|(a) This section applies to Medicare Select policies,
certificates, and plans of operation, as defined in this section.
(b) No policy or certificate may be advertised as a
Medicare Select policy or certificate unless it meets the requirements
of this section.
(c) The following words and terms, when used in this
section, have the following meanings, unless the context indicates
otherwise. These words and terms must be defined and included in all
Medicare Select policies, certificates, and plans of operation.
(1) Complaint--Any dissatisfaction expressed by an
individual concerning a Medicare Select issuer or its network providers.
(2) Emergency care--Bona fide emergency services provided
after the sudden onset of a medical condition manifesting itself by
acute symptoms of sufficient severity, including severe pain, such
that the absence of immediate medical attention could reasonably be
expected to result in:
(A) placing the patient's health in serious jeopardy;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(3) Grievance--Dissatisfaction expressed in writing
by an individual insured under a Medicare Select policy or certificate
with the administration, claims practices, or provision of services
concerning a Medicare Select issuer or its network providers.
(4) Medicare Select issuer--An issuer offering, or
seeking to offer, a Medicare Select policy or certificate.
(5) Medicare Select policy or Medicare Select certificate--A
Medicare supplement policy or certificate, respectively that contains
restricted network provisions.
(6) Network provider--A provider of health care, or
a group of providers of health care, which has entered into a written
agreement with the issuer to provide benefits covered under a Medicare
(7) Nonnetwork provider--A provider of health care,
or a group of providers of health care, that has not entered into
a written agreement with the issuer to provide benefits covered under
a Medicare Select policy.
(8) Restricted network provisions--Any provision that
conditions the payment of benefits, in whole or in part, on the use
of network providers.
(9) Service area--The geographic area approved by the
Commissioner as part of the plan of operation or amended plan of operation,
within which an issuer is authorized to offer a Medicare Select policy.
(d) The Commissioner may authorize an issuer to offer
a Medicare Select policy or certificate, under this section and the
Omnibus Budget Reconciliation Act (OBRA) of 1990, §4358, if the
Commissioner finds that the issuer has satisfied all of the requirements
of this subchapter.
(e) A Medicare Select issuer may not issue a Medicare
Select policy or certificate in this state until the Commissioner
approves its plan of operation. A Medicare Select issuer may not file
a Medicare Select policy under Insurance Code Chapter 1701, Subchapter
B, until the Commissioner has approved its plan of operation.
(f) A Medicare Select issuer must file a proposed plan
of operation with the department, the form and content of which is
subject to approval by the Commissioner. The plan of operation must
contain, at a minimum, the information in paragraphs (1) - (7) of
this subsection, and at the time of submission must have a form number
printed or typed on the lower left hand corner of the face page.
(1) The plan must contain evidence that all covered
services that are subject to restricted network provisions are available
and accessible through network providers, including a demonstration
of each of the items referenced in subparagraphs (A) - (E) of this
(A) 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 must reflect usual practice in the local area.
Geographic availability must reflect the usual travel times within
(B) The number of network providers in the service
area must be documented by credible statistics to be sufficient, with
respect to current and expected policyholders, either:
(i) to deliver adequately all services that are subject
to a restricted network provision; or
(ii) to make appropriate referrals.
(C) Written agreements with network providers describing
specific responsibilities must be included.
(D) Emergency care availability 24 hours per day and
seven days a week must be demonstrated.
(E) In the case of covered services subject to a restricted-network
provision and that are provided on a prepaid basis, there are written
agreements with network providers prohibiting the providers from billing
or otherwise seeking reimbursement from or recourse against any individual
covered under a Medicare Select policy or certificate. This subparagraph
does not apply to supplemental charges or coinsurance amounts as stated
in the Medicare Select policy or certificate.
(2) A clear description of the service area must be
provided by narrative statement or a map.
(3) The grievance procedure used must be described.
(4) The quality assurance program must be described,
(A) the formal organizational structure;
(B) the written criteria for selection, retention,
and removal of network providers; and
(C) the procedures for evaluating quality of care provided
by network providers, and the process to initiate corrective action
(5) Network providers must be listed and described
(6) Copies of the written information proposed to be
used by the issuer to comply with subsection (k) of this section must
(7) Any other information requested by the Commissioner
must be provided.
(g) A Medicare Select issuer must file any proposed
changes to the plan of operation, except for changes to the list of
network providers, with the Commissioner 60 days before implementing
the changes. Changes will be considered approved by the Commissioner
after 30 days unless specifically disapproved or unless the issuer
requests an extension of the 30-day period and the Commissioner grants
the requested extension.
(h) An updated list of network providers must be filed
with the Commissioner at least quarterly. If there is no change to
the list of network providers within a particular calendar quarter,
correspondence indicating no change from the prior reporting period
to the current reporting period must, at a minimum, be filed to meet
the reporting requirements of this subchapter.
(i) A Medicare Select policy or certificate may not
restrict payment for covered services provided by nonnetwork providers
(1) the services are for symptoms requiring emergency
care or are immediately required for an unforeseen illness, injury,
or a condition; and
(2) it is not reasonable to obtain the services through
a network provider.
(j) A Medicare Select policy or certificate must provide
payment for full coverage under the policy for covered services that
are not available through network providers.
(k) A Medicare Select issuer must make full and fair
disclosure, in writing, of the provisions, restrictions, and limitations
of the Medicare Select policy or certificate to each applicant. This
disclosure must include at least the following:
(1) an outline of coverage sufficient to permit the
applicant to compare the coverage and premiums of the Medicare Select
policy or certificate with other Medicare supplement policies or certificates
offered by the issuer and with other Medicare Select policies or certificates;
(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;
(3) a description of the restricted network provisions,
including payments for 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 plans K and L);
(4) a description of coverage for emergency and urgently
needed care and other out-of-service area coverage;
(5) a description of limitations on referrals to restricted
network providers and to other providers;
(6) a description of the policyholder's rights to purchase
any other Medicare supplement policy or certificate otherwise offered
by the issuer; and
(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.