Chapter Ins 3

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

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

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

Ins 3.39(30t)(e)4.c. c. The procedures for evaluating quality of care provided by network providers.

Ins 3.39(30t)(e)4.d. d. The process to initiate corrective action when warranted.

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

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

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

Ins 3.39(30t)(f) (f)

Ins 3.39(30t)(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 after filing unless specifically disapproved.

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

Ins 3.39(30t)(g) (g) A Medicare select policy or certificate may not restrict payment for covered services provided by non-network providers if all of the following occur:

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

Ins 3.39(30t)(g)2. 2. It is not reasonable to obtain services described in subd. 1. through a network provider.

Ins 3.39(30t)(h) (h) A Medicare select policy or certificate shall provide payment for full coverage under the policy or certificate for covered services that are not available through network providers.

Ins 3.39(30t)(i) (i) A Medicare select issuer shall make full and fair disclosure in writing of the provisions, coinsurance, or copayments, restrictions, and limitations of the Medicare select policy or certificate to each applicant. This disclosure shall include at least the following:

Ins 3.39(30t)(i)1. 1. An outline of coverage in substantially the same format as Appendices 2t and 5t sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate to the following:

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

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

Ins 3.39(30t)(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(30t)(i)3. 3. A description of the restricted network provisions, including payments for copayments or 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 under pars. (r) and (s).

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

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

Ins 3.39(30t)(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(30t)(i)7. 7. A description of the Medicare select issuer’s quality assurance program and grievance procedure.

Ins 3.39(30t)(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. (4t) (a) 10.

Ins 3.39(30t)(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(30t)(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(30t)(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. These grievance procedures shall be aimed at mutual agreement for settlement, shall include arbitration procedures, and may include all of the following:

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

Ins 3.39(30t)(k)2. 2. At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder or certificateholder describing how a grievance may be registered with the issuer.

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

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

Ins 3.39(30t)(k)6. 6. The issuer shall report to the commissioner no later than each March 31st 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(30t)(L) (L) At the time of initial purchase of a Medicare select policy or certificate, a Medicare select issuer shall make available to each applicant for the policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer.

Ins 3.39(30t)(m) (m)

Ins 3.39(30t)(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, that has comparable or lesser benefits and that does not contain a restricted network provision. The issuer shall make Medicare select 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(30t)(m)2. 2. For the purposes of this paragraph, 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. In this subdivision, “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(30t)(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 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, then all of the following apply:

Ins 3.39(30t)(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 Medicare supplement policies and certificates available without requiring evidence of insurability.

Ins 3.39(30t)(n)2. 2. For the purposes of this paragraph, 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. In this subdivision, 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(30t)(o) (o) A Medicare select issuer shall comply with reasonable requests for data made by state or federal agencies, including the CMS, for the purpose of evaluating the Medicare select program.

Ins 3.39(30t)(p) (p) Except as provided in par. (r) or (s), a Medicare select policy or certificate issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020, shall contain the following coverages:

Ins 3.39(30t)(p)1. 1. The “basic Medicare supplement coverage” as described in sub. (5t) (d).

Ins 3.39(30t)(p)2. 2. Coverage for 100% of the Medicare Part A hospital deductible as described in sub. (5t) (e) 1.

Ins 3.39(30t)(p)3. 3. Coverage for home health care for an aggregate of 365 visits per policy or certificate year as described in sub. (5t) (e) 3.

Ins 3.39(30t)(p)4. 4. Coverage for preventive health care services as described in sub. (5t) (d) 15.

Ins 3.39(30t)(p)5. 5. Coverage for emergency care obtained outside of the United States as described in sub. (5t) (e) 6.

Ins 3.39(30t)(q) (q) Permissible additional coverage may only be added to the policy or certificate as separate riders. The issuer shall issue a separate rider for each additional rider offered. Issuers shall ensure that the riders offered are compliant with MMA and that each rider is priced separately, available for purchase separately at any time, subject to underwriting and the preexisting limitation allowed in sub. (4t) (a) 2., and may consist of any of the following:

Ins 3.39(30t)(q)1. 1. Coverage for 50% of the Medicare Part A hospital deductible with no out-of-pocket maximum as described in sub. (5t) (e) 2.

Ins 3.39(30t)(q)2. 2. Coverage for Medicare Part B copayment or coinsurance as described in sub. (5t) (e) 4.

Ins 3.39(30t)(r) (r) The Medicare Select 50% Cost-Sharing plans issued to persons who first became eligible for Medicare on or after January 1, 2020, shall only contain the following coverages:

Ins 3.39(30t)(r)1. 1. The designation: MEDICARE SELECT 50% COST-SHARING PLAN.

Ins 3.39(30t)(r)2. 2. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each day used from the 61st through the 90th day in any Medicare benefit period.

Ins 3.39(30t)(r)3. 3. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.

Ins 3.39(30t)(r)4. 4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage for 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days.

Ins 3.39(30t)(r)5. 5. Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(r)6. 6. Coverage for 50% of the coinsurance or copayment amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(r)7. 7. Coverage for 50% of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(r)8. 8. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(r)9. 9. Except for coverage provided in subd. 11., coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder or certificateholder pays the Medicare Part B deductible until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(r)10. 10. Coverage for 100% of the cost sharing for the benefits described in sub. (5t) (d) 1., 6., 7., 9., 14., 16., and 17. and (e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductible and the out-of-pocket limitation described in subd. 12. is met.

Ins 3.39(30t)(r)11. 11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.

Ins 3.39(30t)(r)12. 12. Coverage for 100% of all cost sharing under Medicare Part A or B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B indexed each year by the appropriate inflation adjustment specified by the secretary.

Ins 3.39(30t)(s) (s) The Medicare Select 25% Coverage Cost-Sharing plans issued to persons who first became eligible for Medicare on or after January 1, 2020, shall only contain all of the following phrases and coverages:

Ins 3.39(30t)(s)1. 1. The designation: MEDICARE SELECT 25% COST-SHARING PLAN.

Ins 3.39(30t)(s)2. 2. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each day used from the 61st through the 90th day in any Medicare benefit period.

Ins 3.39(30t)(s)3. 3. Coverage for 100% of the Medicare Part A hospital coinsurance or copayment amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.

Ins 3.39(30t)(s)4. 4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage for 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days.

Ins 3.39(30t)(s)5. 5. Coverage for 75% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(s)6. 6. Coverage for 75% of the coinsurance or copayment amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(s)7. 7. Coverage for 75% of cost sharing for all Medicare Part A eligible expenses and respite care until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(s)8. 8. Coverage for 75%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(s)9. 9. Except for coverage provided in subd. 11., coverage for 75% of the cost sharing otherwise applicable under Medicare Part B, except there shall be no coverage for the Medicare Part B deductible until the out-of-pocket limitation as described in subd. 12. is met.

Ins 3.39(30t)(s)10. 10. Coverage for 100% of the cost sharing for the benefits described in sub. (5t) (d) 1., 6., 7., 9., 14., 16., and 17. and (e) 3., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder or certificateholder pays the Medicare Part A and B deductible and the out-of-pocket limitation described in subd. 12. is met.

Ins 3.39(30t)(s)11. 11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder or certificateholder pays the Medicare Part B deductible.

Ins 3.39(30t)(s)12. 12. Coverage for 100% of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B, indexed each year by the appropriate inflation adjustment specified by the secretary.

Ins 3.39(30t)(t) (t) A Medicare select policy or certificate may include permissible additional coverage as described in sub. (5t) (e) 2., 4., and 6. These riders, if offered, shall be added to the policy or certificate as separate riders or amendments and shall be priced separately and available for purchase separately.

Ins 3.39(30t)(u) (u) Issuers writing Medicare select policies or certificates shall additionally comply with subchs. I and III of ch. Ins 9.

Ins 3.39(31) (31) Refund or credit calculation.

Ins 3.39(31)(a) (a) Every issuer providing individual or group Medicare supplement policies or certificates and every issuer providing individual or group Medicare select policies or certificates shall collect and file the following information with the commissioner. The data must be provided on a form made available by the commissioner. Issuers shall submit the following information in the manner compliant with the commissioner’s instructions on or before May 31 of each year:

Ins 3.39(31)(a)1. 1. The actual experience loss ratio of incurred claims to earned premium net of refunds.

Ins 3.39(31)(a)2. 2. A credibility adjustment based on a creditability factor.

Ins 3.39(31)(a)3. 3. A comparison to the benchmark loss ratio that is a cumulative incurred claims divided by the cumulative earned premiums to date.

Ins 3.39(31)(a)4. 4. A calculation of the amount of refund or premium credit, if any.

Ins 3.39(31)(a)5. 5. A certification that the refund calculation is accurate.

Ins 3.39(31)(b) (b)

Ins 3.39(31)(b)1. 1. For policies or certificates issued between December 31, 1980, and January 1, 1992, issuers shall combine the Wisconsin experience of all policy or certificate forms of the same type, as defined at sub. (3) (zar), for purposes of calculating the amount of refund or premium credit, if any. Issuers may combine the Wisconsin experience of all policies issued prior to January 1, 1981, with those issued between December 31, 1980, and January 1, 1992, if the issuer uses the 60% loss ratio for individual policies and the 70% loss ratio for group certificates renewed prior to January 1, 1996, and the appropriate loss ratios specified in sub. (16) (d), thereafter.