1358.10
. (a) (1) This section shall apply to Medicare Select
contracts, as defined in this section.
(2) A contract shall not be advertised as a Medicare Select
contract unless it meets the requirements of this section.
(b) For the purposes of this section:
(1) "Complaint" means any dissatisfaction expressed by an
individual concerning a Medicare Select issuer or its network
providers.
(2) "Grievance" means dissatisfaction expressed in writing by an
individual covered by a Medicare Select contract with the
administration, claims practices, or provision of services concerning
a Medicare Select issuer or its network providers.
(3) "Medicare Select issuer" means an issuer offering, or seeking
to offer, a Medicare Select contract.
(4) "Medicare Select contract" means a Medicare supplement
contract that contains restricted network provisions.
(5) "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 covered under a
Medicare Select contract. "Provider network" means a grouping of
network providers.
(6) "Restricted network provision" means any provision which
conditions the payment of benefits, in whole or in part, on the use
of network providers.
(7) "Service area" means the geographic area approved by the
director within which an issuer is authorized to offer a Medicare
Select contract.
(c) The director may authorize an issuer to offer a Medicare
Select contract pursuant to Section 4358 of the federal Omnibus
Budget Reconciliation Act (OBRA) of 1990 if the director finds that
the issuer's Medicare Select contracts are in compliance with this
chapter and if the director finds that the issuer has satisfied all
of the requirements of this section.
(d) A Medicare Select issuer shall not issue a Medicare Select
contract in this state until its plan of operation has been approved
by the director.
(e) 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:
(1) Evidence that all covered services that are subject to
restricted network provisions are available and accessible through
network providers, including a demonstration of all of the following:
(A) That services can be provided by network providers with
reasonable promptness with respect to geographic location, hours of
operation, and afterhour care. The hours of operation and
availability of afterhour care shall reflect usual practice in the
local area. Geographic availability shall reflect the usual travel
times within the community.
(B) That the number of network providers in the service area is
sufficient, with respect to current and expected enrollees, as to
either of the following:
(i) To deliver adequately all services that are subject to a
restricted network provision.
(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,
that 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
contract.
This subparagraph shall not apply to supplemental charges or
coinsurance amounts as stated in the Medicare Select contract.
(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 all
of the following:
(A) The formal organizational structure.
(B) The written criteria for selection, retention, and removal of
network providers.
(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 subdivision (i).
(7) Any other information requested by the director.
(f) (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 director prior to implementing the changes.
Changes shall be considered approved by the director after 30 days
unless specifically disapproved.
(2) An updated list of network providers shall be filed with the
director at least quarterly.
(g) A Medicare Select contract shall 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 condition.
(2) It is not reasonable to obtain services through a network
provider.
(h) A Medicare Select contract shall provide payment for full
coverage under the contract 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 contract 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 charges of the Medicare Select contract with
both of the following:
(A) Other Medicare supplement contracts offered by the issuer.
(B) Other Medicare Select contracts.
(2) A description, including address, telephone 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. The description shall inform the
applicant that expenses incurred when using out-of-network providers
are excluded from the out-of-pocket annual limit in benefit plans K
and L, unless the contract provides otherwise.
(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 enrollee's rights to purchase any other
Medicare supplement contract 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 contract, 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 subdivision (i) and that the applicant understands the
restrictions of the Medicare Select contract.
(k) A Medicare Select issuer shall have and use procedures for
hearing complaints and resolving written grievances from the
enrollees. The procedures shall be aimed at mutual agreement for
settlement and may include arbitration procedures.
(1) The grievance procedure shall be described in the contract and
in the outline of coverage.
(2) At the time the contract is issued, the issuer shall provide
detailed information to the enrollee 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 decisionmakers 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 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 those grievances.
(l) At the time of initial purchase, a Medicare Select issuer
shall make available to each applicant for a Medicare Select contract
the opportunity to purchase any Medicare supplement contract
otherwise offered by the issuer.
(m) (1) At the request of an enrollee under a Medicare Select
contract, a Medicare Select issuer shall make available to the
enrollee the opportunity to purchase a Medicare supplement contract
offered by the issuer that has comparable or lesser benefits and that
does not contain a restricted network provision, if a Medicare
supplement contract of that nature is offered by the issuer. The
issuer shall make the contracts available without regard to the
health status of the enrollee and without requiring evidence of
insurability after the Medicare Select contract has been in force for
six months.
(2) For the purposes of this subdivision, a Medicare supplement
contract will be considered to have comparable or lesser benefits
unless it contains one or more significant benefits not included in
the Medicare Select contract 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.
(n) Medicare Select contracts shall provide for continuation of
coverage in the event the secretary determines that Medicare Select
contracts 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
enrollee covered by a Medicare Select contract the opportunity to
purchase any Medicare supplement contract offered by the issuer that
has comparable or lesser benefits and that does not contain a
restricted provider network provision, if a Medicare supplement
contract of that nature is offered by the issuer. The issuer shall
make the contracts available without regard to the health status of
the enrollee and without requiring evidence of insurability after the
Medicare Select contract has been in force for six months.
(2) For the purposes of this subdivision, a Medicare supplement
contract will be considered to have comparable or lesser benefits
unless it contains one or more significant benefits not included in
the Medicare Select contract 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.
(o) An issuer offering Medicare Select contracts 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. An issuer
shall not issue a Medicare Select contract in this state until the
contract has been approved by the director.