (c), (9) (b), (14) (title), (a), (d) 3., (15), (23) (d), (24) (g), (26) (b), (30) (a) 1., 2., (b) (intro.), (31) (a) and (34) (e) (title), renum. (1) (c) to be (1) (d), cr. (1) (c), (3) (ce), (cs), (4s), (5m), (14m), (17), (18), (30m), (34) (ez), (35) and (36) Register June 2009 No. 642, eff. 7-1-09; CR 09-076: am. (5m) (e) (intro.), 5., (6) (intro.), (7) (a) (intro.), (8) (a) (intro.), (14m) (d) (intro.), (34) (b) 1., (c) 1., (ez) 1. and Appendix 3, cr. (5m) (k), (7) (cm), (dm), (30m) (p) 6., (34) (b) 1. c., 1s. and (f) 3., r. (30m) (q) 1., renum. (30m) (q) 2. and 3. to be (30m) (q) 1. and 2. Register May 2010 No. 653, eff. 6-1-10; correction in (7) (cm) made under s. 13.93 (2m) (b) 7., Stats., Register, May 2010 No. 653.
Ins 3.39 APPENDIX 1
For policies with an effective date prior to June 1, 2010 the following information shall be inserted prior to each outline of coverage provided to an insured and include the information specific to the plan type.
PREMIUM INFORMATION
We can only raise your premium if we raise the premium for all policies like yours in this state. [Include information specifying when premiums will change.]
If your policy was issued as an under age 65 policy due to disability, when you turn 65 premiums will remain at the disabled rates. [Include this statement within premium information when issuer does not change premium to age 65 rate.]
DISCLOSURES
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY
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