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.b.b. The written criteria for selection, retention, and removal of 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)(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)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: