Current through Register Vol. XLI, No. 38, September 20, 2024
8.1. This section shall apply to Medicare Select
policies and certificates, as defined in this section.
8.2. No policy or certificate may be advertised as
a Medicare Select policy or certificate unless it meets the requirements of this
section.
8.3. For the purposes of this
section:
8.3.a. "Complaint" means any
dissatisfaction expressed by an individual concerning a Medicare Select issuer or
its network providers.
8.3.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.
8.3.c. "Medicare
Select issuer" means an issuer offering, or seeking to offer, a Medicare Select
policy or certificate.
8.3.d. "Medicare
Select policy" or "Medicare Select certificate" mean respectively a Medicare
supplement policy or certificate that contains restricted network
provisions.
8.3.e. "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.
8.3.f.
"Restricted network provision" means any provision which conditions the payment of
benefits, in whole or in part, on the use of network providers.
8.3.g. "Service area" means the geographic area
approved by the Commissioner within which an issuer is authorized to offer a
Medicare Select policy.
8.4.
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 rule.
8.5. 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 Commissioner.
8.6.
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:
8.6.a.
Evidence that all covered services that are subject to restricted network provisions
are available and accessible through network providers, including a demonstration
that:
8.6.a.1. 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.
8.6.a.2. The number of network providers in the
service area is sufficient, with respect to current and expected policyholders,
either:
8.6.a.2.A. To deliver adequately all
services that are subject to a restricted network provision; or
8.6.a.2.B. To make appropriate
referrals.
8.6.a.3. There are
written agreements with network providers describing specific
responsibilities.
8.6.a.4. Emergency
care is available twenty-four (24) hours per day and seven (7) days per
week.
8.6.a.5. 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.
8.6.b. A statement or map providing a clear
description of the service area.
8.6.c.
A description of the grievance procedure to be utilized.
8.6.d. A description of the quality assurance
program, including:
8.6.d.1. The formal
organizational structure;
8.6.d.2. The
written criteria for selection, retention and removal of network providers;
and
8.6.d.3. The procedures for
evaluating quality of care provided by network providers, and the process to
initiate corrective action when warranted.
8.6.e. A list and description, by specialty, of
the network providers.
8.6.f. Copies of
the written information proposed to be used by the issuer to comply with subsection
8.10 of this section.
8.6.g. Any other
information requested by the Commissioner.
8.7. A Medicare Select issuer shall file:
8.7.a. Any proposed changes to the plan of
operation, except for changes to the list of network providers, with the
Commissioner prior to implementing the changes. The changes shall be considered
approved by the Commissioner after thirty (30) days unless specifically
disapproved.
8.7.b. An updated list of
network providers with the Commissioner at least quarterly.
8.8. A Medicare Select policy or certificate shall
not restrict payment for covered services provided by non-network providers if:
8.8.a. The services are for symptoms requiring
emergency care or are immediately required for an unforeseen illness, injury or a
condition; and
8.8.b. It is not
reasonable to obtain services through a network provider.
8.9. 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.
8.10. 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:
8.10.a. An outline
of coverage sufficient to permit the applicant to compare the coverage and premiums
of the Medicare Select policy or certificate with:
8.10.a.1. Other Medicare supplement policies or
certificates offered by the issuer; and
8.10.a.2. Other Medicare Select policies or
certificates.
8.10.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.
8.10.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.
8.10.d. A
description of coverage for emergency and urgently needed care and other out of
service area coverage.
8.10.e. A
description of limitations on referrals to restricted network providers and to other
providers.
8.10.f. A description of the
policyholder's right to purchase any other Medicare supplement policy or certificate
otherwise offered by the issuer.
8.10.g.
A description of the Medicare Select issuer's quality assurance program and
grievance procedure.
8.11.
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 subsection 8.10 of this
section and that the applicant understands the restrictions of the Medicare Select
policy or certificate.
8.12. 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.
8.12.a. The grievance procedure shall be described
in the policy and certificates and in the outline of coverage.
8.12.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.
8.12.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.
8.12.d. If a grievance is found to be valid,
corrective action shall be taken promptly.
8.12.e. All concerned parties shall be notified
about the results of a grievance.
8.12.f. 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 grievances.
8.13. 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.
8.14.
8.14.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 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 (6) months.
8.14.b. 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
subdivision, a significant benefit means coverage for the Medicare Part A
deductible, coverage for at-home recovery services or coverage for Part B excess
charges.
8.15. 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 section should be discontinued due
to either the failure of the Medicare Select Program to be reauthorized under law or
its substantial amendment.
8.15.a. 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.
8.15.b. 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 subdivision, a significant benefit means coverage for the
Medicare Part A deductible, coverage for at-home recovery services or coverage for
Part B excess charges.
8.16.
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.
