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 for Wisconsin mandated benefits. The grievance procedures shall be aimed at mutual agreement for settlement, may include arbitration procedures, and may include all of the following:
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.
Ins 3.39(30)(m)2.
2. For the purposes of subd.
1., a Medicare supplement policy or certificate shall 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 Medicare Part B excess charges.
Ins 3.39(30)(n)
(n) Medicare select policies and certificates shall provide for continuation of coverage in the event the secretary determines that Medicare select policies and certificates issued pursuant to this section should be discontinued due to either the failure of the Medicare select federal program to be reauthorized under law or its substantial amendment.
Ins 3.39(30)(n)1.
1. Each Medicare select issuer shall make available to each individual insured under a Medicare select policy or certificate the opportunity to purchase any 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 and certificates available without requiring evidence of insurability.
Ins 3.39(30)(n)2.
2. For the purposes of subd.
1., a Medicare supplement policy or certificate shall 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 Medicare Part B excess charges.
Ins 3.39(30)(o)
(o) A Medicare select issuer shall comply with reasonable requests for data made by state or federal agencies, including the CMS, for the purpose of evaluating the Medicare select program.
Ins 3.39(30)(p)
(p) Except as provided in par.
(q) or
(r), a Medicare select policy shall contain the following benefits:
Ins 3.39(30)(p)5.
5. Coverage for the difference between Medicare Part B eligible charges and the actual charges for authorized referral services. This coverage shall not be described with words or terms that would lead insureds to believe the coverage is for Medicare part B Excess Charges as described in sub.
(5) (i) 4. Ins 3.39(30)(p)8.
8. Coverage for at least 80% of the charges for outpatient prescription drugs after a drug deductible of no more than $6,250 per calendar year. This coverage may only be included in a Medicare select policy issued before January 1, 2006.
Ins 3.39(30)(q)
(q) The Medicare Select 50% Cost-Sharing plans shall only contain the following:
Ins 3.39(30)(q)2.
2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
Ins 3.39(30)(q)3.
3. Coverage for 100% of the Medicare Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
Ins 3.39(30)(q)4.
4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;
Ins 3.39(30)(q)5.
5. Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd.
12.;
Ins 3.39(30)(q)6.
6. Skilled Nursing Facility Care: Coverage for 50% of the coinsurance 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(30)(q)7.
7. Hospice Care: Coverage for 50% 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(30)(q)8.
8. Coverage for 50%, 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(30)(q)9.
9. Except for coverage provided in subd.
11., coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described under subd.
12.;
Ins 3.39(30)(q)10.
10. Coverage of 100% of the cost sharing for the benefits described in sub.
(5) (c) 1.,
5.,
6.,
8.,
13.,
16., and
17., and
(i) 2., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder pays the Medicare Part A and Part B deductible and meets the out-of-pocket limitation described under subd.
12.;
Ins 3.39(30)(q)11.
11. Coverage of 100% of the cost sharing for Medicare Part B preventive services
after the policyholder pays the Medicare Part B deductible; and
Ins 3.39(30)(q)12.
12. Coverage of 100% of all cost sharing under Medicare Part A or 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 $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary.
Ins 3.39(30)(r)
(r) The Medicare Select 25% Coverage Cost-Sharing plans shall only contain the following:
Ins 3.39(30)(r)2.
2. Coverage of 100% of the Medicare Part A hospital coinsurance amount for each day used from the 61
st through the 90
th day in any Medicare benefit period;
Ins 3.39(30)(r)3.
3. Coverage for 100% of the Medicare Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
Ins 3.39(30)(r)4.
4. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system rate, or other appropriate Medicare standard of payment, subject to a lifetime limitation benefit of an additional 365 days;
Ins 3.39(30)(r)5.
5. Medicare Part A Deductible: Coverage for 75% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subd.
12.;
Ins 3.39(30)(r)6.
6. Skilled Nursing Facility Care: Coverage for 75% of the coinsurance 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(30)(r)7.
7. Hospice Care: 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(30)(r)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(30)(r)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(30)(r)10.
10. Coverage of 100% of the cost sharing for the benefits described in sub.
(5) (c) 1.,
5.,
6.,
8.,
13.,
16., and
17., and
(i) 2., to the extent the benefits do not duplicate benefits paid by Medicare and after the policyholder pays the Medicare Part A and Part B deductible and meets the out-of-pocket limitation described under subd.
12.;
Ins 3.39(30)(r)11.
11. Coverage for 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare Part B deductible; and
Ins 3.39(30)(r)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 $2,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary.
Ins 3.39(30)(s)
(s) A Medicare select policy may include permissible additional coverage as described in sub.
(5) (i) 7. This rider, if offered, shall be added to the policy as a separate rider or amendment, shall be priced separately and available for purchase separately. Subject to sub.
(4) (a) 20., this rider may be offered by issuance or sale until January 1, 2006.
Ins 3.39(30m)(a)1.1. This subsection shall only apply to Medicare select policies and certificates issued to persons first eligible for Medicare on or after June 1, 2010 and prior to January 1, 2020. This subsection does not apply to Medicare supplement policies or certificates.
Ins 3.39(30m)(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(30m)(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(30m)(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(30m)(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(30m)(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(30m)(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(30m)(e)1.b.
b. 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(30m)(e)1.c.
c. There are written agreements with network providers describing specific responsibilities.
Ins 3.39(30m)(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(30m)(e)2.
2. A statement or map providing a clear description of the service area.
Ins 3.39(30m)(e)4.
4. A description of the quality assurance program, including all of the following:
Ins 3.39(30m)(e)4.b.
b. The written criteria for selection, retention and removal of network providers.
Ins 3.39(30m)(e)4.c.
c. The procedures for evaluating quality of care provided by network providers.
Ins 3.39(30m)(e)6.
6. Copies of the written information proposed to be used by the issuer to comply with par.
(i).
