Current through Reg. 50, No. 13; March 28, 2025
(a) This section applies to Medicare Select
policies, certificates, and plans of operation, as defined in this
section.
(b) No policy or
certificate may be advertised as a Medicare Select policy or certificate unless
it meets the requirements of this section.
(c) The following words and terms, when used
in this section, have the following meanings, unless the context indicates
otherwise. These words and terms must be defined and included in all Medicare
Select policies, certificates, and plans of operation.
(1) Complaint--Any dissatisfaction expressed
by an individual concerning a Medicare Select issuer or its network
providers.
(2) Emergency care--Bona
fide emergency services provided after the sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient severity, including severe
pain, such that the absence of immediate medical attention could reasonably be
expected to result in:
(A) placing the
patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
or
(C) serious dysfunction of any
bodily organ or part.
(3)
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.
(4) Medicare
Select issuer--An issuer offering, or seeking to offer, a Medicare Select
policy or certificate.
(5) Medicare
Select policy or Medicare Select certificate--A Medicare supplement policy or
certificate, respectively that contains restricted network
provisions.
(6) 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 covered
under a Medicare Select policy.
(7)
Nonnetwork provider--A provider of health care, or a group of providers of
health care, that has not entered into a written agreement with the issuer to
provide benefits covered under a Medicare Select policy.
(8) Restricted network provisions--Any
provision that conditions the payment of benefits, in whole or in part, on the
use of network providers.
(9)
Service area--The geographic area approved by the Commissioner as part of the
plan of operation or amended plan of operation, within which an issuer is
authorized to offer a Medicare Select policy.
(d) The Commissioner may authorize an issuer
to offer a Medicare Select policy or certificate, under this section and the
Omnibus Budget Reconciliation Act (OBRA) of 1990, §4358, if the
Commissioner finds that the issuer has satisfied all of the requirements of
this subchapter.
(e) A Medicare
Select issuer may not issue a Medicare Select policy or certificate in this
state until the Commissioner approves its plan of operation. A Medicare Select
issuer may not file a Medicare Select policy under Insurance Code Chapter 1701,
Subchapter B, until the Commissioner has approved its plan of
operation.
(f) A Medicare Select
issuer must file a proposed plan of operation with the department, the form and
content of which is subject to approval by the Commissioner. The plan of
operation must contain, at a minimum, the information in paragraphs (1) - (7)
of this subsection, and at the time of submission must have a form number
printed or typed on the lower left hand corner of the face page.
(1) The plan must contain evidence that all
covered services that are subject to restricted network provisions are
available and accessible through network providers, including a demonstration
of each of the items referenced in subparagraphs (A) - (E) of this paragraph.
(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 must reflect usual practice in the local area. Geographic
availability must reflect the usual travel times within the
community.
(B) The number of
network providers in the service area must be documented by credible statistics
to be 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) Written agreements with
network providers describing specific responsibilities must be
included.
(D) Emergency care
availability 24 hours per day and seven days a week must be
demonstrated.
(E) In the case of
covered services subject to a restricted-network provision and that 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 covered under a Medicare
Select policy or certificate. This subparagraph does not apply to supplemental
charges or coinsurance amounts as stated in the Medicare Select policy or
certificate.
(2) A clear
description of the service area must be provided by narrative statement or a
map.
(3) The grievance procedure
used must be described.
(4) The
quality assurance program must be described, 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) Network providers must be listed and
described by specialty.
(6) Copies
of the written information proposed to be used by the issuer to comply with
subsection (k) of this section must be provided.
(7) Any other information requested by the
Commissioner must be provided.
(g) A Medicare Select issuer must file any
proposed changes to the plan of operation, except for changes to the list of
network providers, with the Commissioner 60 days before implementing the
changes. Changes will be considered approved by the Commissioner after 30 days
unless specifically disapproved or unless the issuer requests an extension of
the 30-day period and the Commissioner grants the requested
extension.
(h) An updated list of
network providers must be filed with the Commissioner at least quarterly. If
there is no change to the list of network providers within a particular
calendar quarter, correspondence indicating no change from the prior reporting
period to the current reporting period must, at a minimum, be filed to meet the
reporting requirements of this subchapter.
(i) A Medicare Select policy or certificate
may not restrict payment for covered services provided by nonnetwork 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 the services through a network provider.
(j) A Medicare Select policy or
certificate must provide payment for full coverage under the policy for covered
services that are not available through network providers.
(k) A Medicare Select issuer must 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 must 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 other Medicare supplement policies or
certificates offered by the issuer and with 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; and
(7) a description of the Medicare Select
issuer's quality assurance program and grievance procedure.
(8) For hospital network providers, the
statement in 12-point bold-face type: "Only certain hospitals are network
providers under this policy. Check with your physician to determine if he or
she has admitting privileges at the network hospital. If he or she does not,
you may be required to use another physician at time of hospitalization or you
will be required to pay for all expenses." This statement must also be included
in the "invitation to contract" advertisement, as that term is defined in
§
21.113(b) of
this title (relating to Rules Pertaining Specifically to Accident and Health
Insurance Advertising and Health Maintenance Organization
Advertising).
(l) Before
the sale of a Medicare Select policy or certificate, a Medicare Select issuer
must obtain from the applicant a signed and dated form stating that the
applicant has received the information provided under subsection (k) of this
section and that the applicant understands the restrictions of the Medicare
Select policy or certificate.
(m) A
Medicare Select issuer must have and use procedures for hearing complaints and
resolving written grievances from the subscribers. Such procedures must be
aimed at mutual agreement for settlement and may include arbitration
procedures. If a binding arbitration procedure is included, the insured must
have made an informed choice to accept binding arbitration after having been
advised of the right to reject this method of dispute or claim resolution.
(1) The grievance procedure must be described
in the policy and certificates and in the outline of coverage. The in-hospital
grievance procedure must be outlined separately from the grievance procedures
for other treatments or services, or both. All grievances should be addressed
immediately and resolved as soon as possible. Grievances relating to ongoing
hospital treatment should be addressed immediately on receipt of any written or
oral grievance, and be resolved as quickly as possible in a manner that does
not interfere with, obstruct, or interrupt continued proper medical treatment
and care of the patient. The timetable for their resolution must comply with
all applicable provisions of the Insurance Code.
(2) At the time the policy or certificate is
issued, the issuer must provide detailed information to the policyholder
describing how a grievance may be registered with the issuer, both during the
period of care and after care.
(3)
Grievances must be considered in a timely manner and must 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 must be taken
promptly.
(5) All concerned parties
must be notified about the results of a grievance.
(6) The issuer must report no later than each
March 31st to the Commissioner regarding its grievance procedure. The report
must be in a format prescribed by the Commissioner, must contain the number of
grievances filed in the past year, and must include a summary of the subject,
nature, and resolution of the grievances.
(n) At the time of initial purchase, a
Medicare Select issuer must 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.
(o) At the request of an individual covered
under a Medicare Select policy or certificate, a Medicare Select issuer must
make available to the individual covered 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 must 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.
(p) 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.
(q)
Medicare Select policies and certificates must provide for continuation of
coverage in the event the Secretary determines that Medicare Select policies
and certificates issued under 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 must make available to each individual covered 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 must make these 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 purpose 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.
(r) A Medicare Select issuer must 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.
