Ins 3.39(30m)(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 is met as described in subd. 12.
Ins 3.39(30m)(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 is met as described in subd. 12.
Ins 3.39(30m)(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 is met as described in subd. 12.
Ins 3.39(30m)(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 is met as described in subd. 12.
Ins 3.39(30m)(s)10.10. Coverage for 100% of the cost sharing for the benefits described in sub. (5m) (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 meets the out-of-pocket limitation described in subd. 12.
Ins 3.39(30m)(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(30m)(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 of [$2,220] in 2010, indexed each year by the appropriate inflation adjustment specified by the secretary.
Ins 3.39(30m)(t)(t) A Medicare select policy or certificate may include permissible additional coverage as described in sub. (5m) (e) 2., 5., and 7. 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(30m)(u)(u) Issuers writing Medicare select policies or certificates shall additionally comply with subchs. I and III of ch. Ins 9.
Ins 3.39(30t)(30t)Medicare select policies and certificates.
Ins 3.39(30t)(a)(a)
Ins 3.39(30t)(a)1.1. This subsection shall apply only to Medicare select policies and certificates issued to persons newly eligible for Medicare on or after January 1, 2020. This subsection does not apply to Medicare supplement policies or certificates or to Medicare cost policies.
Ins 3.39(30t)(a)2.2. No Medicare select policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requirements of this subsection.
Ins 3.39(30t)(c)(c) The commissioner may authorize an issuer to offer a Medicare select policy or certificate, pursuant to this subsection and OBRA, if the commissioner finds that the issuer has satisfied all of the requirements of this subsection.
Ins 3.39(30t)(d)(d) A Medicare select issuer may 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(30t)(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 all of the following information:
Ins 3.39(30t)(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 of all of the following:
Ins 3.39(30t)(e)1.a.a. That covered 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(30t)(e)1.b.b. That the number of network providers in the service area is sufficient, with respect to current and expected policyholders or certificateholders, either to deliver adequately all services that are subject to a restricted network provision or to make appropriate referrals.
Ins 3.39(30t)(e)1.c.c. That there are written agreements with network providers describing specific responsibilities.
Ins 3.39(30t)(e)1.d.d. Emergency care is available 24 hours per day and 7 days per week.
Ins 3.39(30t)(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 subd. 1. e. may not apply to supplemental charges, copayment, or coinsurance amounts as stated in the Medicare select policy or certificate.
Ins 3.39(30t)(e)2.2. A statement or map providing a clear description of the service area.
Ins 3.39(30t)(e)3.3. A description of the grievance procedure to be utilized.
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.