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OAC 365:10


disenrollment or Medicare Part D enrollment with the application for a Medicare supplement policy.

    • (2)

      With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of a Medicare supplement policy described in subsection (c) that is offered and is available for issuance to new enrollees by the issuer, shall not discriminate in the pricing of such a Medicare supplement policy 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 Medicare supplement policy.

  • (b)

    Eligible Persons. An eligible person is an individual described in any of the following



Employee welfare benefit plan. The individual 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 or substantially all supplemental health benefits to the individual. (2) Medicare Advantage. The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under part C of Medicare, and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the Social Security Act, and there are circumstances similar to those described below that would permit discontinuance of the individual’s enrollment with such provider if such

individual were enrolled in a Medicare Advantage plan:

  • (A)

    The certification of the organization or has been terminated;

  • (B)

    The organization has terminated or otherwise discontinued providing the plan

in the area in which the individual resides;


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;


The individual demonstrates, in accordance with guidelines established by the

Secretary, that:

    • (i)

      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

    • (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 individual; or

  • (E)

    The individual meets such other exceptional conditions as the Secretary may


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