Ins 3.39(24)(e)
(e) In regards to any transaction involving a Medicare supplement policy, no person subject to regulation under chs.
600 to
655, Stats., may knowingly prevent or dissuade or attempt to prevent or dissuade, any person from:
Ins 3.39(24)(e)1.
1. Filing a complaint with the office of the commissioner of insurance; or
Ins 3.39(24)(e)2.
2. Cooperating with the office of the commissioner of insurance in any investigation; or
Ins 3.39(24)(e)3.
3. Attending or giving testimony at any proceeding authorized by law.
Ins 3.39(24)(f)
(f) If an insured exercises the right to return a policy during the free-look period, the issuer shall mail the entire premium refund directly to the person who paid the premium.
Ins 3.39(24)(g)
(g) The terms "Medicare Supplement," "Medigap," "Medicare Wrap Around," and "Medicare Advantage Supplement" and words of similar import may not be used in any materials including advertisements as defined in
s. Ins 3.27 (5) (a), unless the policy or certificate is issued in compliance with this section.
Ins 3.39(25)
(25) Appropriateness of recommended purchase and excessive insurance. Ins 3.39(25)(a)(a) In recommending the purchase or replacement of any Medicare supplement or Medicare replacement policy or certificate, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.
Ins 3.39(25)(b)
(b) Any sale of Medicare supplement or Medicare replacement policy or certificate that will provide an individual more than one Medicare supplement or Medicare replacement policy or certificate is prohibited.
Ins 3.39(25)(c)
(c) An agent shall forward each application taken for a Medicare supplement or Medicare replacement policy to the issuer within 7 calendar days after taking the application. An agent shall mail the portion of any premium collected due the issuer to the issuer within 7 days after receiving the premium.
Ins 3.39(25)(d)
(d) An agent may not take and an issuer may not accept an application from an insured more than 3 months prior to the insured becoming eligible.
Ins 3.39(26)(a)(a) On or before March 1 of each year, every issuer providing Medicare supplement or Medicare cost insurance coverage in this state shall report the following information for every individual resident of this state for which the insurer has in force more than one Medicare supplement or Medicare cost insurance policy or certificate:
Ins 3.39(26)(b)
(b) The items in
par. (a) must be grouped by individual policyholder or certificateholder and listed on a form in substantially the same format as Appendix 9 on or before March 1 of each year.
Ins 3.39(27)
(27) Waiting periods in replacement policies or certificates. If a Medicare supplement or Medicare cost policy or certificate replaces another Medicare supplement or Medicare cost policy or certificate, the replacing issuer shall waive any time periods applicable to pre-existing condition waiting periods in the new Medicare supplement or new Medicare cost policy to the extent such time was satisfied under the original policy or certificate.
Ins 3.39(28)
(28) Group policy continuation and conversion requirements. Ins 3.39(28)(a)(a) If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in
par. (c), the issuer shall offer certificateholders at least the following choices:
Ins 3.39(28)(a)1.
1. An individual Medicare supplement policy which provides for continuation of the benefits contained in the group policy; and
Ins 3.39(28)(a)2.
2. An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards in
sub. (5) (c).
Ins 3.39(28)(b)
(b) If membership in a group is terminated, the issuer shall:
Ins 3.39(28)(b)1.
1. Offer the certificateholder such conversion opportunities as are described in
par. (a); or
Ins 3.39(28)(b)2.
2. At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy for the time specified in s.
632.897, Stats.
Ins 3.39(28)(c)
(c) If a group Medicare supplement policy is replaced by another group Medicare supplement policy, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any limitation for pre-existing conditions that would have been covered under the group policy being replaced.
Ins 3.39(29)(a)(a) An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate 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 enrollees 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)1.1. This subsection shall apply to Medicare select policies and certificates issued prior to June 1, 2010.
Ins 3.39(30)(a)2.
2. No policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requirements of this subsection.
Ins 3.39(30)(b)1.
1. "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare select issuer or its network providers.
Ins 3.39(30)(b)2.
2. "Grievance" means 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.
Ins 3.39(30)(b)3.
3. "Medicare select issuer" means an issuer offering, or seeking to offer, a Medicare select policy or certificate.
Ins 3.39(30)(b)4.
4. "Medicare select policy" or "Medicare select certificate"mean, respectively, a Medicare supplement policy or certificate that contains restricted network provisions.
Ins 3.39(30)(b)5.
5. "Network provider" means 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 insured under a Medicare select policy.
Ins 3.39(30)(b)6.
6. "Restricted network provision" means any provision that conditions the payment of benefits, in whole or in part, on the use of network providers.
Ins 3.39(30)(b)7.
7. "Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare select policy.
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.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)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)6.
6. Copies of the written information proposed to be used by the issuer to comply with
par. (i).
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.
Ins 3.39(30)(g)
(g) A Medicare select policy or certificate shall not restrict payment for covered services provided by non-network providers if:
Ins 3.39(30)(g)1.
1. The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and
Ins 3.39(30)(g)2.
2. It is not reasonable to obtain such services through a network provider.
Ins 3.39(30)(h)
(h) A Medicare select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.
Ins 3.39(30)(i)
(i) A Medicare select issuer shall 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 shall include at least the following:
Ins 3.39(30)(i)1.
1. An outline of coverage in substantially the same format as Appendix 1 sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate with:
Ins 3.39(30)(i)1.a.
a. Other Medicare supplement policies or certificates offered by the issuer; and
Ins 3.39(30)(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(30)(i)3.
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 the Medicare Select 50% and 25% Coverage Cost-Sharing plans offered by the Medicare select issuer pursuant to
pars. (q) and
(r).
Ins 3.39(30)(i)4.
4. A description of coverage for emergency and urgently needed care and other out of service area coverage.
Ins 3.39(30)(i)5.
5. A description of limitations on referrals to restricted network providers and to other providers.
Ins 3.39(30)(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(30)(i)7.
7. A description of the Medicare select issuer's quality assurance program and grievance procedure.
Ins 3.39(30)(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. (5) (a) or
(7) (b) 1.
Ins 3.39(30)(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(30)(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(30)(k)
(k) A Medicare select issuer shall have and use procedures for hearing complaints and resolving written grievances from its subscribers. Such procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures.
Ins 3.39(30)(k)1.
1. The grievance procedure shall be described in the policy and certificate and in the outline of coverage.
Ins 3.39(30)(k)2.
2. At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder describing how a grievance may be registered with the issuer.
Ins 3.39(30)(k)3.
3. Grievances shall be considered in a timely manner and shall be transmitted to appropriate decision-makers who have authority to fully investigate the issue and take corrective action.
Ins 3.39(30)(k)4.
4. If a grievance is found to be valid, corrective action shall be taken promptly.
Ins 3.39(30)(k)5.
5. All concerned parties shall be notified about the results of a grievance.
Ins 3.39(30)(k)6.
6. The issuer shall report no later than each March 31st to the commissioner regarding its grievance procedure. The report shall be in a format prescribed by the commissioner and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances.
Ins 3.39(30)(L)
(L) At the time of initial purchase, a Medicare select issuer shall 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.
Ins 3.39(30)(m)1.1. At the request of an individual insured under a Medicare select policy or certificate, a Medicare select issuer shall make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer, which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make such policies or certificates available without requiring evidence of insurability after the Medicare select policy or certificate has been in force for 6 months.
