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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyIdaho DOI Medicare Supplement Coverage | OpenPayer
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    CurrentIdaho Department of InsurancePolicy N/A

    026. Open Enrollment

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    Governs when issuers must offer Medicare supplement policies and certificates in Idaho without health-status discrimination, how preexisting-condition exclusions are handled, and the limited bases permitted for pricing discrimination.

    Policy Summary
    PayerIdaho Department of Insurance
    Policy026. Open Enrollment
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionIssuers shall not deny or condition issuance or effectiveness of an available Medicare supplement policy or certificate, or discriminate in pricing, based on an applicant's health status, claims experience, receipt of health care, or medical condition during the applicable open-enrollment period.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 monthsStandard open-enrollment period
    Oct 1–Dec 31, 2018Special under-65 application window
    Oct 1, 2018–Feb 1, 2019Special under-65 effective-date range
    2Permitted pricing criteria
    6 monthsCreditable coverage threshold

    Medicare Supplement Open-Enrollment Protections

    Qualifying Open-Enrollment Applications

    An application qualifies for the Medicare supplement open-enrollment protections when it is submitted before or during the applicable six-month period beginning on the qualifying Medicare Part B enrollment or notice date, as applicable.

    ONE of the following qualifying enrollment circumstances

    • ALL of the following

      • The individual is age 65 or older and enrolled in Medicare Part B.
      • The application is submitted prior to or during the six-month period beginning on the first day of the first month in which both conditions are met.

    • ALL of the following

      • The individual is under age 65 and enrolled in Medicare Part B because of disability or end-stage renal disease.
    Policy Summary
    PayerIdaho Department of Insurance
    Policy026. Open Enrollment
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionIssuers shall not deny or condition issuance or effectiveness of an available Medicare supplement policy or certificate, or discriminate in pricing, based on an applicant's health status, claims experience, receipt of health care, or medical condition during the applicable open-enrollment period.
    SourceLink
    On This Page
    Medicare Supplement Open-Enrollment ProtectionsEnrollment and Coverage TimeframesIssuer ResponsibilitiesEnrollment and Coverage Terms

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  1. The application is submitted prior to or during the six-month period beginning on the later of January 1, 2018, or the first day of the first month of Medicare Part B eligibility due to disability or end-stage renal disease.

  2. ALL of the following

    • The individual receives written notice of retroactive Medicare Part B enrollment resulting from a retroactive eligibility decision by the Social Security Administration.
    • The application is submitted prior to or during the six-month period beginning on the first day of the first month after the individual receives that written notice.

  3. ALL of the following

    • The individual is under age 65, eligible for Medicare Part B, and enrolled in Medicare Part B.
    • The application is submitted between October 1, 2018, and December 31, 2018, for an effective date between October 1, 2018, and February 1, 2019.

    4. Open-Enrollment Offer and Underwriting Protections

    For a qualifying application, the issuer must make available every Medicare supplement policy and certificate currently available for sale in Idaho and may not impose health-status-based issuance, effectiveness, or pricing restrictions.

    ALL of the following

    • The applicant qualifies under the applicable open-enrollment timing rules.
    • Each Medicare supplement policy and certificate currently available from the issuer is made available to the applicant without regard to age.
    • The issuer does not deny or condition issuance of an available Medicare supplement policy or certificate because of the applicant's health status, claims experience, receipt of health care, or medical condition.
    • The issuer does not deny or condition the effectiveness of an available Medicare supplement policy or certificate because of the applicant's health status, claims experience, receipt of health care, or medical condition.
    • The issuer does not discriminate in pricing because of the applicant's health status, claims experience, receipt of health care, or medical condition.

    Preexisting-Condition Rules

    Preexisting-condition treatment is determined as of the application date for an applicant who qualifies under the open-enrollment provisions and applies during the applicable enrollment period.

    ALL of the following

    • The applicant qualifies under the open-enrollment provisions and submits the application during the applicable open-enrollment period.

    • ONE of the following creditable-coverage rules applies

      • ALL of the following

        • As of the date of application, the applicant has had a continuous period of creditable coverage of at least six months.
        • The issuer does not exclude benefits based on a preexisting condition.

      • ALL of the following

        • As of the date of application, the applicant has had a continuous period of creditable coverage of less than six months.
        • Any preexisting-condition exclusion period is reduced by the aggregate period of creditable coverage applicable to the applicant as of the enrollment date.
        • The reduction is made in the manner specified by the Secretary of Health and Human Services.

      • ALL of the following

        • Neither of the preceding creditable-coverage rules applies, and no exception under Sections 027 or 038 applies.
        • The policy may exclude benefits during the first six months of coverage for a preexisting condition for which the policyholder or certificateholder received treatment or was otherwise diagnosed during the six months before coverage became effective.

    Permitted Pricing Criteria

    Pricing discrimination for a Medicare supplement policy or certificate issued under the open-enrollment provisions is prohibited except on the permitted criteria below.

    ALL of the following

    • The issuer does not discriminate in pricing based on any criterion other than the permitted criteria.

    • Pricing may be based on ONE of the following

      • Issue age.
      • Smoking or tobacco use.

    Enrollment and Coverage Timeframes

    Coding
    Standard open-enrollment durationSix months beginning with the applicable Medicare Part B eligibility event
    Coding
    Special under-65 application periodOctober 1, 2018 through December 31, 2018
    Coding
    Special under-65 effective-date rangeOctober 1, 2018 through February 1, 2019
    Coding
    Creditable coverage thresholdAt least six continuous months
    Coding
    Default preexisting-condition lookback and exclusion periodSix months before coverage becomes effective and the first six months of coverage

    Issuer Responsibilities

    Denial Risk

    Offer coverage during open enrollment

    During the applicable open-enrollment period, do not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in Idaho. Do not discriminate in pricing because of an applicant’s health status, claims experience, receipt of health care, or medical condition.

    Note

    Make all available policies accessible

    Make each Medicare supplement policy and certificate currently available from the issuer available to every applicant who qualifies for open-enrollment protection, without regard to age.

    Denial Risk

    Apply special under-65 enrollment protection

    For an individual under age 65 who is eligible for and enrolled in Medicare Part B, do not deny or condition issuance or effectiveness, or discriminate in pricing based on health status, claims experience, receipt of health care, or medication, when the application and effective date fall within the specified special periods.

    • Applications submitted: October 1, 2018 through December 31, 2018
    • Effective dates: October 1, 2018 through February 1, 2019
    Denial Risk

    Honor creditable coverage

    Do not exclude benefits for a preexisting condition when the applicant qualifies for open enrollment and, as of the application date, has had at least six months of continuous creditable coverage.

    Documentation Required

    Reduce preexisting-condition exclusion

    When an eligible applicant has less than six months of continuous creditable coverage as of the application date, reduce any preexisting-condition exclusion by the aggregate period of applicable creditable coverage.

    Billing Rule

    Limit permissible pricing factors

    Do not discriminate in the pricing of a Medicare supplement policy or certificate issued under the open-enrollment provision, except on the basis of issue age or smoking or tobacco use.

    • Permitted pricing factors: issue age
    • Permitted pricing factors: smoking or tobacco use

    Enrollment and Coverage Terms

    Definitions
    Initial Medicare Part B open-enrollment triggerThe first day of the first month in which an individual is age 65 or older and enrolled in Medicare Part B
    Definitions
    Under-65 Medicare Part B open-enrollment triggerJanuary 1, 2018, or the first day of the first month of Medicare Part B eligibility due to disability or end-stage renal disease, whichever is later, for an individual under age 65 enrolled in Medicare Part B
    Definitions
    Retroactive Medicare Part B open-enrollment triggerThe first day of the first month after an individual receives written notice of retroactive Medicare Part B enrollment resulting from a retroactive eligibility decision made by the Social Security Administration
    Definitions
    Creditable coverageCoverage that may be aggregated to determine whether a preexisting-condition exclusion must be prohibited or reduced; the rule applies the applicant's continuous coverage period as of the application or enrollment date