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.