| (7) a description of the Medicare Select issuer's quality
assurance program and grievance procedure.
(8) For hospital network providers, the statement in
12-point bold-face type: "Only certain hospitals are network providers
under this policy. Check with your physician to determine if he or
she has admitting privileges at the network hospital. If he or she
does not, you may be required to use another physician at time of
hospitalization or you will be required to pay for all expenses."
This statement must also be included in the "invitation to contract"
advertisement, as that term is defined in §21.113(b) of this
title (relating to Rules Pertaining Specifically to Accident and Health
Insurance Advertising and Health Maintenance Organization Advertising).
(l) Before the sale of a Medicare Select policy or
certificate, a Medicare Select issuer must obtain from the applicant
a signed and dated form stating that the applicant has received the
information provided under subsection (k) of this section and that
the applicant understands the restrictions of the Medicare Select
policy or certificate.
(m) A Medicare Select issuer must have and use procedures
for hearing complaints and resolving written grievances from the subscribers.
Such procedures must be aimed at mutual agreement for settlement and
may include arbitration procedures. If a binding arbitration procedure
is included, the insured must have made an informed choice to accept
binding arbitration after having been advised of the right to reject
this method of dispute or claim resolution.
(1) The grievance procedure must be described in the
policy and certificates and in the outline of coverage. The in-hospital
grievance procedure must be outlined separately from the grievance
procedures for other treatments or services, or both. All grievances
should be addressed immediately and resolved as soon as possible.
Grievances relating to ongoing hospital treatment should be addressed
immediately on receipt of any written or oral grievance, and be resolved
as quickly as possible in a manner that does not interfere with, obstruct,
or interrupt continued proper medical treatment and care of the patient.
The timetable for their resolution must comply with all applicable
provisions of the Insurance Code.
(2) At the time the policy or certificate is issued,
the issuer must provide detailed information to the policyholder describing
how a grievance may be registered with the issuer, both during the
period of care and after care.
(3) Grievances must be considered in a timely manner
and must be transmitted to appropriate decision makers who have authority
to fully investigate the issue and take corrective action.
(4) If a grievance is found to be valid, corrective
action must be taken promptly.
(5) All concerned parties must be notified about the
results of a grievance.
(6) The issuer must report no later than each March
31st to the Commissioner regarding its grievance procedure. The report
must be in a format prescribed by the Commissioner, must contain the
number of grievances filed in the past year, and must include a summary
of the subject, nature, and resolution of the grievances.
(n) At the time of initial purchase, a Medicare Select
issuer must 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.
(o) At the request of an individual covered under a
Medicare Select policy or certificate, a Medicare Select issuer must
make available to the individual covered the opportunity to purchase
any 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 must make the policies or
certificates available without requiring evidence of insurability
after the Medicare Select policy or certificate has been in force
for six months.
(p) For the purposes of this subsection, a Medicare
supplement policy or certificate will 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 Part B excess charges.
(q) Medicare Select policies and certificates must
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.
(1) Each Medicare Select issuer must make available
to each individual covered under a Medicare Select policy or certificate
the opportunity to purchase any 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 must make
these policies and certificates available without requiring evidence
of insurability.
(2) For the purposes of this subsection, a Medicare
supplement policy or certificate will 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 purpose of this paragraph, a significant benefit means coverage
for the Medicare Part A deductible, coverage for at-home recovery
services, or coverage for Part B excess charges.
(r) A Medicare Select issuer must comply with reasonable
requests for data made by state or federal agencies, including the
United States Department of Health and Human Services, for the purpose
of evaluating the Medicare Select Program.
|
| Source Note: The provisions of this §3.3325 adopted to be effective April 15, 1992, 17 TexReg 2238; amended to be effective January 1, 1997, 21 TexReg 10753; amended to be effective May 10, 2005, 30 TexReg 2669; amended to be effective June 13, 2018, 43 TexReg 3787 |
