Chapter Ins 3

Ins 3.39(23)(b) (b) Agents shall list, in a supplementary form signed by the agent and submitted to the issuer with each application for Medicare supplement coverage, any other health insurance policies they have sold to the applicant as follows:

Ins 3.39(23)(b)1. 1. Any policy sold which is still in force.

Ins 3.39(23)(b)2. 2. Any policy sold in the past 5 years which is no longer in force.

Ins 3.39(23)(bL) (bL) In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant, and acknowledged by the issuer, shall be returned to the applicant by the issuer upon delivery of the policy.

Ins 3.39(23)(c) (c) Upon determining that a sale will involve replacement, an issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy, a notice regarding the replacement of Medicare supplement coverage in no less than 12 point type. One copy of the notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the solicitation of the policy the notice regarding replacement of Medicare supplement coverage.

Ins 3.39(23)(d) (d) The notice required by par. (c) for an issuer shall be provided in substantially the form as shown in Appendix 7.

Ins 3.39(23)(e) (e) If the application contains questions regarding health and tobacco usage, include a statement that health questions should not be answered if the applicant is in the open-enrollment period described in sub. (3r), or during a guaranteed issue period under sub. (34).

Ins 3.39(24) (24) Standards for marketing.

Ins 3.39(24)(a) (a) Every issuer marketing Medicare supplement insurance coverage in this state, directly or through its producers, shall do all of the following:

Ins 3.39(24)(a)1. 1. Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate.

Ins 3.39(24)(a)2. 2. Establish marketing procedures to assure excessive insurance is not sold or issued.

Ins 3.39(24)(a)3. 3. Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or insured for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of any such insurance.

Ins 3.39(24)(a)4. 4. Display prominently by type-size, stamp or other appropriate means, on the first page of the policy the following: “Notice to buyer: This policy may not cover all of your medical expenses.”

Ins 3.39(24)(b) (b) Every issuer marketing Medicare supplement insurance shall establish auditable procedures for verifying compliance with par. (a).

Ins 3.39(24)(c) (c) In addition, the following acts and practices are prohibited:

Ins 3.39(24)(c)1. 1. ‘Twisting.’ Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or issuers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another issuer.

Ins 3.39(24)(c)2. 2. ‘High pressure tactics.’ Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

Ins 3.39(24)(c)3. 3. ‘Cold lead advertising.’ Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose is solicitation of the purchase of insurance and that contact will be made by an agent or issuer.

Ins 3.39(24)(e) (e) In regards to any transaction involving a Medicare supplement policy, no person subject to regulation under chs. 600 to 655, Stats., may knowingly prevent or dissuade or attempt to prevent or dissuade, any person from:

Ins 3.39(24)(e)1. 1. Filing a complaint with the office of the commissioner of insurance; or

Ins 3.39(24)(e)2. 2. Cooperating with the office of the commissioner of insurance in any investigation; or

Ins 3.39(24)(e)3. 3. Attending or giving testimony at any proceeding authorized by law.

Ins 3.39(24)(f) (f) If an insured exercises the right to return a policy during the free-look period, the issuer shall mail the entire premium refund directly to the person who paid the premium.

Ins 3.39(24)(g) (g) The terms “Medicare Supplement,” “Medigap,” “Medicare Wrap Around,” and “Medicare Advantage Supplement” and words of similar import may not be used in any materials including advertisements as defined in s. Ins 3.27 (5) (a), unless the policy or certificate is issued in compliance with this section.

Ins 3.39(25) (25) Appropriateness of recommended purchase and excessive insurance.

Ins 3.39(25)(a) (a) In recommending the purchase or replacement of any Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.

Ins 3.39(25)(b) (b) Any sale of Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy that will provide an individual more than one Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy is prohibited.

Ins 3.39(25)(c) (c) An agent shall forward each application taken for a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy to the issuer within 7 calendar days after taking the application. An agent shall mail the portion of any premium collected due the issuer to the issuer within 7 days after receiving the premium.

Ins 3.39(25)(d) (d) An agent may not take and an issuer may not accept an application from an insured more than 3 months prior to the insured becoming eligible.

Ins 3.39(26) (26) Reporting of multiple policies.

Ins 3.39(26)(a) (a) On or before March 1 of each year, every issuer providing Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy in this state shall report the following information for every individual resident of this state for which the insurer has in force more than one Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy:

Ins 3.39(26)(a)1. 1. Policy and certificate number.

Ins 3.39(26)(a)2. 2. Date of issuance.

Ins 3.39(26)(a)3. 3. Type of policy.

Ins 3.39(26)(a)4. 4. Company name and national association of insurance commissioners number.

Ins 3.39(26)(a)5. 5. Name and contact information of person completing the form.

Ins 3.39(26)(a)6. 6. Other information as requested by the commissioner.

Ins 3.39(26)(b) (b) The items in par. (a) must be grouped by individual policyholder or certificateholder and listed on a form made available by the commissioner. Issuers shall submit the information in the manner compliant with the commissioner’s instructions on or before March 1 of each year.

Ins 3.39(27) (27) Waiting periods in replacement policies or certificates. If a Medicare supplement policy or certificate, Medicare select policy or certificate, or Medicare cost policy replaces another Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy that has been in effect for at least 6 months, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare supplement, Medicare select, or new Medicare cost policy for similar benefits to the extent such periods were satisfied under the original policy or certificate.

Ins 3.39(28) (28) Group certificate continuation and conversion requirements.

Ins 3.39(28)(a) (a) If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in par. (c), the issuer shall offer certificateholders at least the following choices:

Ins 3.39(28)(a)1. 1. An individual Medicare supplement policy which provides for continuation of the benefits contained in the group policy; and

Ins 3.39(28)(a)2. 2. At the option of the group issued a certificate, offer the certificateholder continuations of coverage under the group certificate for the time specified in s. 632.897, Stats.

Ins 3.39(28)(b) (b) If membership in a group is terminated, the issuer shall:

Ins 3.39(28)(b)1. 1. Offer the certificateholder such conversion opportunities as are described in par. (a); or

Ins 3.39(28)(b)2. 2. At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy for the time specified in s. 632.897, Stats.

Ins 3.39(28)(c) (c) If a group Medicare supplement certificate is replaced by another group Medicare supplement certificate, the issuer of the replacement certificate shall offer coverage to all persons covered under the old group certificate on its date of termination. Coverage under the new group certificate shall not result in any exclusion for preexisting conditions that would have been covered under the group certificate being replaced.

Ins 3.39(29) (29) Filing and approval requirements.

Ins 3.39(29)(a) (a) An issuer shall not deliver or issue for delivery a Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy to a resident of this state unless the policy form or certificate form has been filed with and approved by the commissioner in accordance with filing requirements and procedures prescribed by the commissioner.

Ins 3.39(29)(b) (b) An issuer shall file with the commissioner any new riders or amendments to policy or certificate forms to delete coverage for outpatient prescription drugs as required by MMA.

Ins 3.39(29)(b)1. 1. Beginning January 1, 2007, issuers shall replace existing amended policies and riders for current and renewing insureds with filed and approved policy or certificate forms that are compliant with the MMA. An issuer shall, beginning January 1, 2007, use filed and approved policy or certificate forms that are compliant with the MMA for all new business.

Ins 3.39(30) (30) Medicare select policies and certificates.

Ins 3.39(30)(a) (a)

Ins 3.39(30)(a)1. 1. This subsection shall apply only to Medicare select policies and certificates issued to persons first eligible for Medicare prior to June 1, 2010. This subsection does not apply to Medicare supplement policies and certificates or Medicare cost policies.

Ins 3.39(30)(a)2. 2. No Medicare select policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requires of this subsection.

Ins 3.39(30)(c) (c) The commissioner may authorize an issuer to offer a Medicare select policy or certificate, pursuant to this subsection and section 4358 of the Omnibus Budget Reconciliation Act of 1990, if the commissioner finds that the issuer has satisfied all of the requirements of this subsection.

Ins 3.39(30)(d) (d) 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.

Ins 3.39(30)(e) (e) 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:

Ins 3.39(30)(e)1. 1. Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

Ins 3.39(30)(e)1.a. a. Such 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 medical travel times within the community.

Ins 3.39(30)(e)1.b. b. The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either to deliver adequately all services that are subject to a restricted network provision or to make appropriate referrals.

Ins 3.39(30)(e)1.c. c. There are written agreements with network providers describing specific responsibilities.

Ins 3.39(30)(e)1.d. d. Emergency care is available 24 hours per day and 7 days per week.

Ins 3.39(30)(e)1.e. 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 such 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.

Ins 3.39(30)(e)2. 2. A statement or map providing a clear description of the service area.

Ins 3.39(30)(e)3. 3. A description of the grievance procedure to be utilized.

Ins 3.39(30)(e)4. 4. A description of the quality assurance program, including:

Ins 3.39(30)(e)4.a. a. The formal organizational structure;

Ins 3.39(30)(e)4.b. b. The written criteria for selection, retention and removal of network providers; and

Ins 3.39(30)(e)4.c. c. The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.

Ins 3.39(30)(e)5. 5. A list and description, by specialty, of the network providers.

Ins 3.39(30)(e)6. 6. Copies of the written information proposed to be used by the issuer to comply with par. (i).

Ins 3.39(30)(e)7. 7. Any other information requested by the commissioner.

Ins 3.39(30)(f) (f)

Ins 3.39(30)(f)1. 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 commissioner prior to implementing such changes. Such changes shall be considered approved by the commissioner after 30 days unless specifically disapproved.

Ins 3.39(30)(f)2. 2. An updated list of network providers shall be filed with the commissioner at least quarterly.

Ins 3.39(30)(g) (g) A Medicare select policy or certificate shall not restrict payment for covered services provided by non-network providers if:

Ins 3.39(30)(g)1. 1. The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and

Ins 3.39(30)(g)2. 2. It is not reasonable to obtain such services through a network provider.

Ins 3.39(30)(h) (h) 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.

Ins 3.39(30)(i) (i) 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:

Ins 3.39(30)(i)1. 1. An outline of coverage in substantially the same format as Appendix 1 sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate with:

Ins 3.39(30)(i)1.a. a. Other Medicare supplement policies or certificates offered by the issuer; and

Ins 3.39(30)(i)1.b. b. Other Medicare select policies or certificates.

Ins 3.39(30)(i)2. 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.

Ins 3.39(30)(i)3. 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 the Medicare Select 50% and 25% Coverage Cost-Sharing plans offered by the Medicare select issuer pursuant to pars. (q) and (r).

Ins 3.39(30)(i)4. 4. A description of coverage for emergency and urgently needed care and other out of service area coverage.

Ins 3.39(30)(i)5. 5. A description of limitations on referrals to restricted network providers and to other providers.

Ins 3.39(30)(i)6. 6. A description of the policyholder’s or certificateholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.