Current through Register Vol. 48, No. 12, March 22, 2024
a) This Section shall apply to Medicare
Select policies and certificates, as defined in this Section. No policy or
certificate may be advertised as a Medicare Select policy or certificate unless
it meets the requirements of this Section.
b) For the purposes of this Section:
1) "Complaint" means any dissatisfaction
expressed by an individual concerning a Medicare Select issuer or its network
providers.
2) "Grievance" means
dissatisfaction expressed in writing by an individual insured under a Medicare
Select policy or certificate with the administration, claims practices, or
provision of services concerning a Medicare Select issuer or its network
providers.
3) "Medicare Select
Issuer" means an issuer offering, or seeking to offer, a Medicare Select policy
or certificate.
4) "Medicare Select
Policy" or "Medicare Select Certificate" means respectively a Medicare
supplement policy or certificate that contains restricted network
provisions.
5) "Network Provider"
means a provider of health care, or a group of providers of health care, which
has entered into a written agreement with the issuer to provide benefits
insured under a Medicare Select policy.
6) "Restricted Network Provision" means any
provision which conditions the payment of benefits, in whole or in part, on the
use of network providers.
7)
"Service Area" means the geographic area approved by the Director within which
an issuer is authorized to offer a Medicare Select policy.
c) The Director may authorize an issuer to
offer a Medicare Select policy or certificate, pursuant to this Section and
Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the
Director finds that the issuer has satisfied all of the requirements of this
Part.
d) A Medicare Select issuer
shall not issue a Medicare Select policy or certificate in this State until its
plan of operation has been approved by the Director.
e) A Medicare Select issuer shall file a
proposed plan of operation with the Director in a format prescribed by the
Director. The plan of operation shall contain at least the following
information:
1) Evidence that all covered
services that are subject to restricted network provisions are available and
accessible through network providers, including a demonstration that:
A) Such services can be provided by network
providers with reasonable promptness with respect to geographic location, hours
of operation and after-hour care. The hours of operation and availability of
after-hour care shall reflect usual practice in the local area. Geographic
availability shall reflect the usual travel times within the
community.
B) The number of network
providers in the service area is sufficient, with respect to current and
expected policyholders, either:
i) To deliver
adequately all services that are subject to a restricted network provision;
or
ii) To make appropriate
referrals.
C) There are
written agreements with network providers describing specific
responsibilities.
D) Emergency care
is available 24 hours per day and 7 days per week.
E) In the case of covered services that are
subject to a restricted network provision and are provided on a prepaid basis,
there are written agreements with network providers prohibiting such providers
from billing or otherwise seeking reimbursement from or recourse against any
individual insured under a Medicare Select policy or certificate. This
subsection shall not apply to supplemental charges or coinsurance amounts as
stated in the Medicare Select policy or certificate.
2) A statement or map providing a clear
description of the service area.
3)
A description of the grievance procedure to be utilized.
4) A description of the quality assurance
program, including:
A) The formal
organizational structure;
B) The
written criteria for selection, retention and removal of network providers;
and
C) The procedures for
evaluating quality of care provided by network providers, and the process to
initiate corrective action when warranted.
5) A list and description, by specialty, of
the network providers.
6) Copies of
the written information proposed to be used by the issuer to comply with
subsection (i).
7) Any other
information requested by the Director.
f) A Medicare Select issuer shall:
1) File any proposed changes to the plan of
operation, except for changes to the list of network providers, with the
Director prior to implementing such changes. Such changes shall be considered
approved by the Director after 30 days unless specifically
disapproved.
2) An updated list of
network providers shall be filed with the Director at least
quarterly.
g) A Medicare
Select policy or certificate shall not restrict payment for covered services
provided by non-network providers if:
1) The
services are for symptoms requiring emergency care or are immediately required
for an unforeseen illness, injury or condition; and
2) It is not reasonable to obtain such
services through a network provider.
h) A Medicare Select policy or certificate
shall provide payment for full coverage under the policy for covered services
that are not available through network providers.
i) A Medicare Select issuer shall make full
and fair disclosure in writing of the provisions, restrictions, and limitations
of the Medicare Select policy or certificate to each applicant. This disclosure
shall include at least the following:
1) An
outline of coverage sufficient to permit the applicant to compare the coverage
and premiums of the Medicare Select policy or certificate with:
A) Other Medicare supplement policies or
certificates offered by the issuer; and
B) Other Medicare Select policies or
certificates.
2) A
description (including address, phone number and hours of operation) of the
network providers, including primary care physicians, specialty physicians,
hospitals, and other providers.
3)
A description of the restricted network provisions, including payments for
coinsurance and deductibles when providers other than network providers are
utilized. Except to the extent specified in the policy or certificate, expenses
incurred when using out-of-network providers do not count toward the
out-of-pocket annual limit contained in Plans K and L.
4) A description of coverage for emergency
and urgently needed care and other out of service area coverage.
5) A description of limitations on referrals
to restricted network providers and to other providers.
6) A description of the policyholder's right
to purchase any other Medicare supplement policy or certificate otherwise
offered by the issuer.
7) A
description of the Medicare Select issuer's quality assurance program and
grievance procedure.
j)
Prior to the sale of a Medicare Select policy or certificate, a Medicare Select
issuer shall obtain from the applicant a signed and dated form stating that the
applicant has received the information provided pursuant to subsection (i) and
that the applicant understands the restrictions of the Medicare Select policy
or certificate.
k) A Medicare
Select issuer shall have and use procedures for hearing complaints and
resolving written grievances from the subscribers. Such procedures shall be
aimed at mutual agreement for settlement and may include arbitration
procedures.
1) The grievance procedure shall
be described in the policy and certificates and in the outline of
coverage.
2) At the time the policy
or certificate is issued, the issuer shall provide detailed information to the
policyholder describing how a grievance may be registered with the
issuer.
3) Grievances shall be
considered in a timely manner and shall be transmitted to decision makers who
have authority to investigate the issue and take corrective action.
4) If a grievance is found to be valid,
corrective action shall be taken promptly.
5) All concerned parties shall be notified
about the results of a grievance.
6) The issuer shall report no later than each
March 31st to the Director regarding its grievance
procedure. The report shall be in a format prescribed by the Director and shall
contain the number of grievances filed in the past year and a summary of the
subject, nature and resolution of such grievances.
l) At the time of initial purchase, a
Medicare Select issuer shall make available to each applicant for a Medicare
Select policy or certificate the opportunity to purchase any Medicare
supplement policy or certificate otherwise offered by the issuer.
m) At the request of an individual insured
under a Medicare Select policy or certificate, a Medicare Select issuer shall
make available to the individual insured the opportunity to purchase a Medicare
supplement policy or certificate offered by the issuer which has comparable or
lesser benefits and which does not contain a restricted network provision. The
issuer shall make such policies or certificates available without requiring
evidence of insurability after the Medicare Select policy or certificate has
been in force for 6 months.
1) For the
purposes of this subsection (m), a Medicare supplement policy or certificate
will be considered to have "comparable or lesser" benefits unless it contains
one or more significant benefits not included in the Medicare Select policy or
certificate being replaced.
2) For
the purposes of subsection (m)(1), a "significant benefit" means coverage for
the Medicare Part A deductible, coverage for at-home recovery services or
coverage for Part B excess charges.
n) Medicare Select policies and certificates
shall provide for continuation of coverage in the event the Secretary of Health
and Human Services determines that Medicare Select policies and certificates
issued pursuant to this Section should be discontinued due to either the
failure of the Medicare Select Program to be reauthorized under law or its
substantial amendment.
1) Each Medicare Select
issuer shall make available to each individual insured under a Medicare Select
policy or certificate the opportunity to purchase any Medicare supplement
policy or certificate offered by the issuer which has comparable or lesser
benefits and which does not contain a restricted network provision. The issuer
shall make such policies and certificates available without requiring evidence
of insurability.
2) For the
purposes of this subsection (n), a Medicare supplement policy or certificate
will be considered to have "comparable or lesser" benefits unless it contains
one or more significant benefits not included in the Medicare Select policy or
certificate being replaced. For the purposes of this subsection (n)(2), a
"significant benefit" means coverage for the Medicare Part A deductible,
coverage for at-home recovery services or coverage for Part B excess
charges.
o) A Medicare
Select issuer shall comply with requests for data made by State or federal
agencies, including the United States Department of Health and Human Services,
for the purpose of evaluating the Medicare Select Program.