Current through Register Vol. 35, No. 18, September 24, 2024
A.
Applicability.
(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.
Authorization. The
superintendent may authorize a Medicare Select 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
superintendent finds that the issuer has satisfied all of the requirements of
this regulation.
C.
Approval
required. 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 superintendent.
D.
Filing of plan of operation. A Medicare Select issuer shall file a
proposed plan of operation with the superintendent in accordance with the
requirements set forth in 13.10.30 NMAC, "Network Access Plans, Network
Adequacy and Provider Directories." 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 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 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 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 of this section.
(7)
Any other information requested by the superintendent.
E.
Plan updates.
(1) A Medicare Select issuer shall file any
proposed changes to the plan of operation, except for changes to the list of
network providers, with the superintendent prior to implementing the changes.
Changes shall be considered approved by the superintendent after 30 days unless
specifically disapproved.
(2) An
updated list of network providers shall be filed with the superintendent at
least quarterly.
F.
Payment of non-network providers.
(1) A Medicare Select policy or certificate
shall not restrict payment for covered services provided by non- network
providers if:
(a) the services are for
symptoms requiring emergency care or are immediately required for an unforeseen
illness, injury or condition; and
(b) it is not reasonable to obtain services
through a network provider.
(2) A Medicare Select policy or certificate
shall not restrict payment for covered services that are not available through
network providers.
G.
Required disclosures. 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 insured's rights to
purchase any other Medicare Supplement policy or certificate otherwise offered
by the issuer; and
(7) a
description of the Medicare Select issuer's quality assurance program and
grievance procedure.
H.
Signed acknowledgment. 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.
I.
Complaint and
grievance procedure. A Medicare Select issuer shall have and use
procedures for hearing complaints and resolving written grievances from the
insureds. The 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 insured 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 1 to the superintendent regarding its grievance procedure. The
report shall be in a format prescribed by the superintendent and shall contain
the number of grievances filed in the past year and a summary of the subject,
nature and resolution of such grievances.
J.
Alternate policies. 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.
K.
Offering
non-network policies.
(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 the 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 Medicare Part B excess charges.
L.
Continuation of coverage.
Medicare select policies and certificates shall provide for continuation
of coverage in the event the secretary 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.
M.
Data calls. 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.
