Texas Guaranteed Issue Guide

Transcription

1 Texas Guaranteed Issue Guide Guaranteed Issue means your automatic acceptance into specified Medicare supplement plans without having to complete the Statement of Health section of the application. How to Use This Guide 1. Review the Situations and Plan in this guide. Pay special attention to the time frame requirements. Refer to the Outline of Coverage to determine benefits for all of our available plans. 2. Turn to the Guaranteed Issue section of the application. Indicate your applicable Situation number and decide which plan best suits your needs from the Plan listed in this guide. You may skip the Statement of Health section of the application. 3. Submit required documentation. You must attach proof of the date your previous coverage ended. Also, please give us the effective date of your previous coverage and the name and telephone number of your previous insurance company. (Example: Send a letter from your insurance company giving the dates your coverage began and ended.) If this Medicare supplement insurance policy is replacing Medicare Advantage plan coverage, you must request, in writing, to be disenrolled from your Medicare Advantage Plan. Your written request will formally confirm that you are disenrolling from your Medicare Advantage Plan and replacing it with a Medicare supplement insurance policy. If you have any questions about this process, please contact your Medicare Advantage Plan Customer Service Department. If you do not qualify for Guaranteed Issue, you must complete the Statement of Health section of the application. NOTE: Only the following plans are currently available from PacifiCare Life Assurance Company in Texas: A, C, F, High Deductible F, G and J.

2

3 MEDICARE SUPPLEMENT GUARANTEED ISSUE GUIDE texas 1 Situation Description You have Medicare Part A and are enrolled in Medicare Part B. If age 65 or older: All plans available from any insurer You must submit your application no later than 6 months after the date your Medicare Part B coverage took effect. 2 Situation Description You enrolled with an employee welfare benefit plan that provides benefits that supplement Medicare, but the plan terminated or stopped providing all such supplemental benefits; or you enrolled with an employee welfare benefit plan that is primary to Medicare and the plan terminates, or the plan ceases to provide all health benefits to you because you disenrolled from the plan. Your guaranteed issue period begins on the date of your first notice of termination or cessation of your supplemental benefits. Notice of a claim denial because of a termination or cessation is notice of termination or cessation. Your guarantee period ends 63 days after the date of your first notice. 3 Situation Description I. You enrolled in one of the following: n A Medicare Advantage Plan; or n A PACE provider, if you are 65 years of age or older And II. One of the following occurs: n You involuntarily lost coverage because: Your organization lost its certification; Your organization stopped providing the plan in your area; You moved, or a specified change in your circumstance caused you to no longer be eligible for your plan, or the plan terminated for everyone in your residential area. This section does not apply if you lost eligibility because you failed to pay premium or engaged in disruptive behavior; Or n You voluntarily terminated coverage but can demonstrate that: The organization substantially violated a material provision of its contract with you; or The organization or its representative materially misrepresented plan provisions in marketing the plan to you; or You meet such other exceptional conditions as the Secretary may provide.

4 MEDICARE SUPPLEMENT GUARANTEED ISSUE GUIDE texas 3 (continued) If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date. 4 Situation Description I. You enrolled in one of the following: n An eligible Medicare cost organization; n A health care prepayment plan; or n A Medicare SELECT policy And II. One of the following occurs: n You involuntarily lost coverage because: Your organization lost its certification; Your organization stopped providing the plan in your area; You moved, or a specified change in your circumstance caused you to no longer be eligible for your plan, or the plan terminated for everyone in your residential area. This section does not apply if you lost eligibility because you failed to pay premium or engaged in disruptive behavior; Or n You voluntarily terminated coverage but can demonstrate that: The organization substantially violated a material provision of its contract with you; or The organization or its representative materially misrepresented plan provisions in marketing the plan to you; or You meet such other exceptional conditions as the Secretary may provide. If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, the guaranteed issue period begins on the effective date of disenrollment and ends 63 days after the effective date of disenrollment. 2

5 MEDICARE SUPPLEMENT GUARANTEED ISSUE GUIDE texas 5 Situation Description You enrolled in a Medicare supplement policy, but your coverage ended involuntarily because of: n The issuer s insolvency or the non-issuer organization s bankruptcy; Or n Another involuntary coverage or enrollment termination. Your guaranteed issue period begins on the earlier of the date on which you receive notice of termination, notice of bankruptcy, or a similar notice, or the date on which your coverage was terminated and ends 63 days after coverage terminates. 6 Situation Description You enrolled in a Medicare supplement policy, and you voluntarily terminated your coverage because: n The insurer substantially violated a material provision of the policy; Or n The insurer or its representative materially misrepresented a policy provision to you. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date. 7 Situation Description You enrolled in a Medicare supplement policy. You terminated that Medicare supplement policy and enrolled, for the first time, in a Medicare Advantage Plan, an eligible Medicare cost program, a similar organization under a demonstration project, a Medicare SELECT policy, or a PACE provider, and terminated that enrollment within the first 12 months. Or if you were most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, the Medicare supplement policy described is the policy available from the same insurer but modified to remove outpatient prescription drug coverage, or at the election of the policyholder, a policy described below. If age 65 or older: The same Medicare supplement policy in which you were most recently enrolled, if available from the same insurer, or, if not available, Plan A, B, C, F, K, L or High Deductible F from any insurer If under age 65: The same Medicare supplement policy in which you were most recently enrolled, if available from the same insurer, or, if not available, Plan A, B, C, F, K, L or High Deductible F from any insurer 3

6 MEDICARE SUPPLEMENT GUARANTEED ISSUE GUIDE texas 7 (continued) If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date. 8 Situation Description Upon first becoming enrolled for benefits under Medicare Part B, at age 65 or older, you enroll in a Medicare Advantage Plan under Medicare Part C, or with a PACE provider under Section 1894 of the Social Security Act, and disenroll from the plan or program by not later than 12 months after the effective date of enrollment. If age 65 or older: All plans available from any insurer If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date. 9 Situation Description You enrolled in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, you enrolled under a Medicare supplement policy that covers outpatient prescription drugs, and you terminate enrollment in the Medicare supplement policy and submit evidence of enrollment in Medicare Part D, along with the application for a policy described below. If age 65 or older: A, B, C, F, K, L or High Deductible F from the same insurer, B, C, F, K, L or High Deductible F from the same insurer The guaranteed issue period begins on the date you receive notice pursuant to Section 1882(v)(2)(B) of the Social Security Act during the 60-day period immediately preceding the initial Part D enrollment period and ends 63 days after the effective date of your coverage under Medicare Part D. 10 Situation Description You lose eligibility for health benefits under Title XIX of the Social Security Act (Medicaid). The guaranteed issue period begins on the effective date of disenrollment and ends 63 days after the effective date of disenrollment. 4

7

8 IMS-GI-5 MSGITX06A SHTX TX 4/06