Current through Register Vol. 50, No. 9, September 20, 2024
A.
1. This
Section shall apply to Medicare select policies and certificates, as defined in
this Section.
2. 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:
Complaint-any dissatisfaction expressed by
an individual concerning a Medicare select issuer or its network
providers.
Grievance-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.
Medicare Select Issuer-an issuer offering,
or seeking to offer, a Medicare select policy or certificate.
Medicare Select Policy or Medicare
Select Certificate-respectively a Medicare supplement policy or
certificate that contains restricted network provisions.
Network Provider-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.
Primary Residence-the policyholder's
residence as listed on the policyholder's application for insurance or any
other residence given by the policyholder to the issuer subsequent to the
application date for the purpose of changing the policyholder's
residence.
Restricted Network Provision-any provision,
which conditions the payment of benefits, in whole or in part, on the use of
network providers.
Service Area-the 50 mile geographical radius
or area approved by the commissioner within which a policyholder's primary
residence must be located in relation to an issuer's network provider and
within which an issuer is authorized to offer a Medicare select policy.
C. The commissioner 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
commissioner finds that the issuer has satisfied all of the requirements of
this regulation.
D.
1. 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 commissioner.
2. After September 1, 2006, issuers shall be
prohibited from selling new Medicare select policies to those persons whose
primary residence is located outside of the issuer's service area.
3. Medicare select issuers shall provide
notice, within 30 days after the publication of this rule, to all Medicare
select policyholders that:
a. if the
policyholder changes his primary residence to a residence located outside of
the issuer's service area:
i. the policyholder
shall have the right to convert his current Medicare select policy to a
Medicare supplement policy; and
ii.
the issuer cannot cancel the policyholder's Medicare select policy on the basis
that the policyholder did not convert his Medicare select policy to a Medicare
supplement policy;
iii. the terms
of the policy shall govern with respect to benefits available to the
policyholder after moving his primary residence outside of the service
area;
b. the
policyholder may incur a penalty in the form of some or all of the benefits
under the Medicare select policy not being payable if the policyholder requires
medical services outside of the service area after the policyholder changes his
primary residence to a residence located outside of the service area without
converting his policy to a Medicare supplement policy.
4. After October 1, 2006, upon the Medicare
select issuer obtaining actual knowledge that a policyholder has changed his
primary residence to a residence located outside of the service area, the
issuer shall mail to the policyholder the same notice, or one substantially
similar, required in the above Paragraph D.3. The issuer shall mail this notice
within 30 days after obtaining actual knowledge of the policyholder's change of
residence.
E. A Medicare
select issuer shall file a proposed plan of operation with the commissioner in
a format prescribed by the commissioner. 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. 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 and/or contracts with network providers describing specific
responsibilities;
d. emergency care
is available 24 hours per day and seven 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 and/or contracts with network providers
prohibiting the providers from billing or otherwise seeking reimbursement from
or recourse against any individual insured under a Medicare select policy or
certificate. This Paragraph 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 detailed description and the method
utilized by the Medicare select insurer of informing policyholders of the
plan's service and features, including but not limited to, the plan's grievance
procedures, its process for choosing and changing in-network providers, and the
procedures for providing and approving emergency and specialty care;
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, including the Medicare select issuer's procedures for
making referrals within and outside its network;
6. copies of the written information proposed
to be used by the issuer to comply with
§525 I;
7. the listing of hospitals and the number of
hospital beds available for the policyholders at an in-network
hospital;
8. any other information
requested by the commissioner.
F.
1. A
Medicare select issuer shall file for approval any proposed changes, material
or otherwise, to the plan of operation or contracts, except for changes to the
listing of network providers, with the commissioner prior to implementation of
any changes. The removal or withdrawal of any hospital from a Medicare select
issuer's network shall constitute a material change to the plan of operation or
contract and shall be filed with the commissioner in accordance with the
provisions of this Subsection. Changes shall be considered approved by the
commissioner after 30 days unless specifically disapproved.
2. All filings of proposed changes, material
or otherwise, to the plan of operation or contracts as required by this Section
shall include, but not be limited to the following:
a. the listing of hospitals and the number of
hospital beds available for the policyholders at an in-network
hospital;
b. any other information
requested by the commissioner.
3. An updated list of network providers shall
be filed with the commissioner 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 a 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 rights 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 of this Section 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. The procedures shall be aimed at
mutual agreement for settlement and may include non-binding 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 appropriate
decision-makers who have authority to fully 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 31 to the commissioner regarding its grievance procedure. The report
shall be in a format prescribed by the commissioner 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.
1. 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 six
months.
2. For the purposes of this
Subsection, 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 Paragraph, 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 the policies and certificates available without requiring evidence
of insurability.
2. For the
purposes of this Subsection, 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 Paragraph, 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
reasonable 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.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:1111 (re-designated from LSA-R.S. 22:224 pursuant
to Acts 2008, No. 415, effective January 1, 2009) and
42 U.S.C.
1395 et seq.
