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. At the option of the group issued a certificate, offer the certificateholder continuations of coverage under the group certificate for the time specified in s.
632.897, Stats.
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 certificate is replaced by another group Medicare supplement certificate, the issuer of the replacement certificate shall offer coverage to all persons covered under the old group certificate on its date of termination. Coverage under the new group certificate shall not result in any exclusion for preexisting conditions that would have been covered under the group certificate being replaced.
Ins 3.39(29)(a)(a) An issuer shall not deliver or issue for delivery a Medicare supplement policy or certificate, Medicare select policy or certificate or Medicare cost policy to a resident of this state unless the policy form or certificate form 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 insureds 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 only to Medicare select policies and certificates issued to persons first eligible for Medicare prior to June 1, 2010. This subsection does not apply to Medicare supplement policies and certificates or Medicare cost policies.
Ins 3.39(30)(a)2.
2. No Medicare select policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requires of this subsection.
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 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
