Current through Register Vol. 63, No. 9, September 1, 2024
(1) This section applies to Medicare Select
policies and certificates, as defined in this rule.
(2) No policy or certificate may be
advertised as a Medicare Select policy or certificate unless it meets the
requirements of this rule.
(3) For
the purposes of this rule:
(a) "Complaint"
means any dissatisfaction expressed by an individual concerning a Medicare
Select issuer or its network providers;
(b) "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;
(c) "Medicare Select issuer" means an issuer
offering, or seeking to offer, a Medicare Select policy or
certificate;
(d) "Medicare Select
policy" or "Medicare Select certificate" means respectively a Medicare
supplement policy or certificate that contains restricted network
provisions;
(e) "Network provider"
means a provider of health care, or a group of providers of health care, that
has entered into a written agreement with the issuer to provide benefits
insured under a Medicare Select policy;
(f) "Restricted network provision" means any
provision that conditions the payment of benefits, in whole or in part, on the
use of network providers; and
(g)
"Service area" means the geographic area approved by the Director of the
Department of Consumer and Business Services within which an issuer is
authorized to offer a Medicare Select policy.
(4) 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 OAR
836-052-0103 to
836-052-0194.
(5) 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.
(6) 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:
(a) 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; and
(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
subparagraph shall not apply to supplemental charges or coinsurance amounts as
stated in the Medicare Select policy or certificate.
(b) A statement or map providing a clear
description of the service area;
(c) A description of the grievance procedure
to be utilized;
(d) 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.
(e) A list and description, by specialty, of
the network providers;
(f) Copies
of the written information proposed to be used by the issuer to comply with
section (10) of this rule; and
(g)
Any other information requested by the Director.
(7) A Medicare Select issuer:
(a) Shall file any proposed changes to the
plan of operation, except for changes to the list of network providers, with
the Director prior to implementing the changes. Changes shall be considered
approved by the Director after 30 days unless specifically disapproved;
and
(b) Shall file with the
Director at least quarterly, an updated list of network providers.
(8) 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 a condition; and
(b) It is not reasonable to obtain services
through a network provider.
(9) 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.
(10) 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:
(a) 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.
(b) A
description (including address, phone number and hours of operation) of the
network providers, including primary care physicians, specialty physicians,
hospitals and other providers;
(c)
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;
(d) A description of coverage for emergency
and urgently needed care and other out-of-service area coverage;
(e) A description of limitations on referrals
to restricted network providers and to other providers;
(f) A description of the policyholder's
rights to purchase any other Medicare supplement policy or certificate
otherwise offered by the issuer; and
(g) A description of the Medicare Select
issuer's quality assurance program and grievance procedure.
(11) 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 section (10) of this rule and that the applicant
understands the restrictions of the Medicare Select policy or
certificate.
(12) 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 arbitration procedures. The
following apply to grievance procedures:
(a)
The grievance procedure shall be described in the policy and certificates and
in the outline of coverage;
(b) 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.
(c) 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.
(d) If a
grievance is found to be valid, corrective action shall be taken
promptly.
(e) All concerned parties
shall be notified about the results of a grievance.
(f) 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.
(13) 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.
(14)
(a) 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 that has comparable or lesser benefits and that 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.
(b) For the purposes of this
section, a Medicare supplement policy or certificate is 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 subparagraph, a significant benefit means
coverage for the Medicare Part A deductible, coverage for at-home recovery
services or coverage for Part B excess charges.
(15) 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 rule should be discontinued due to
either the failure of the Medicare Select Program to be reauthorized under law
or its substantial amendment.
(a) Each
Medicare Select issuer shall make available to each individual insurer under a
Medicare Select policy or certificate the opportunity to purchase any Medicare
supplement policy or certificate offered by the issuer that has comparable or
lesser benefits and that does not contain a restricted network provision. The
issuer shall make the policies and certificates available without requiring
evidence of insurability.
(b) For
the purposes of this subsection, a Medicare supplement policy or certificate is
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 subparagraph, a significant benefit
means coverage for the Medicare Part A deductible, coverage for at-home
recovery services or coverage for Part B excess charges.
(16) 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.
Stat. Auth.: ORS
743.683
Stats. Implemented: ORS
743.010 &
743.683
