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31 Pa. Code § 89.778. Open enrollment.

§ 89.778. Open enrollment.

 (a)  Prohibitions regarding denial, issuance and pricing of Medicare supplement policies or certificates.

   (1)  An issuer may not deny or condition the issuance or effectiveness of a Medicare supplement policy or certificate available for sale in this Commonwealth, nor discriminate in the pricing of a policy or certificate because of the health status, claims experience, receipt of health care or medical condition of an applicant in the case of an application for a policy or certificate that is submitted prior to or during the 6-month period beginning with the first day of the first month in which either of the following occurs:

     (i)   An individual enrolled for benefits under Medicare Part B.

     (ii)   An applicant who is retroactively enrolled in Medicare Part B due to a retroactive eligibility decision made by the Social Security Administration received notice of retroactive eligibility to enroll.

   (2)  Each Medicare supplement policy and certificate currently available from an issuer shall be made available to applicants who qualify under this subsection without regard to age. In the case of group policies, an issuer may condition issuance on whether an applicant is a member or is eligible for membership in the insured group.

 (b)  Exclusion of benefits based on a pre-existing condition prohibited. If an applicant qualifies under subsection (a) and submits an application during the time period referenced in subsection (a) and, as of the date of application, has had a continuous period of creditable coverage of at least 6 months, the issuer may not exclude benefits based on a preexisting condition.

 (c)  Reduction of the period of a pre-existing condition exclusion. If the applicant qualifies under subsection (a) and submits an application during the time period referenced in subsection (a) and, as of the date of application, has had a continuous period of creditable coverage that is less than 6 months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The HHS Secretary shall specify the manner of the reduction under this subsection.

 (d)  Prevention of the exclusion of benefits under a policy. Except as provided in subsections (b) and (c) and § §  89.789 and 89.790 (relating to prohibition against preexisting conditions, waiting periods, elimination periods and probationary periods in replacement policies or certificates; and guaranteed issue for eligible persons), subsection (a) will not be construed as preventing the exclusion of benefits under a policy, during the first 6 months, based on a preexisting condition for which the policyholder or certificateholder received treatment or was otherwise diagnosed during the 6 months before it became effective.


   The provisions of this §  89.778 amended under the Omnibus Budget Reconciliation Act (OBRA 90) of November 15, 1990, P. L. 101—508; sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P.S. § §  66, 186, 411 and 412); sections 356 and 616 of The Insurance Company Law of 1921 (40 P.S. § §  477b and 751); sections 5 and 9 of the Medicare Supplement Insurance Act (40 P.S. § §  3105 and 3109); and section 314 of the Accident and Health Filing Reform Act (40 P.S. §  3801.314).


   The provisions of this §  89.778 adopted July 24, 1992, effective July 25, 1992, 22 Pa.B. 3841; amended September 2, 1994, effective November 2, 1994, 24 Pa.B. 4467; amended May 10, 1996, effective May 11, 1996, 26 Pa.B. 2196; amended January 8, 1999, effective January 9, 1999, 29 Pa.B. 172; amended May 6, 2005, effective May 7, 2005, 35 Pa.B. 2729; amended September 7, 2018, effective September 8, 2018, 48 Pa.B. 5601. Immediately preceding text appears at serial pages (342843) to (342844).

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