Chapter Ins 3

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.

Ins 3.39(30)(i)7. 7. A description of the Medicare select issuer’s quality assurance program and grievance procedure.

Ins 3.39(30)(i)8. 8. A designation: MEDICARE SELECT POLICY. This designation shall be immediately below and in the same type size as the designation required in sub. (5) (a) or (7) (b) 1.

Ins 3.39(30)(i)9. 9. The caption, except that the word “certificate” may be used instead of “policy,” if appropriate: “The Wisconsin Insurance Commissioner has set standards for Medicare select policies. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see ‘Wisconsin Guide to Health Insurance for People with Medicare,’ given to you when you applied for this policy. Do not buy this policy if you did not get this guide.”

Ins 3.39(30)(j) (j) 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 par. (i) and that the applicant understands the restrictions of the Medicare select policy or certificate.

Ins 3.39(30)(k) (k) A Medicare select issuer shall have and use procedures for hearing complaints and resolving written grievances from its subscribers for Wisconsin mandated benefits. The grievance procedures shall be aimed at mutual agreement for settlement, may include arbitration procedures, and may include all of the following:

Ins 3.39(30)(k)1. 1. The grievance procedure shall be described in the policy and certificate and in the outline of coverage.

Ins 3.39(30)(k)2. 2. 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.

Ins 3.39(30)(k)3. 3. 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.

Ins 3.39(30)(k)4. 4. If a grievance is found to be valid, corrective action shall be taken promptly.

Ins 3.39(30)(k)5. 5. All concerned parties shall be notified about the results of a grievance.

Ins 3.39(30)(k)6. 6. The issuer shall report no later than each March 31st 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 such grievances.

Ins 3.39(30)(L) (L) 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.

Ins 3.39(30)(m) (m)

Ins 3.39(30)(m)1. 1. 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 such policies or certificates available without requiring evidence of insurability after the Medicare select policy or certificate has been in force for 6 months.

Ins 3.39(30)(m)2. 2. For the purposes of subd. 1., a Medicare supplement policy or certificate shall 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 Medicare Part B excess charges.

Ins 3.39(30)(n) (n) Medicare select policies and certificates shall provide for continuation of coverage in the event the secretary determines that Medicare select policies and certificates issued pursuant to this section should be discontinued due to either the failure of the Medicare select federal program to be reauthorized under law or its substantial amendment.

Ins 3.39(30)(n)1. 1. 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 such policies and certificates available without requiring evidence of insurability.

Ins 3.39(30)(n)2. 2. For the purposes of subd. 1., a Medicare supplement policy or certificate shall 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 Medicare Part B excess charges.