(21) (a) An issuer may provide and an agent or other representative may accept commission or other compensation for the sale of a Medicare supplement or Medicare cost policy or certificate only if the first year commission or other first year compensation is at least 100% and no more than 150% no more than 200% of the commission or other compensation paid for selling or servicing the policy or certificate in the 2nd year.
SECTION 61. Ins 3.39 (21) (f) is created to read:
Ins 3.39 (21) (f) No issuer may provide an agent or other representative commission or compensation for the sale of any other Medicare supplement policy or certificate to an individual who is eligible for guaranteed issue under sub. (34), calculated on a different basis of the commissions paid for the sale of a Medicare supplement policy or certificate to an individual who is eligible for open enrollment under sub. (3r).
SECTION 62. Ins 3.39 (22) (d), (f) and 1., (23) (c) and (e), and (24) (a) (intro.) and 3. are amended to read:
Ins 3.39 (22) (d) If a Medicare supplement or Medicare cost policy or certificate contains any limitations with respect to pre-existing preexisting conditions, such limitations shall may appear on the first page. or as a separate paragraph of the policy and be labeled as “Preexisting Condition Limitations.”
(f) As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement or Medicare cost insurance policies or certificates in the format similar to Appendix 4, Appendix 4m, or Appendix 4t. The notice shall contain all of the following:
1. Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate or Medicare cost policy or certificate,; and
(23) (c) Upon determining that a sale will involve replacement, an issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement or Medicare cost policy or certificate, a notice regarding the replacement of accident and sickness Medicare supplement coverage in no less than 12 point type. One copy of the notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the solicitation of the policy the notice regarding replacement of accident and sickness Medicare supplement coverage.
(e) If the application contains questions regarding health and tobacco usage, include a statement that health questions should not be answered if the applicant is in the open-enrollment period described in sub. (4m)(3r), or during a guaranteed issue period under sub. (34).
(24) (a) Every issuer marketing Medicare supplement insurance coverage in this state, directly or through its producers, shall do all of the following:
3. Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrolleeinsured for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of any such insurance.
SECTION 63. Ins 3.39 (24) (a) 4. is created to read:
Ins 3.39 (24) (a) 4. Display prominently by type-size, stamp or other appropriate means, on the first page of the policy the following: “Notice to buyer: This policy may not cover all of your medical expenses.”
SECTION 64. Ins 3.39 (25) (a), (b), and (c), and (26) (a) (intro.) and 1. are amended to read:
Ins 3.39 (25) (a) In recommending the purchase or replacement of any Medicare supplement or Medicare replacement cost policy or certificate, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.
(b) Any sale of Medicare supplement or Medicare replacement cost policy or certificate that will provide an individual more than one Medicare supplement or Medicare replacement cost policy or certificate is prohibited.
(c) An agent shall forward each application taken for a Medicare supplement or Medicare replacement cost 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.
(26) (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:
1. Policy and certificate number, and.
SECTION 65. Ins 3.39 (26) (a) 3. to 6. are created to read:
Ins 3.39 (26) (a) 3. Type of policy.
4. Company name and National Association of Insurance Commissioners number.
5. Name and contact information of person completing the form.
6. Other information as requested by the commissioner.
SECTION 66. Ins 3.39 (26) (b), (27), (28) (c), (29) (a) and (b) 1., are amended to read:
Ins 3.39 (26) (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 made available by the commissioner. Appendix 9 Issuers shall submit the information in the manner compliant with the commissioner’s instructions on or before March 1 of each year.
(27) 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 preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare supplement or new Medicare cost policy for similar benefits to the extent such time was satisfied under the original policy or certificate. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate that has been in effect for at least 6 months, the replacing policy shall not provide any time period applicable to preexisting conditions, waiting periods, elimination periods and probationary periods for benefits similar to those contained in the original policy or certificate.
(28) (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 limitationexclusion for pre-existingpreexisting conditions that would have been covered under the group policy being replaced.
(29) (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 form has been filed with and approved by the commissioner in accordance with filing requirements and procedures prescribed by the commissioner.
(b) 1. Beginning January 1, 2007, issuers shall replace existing amended policies and riders for current and renewing enrolleesinsureds 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.
SECTION 67. Ins 3.39 (30) (b) is repealed.
SECTION 68. Ins 3.39 (30) (n) (intro.), (q) 12., and (r) 12. are amended to read:
Ins 3.39 (30) (n) Medicare select policies and certificates shall provide for continuation of coverage in the event the Secretary 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 program to be reauthorized under law or its substantial amendment.
(q) 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 secretary.
(r) 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 secretary.
SECTION 69. Ins 3.39 (30m) (b) is repealed.
SECTION 70. Ins 3.39 (30m) (i) 1. and 8., (n) (intro.), (q) (intro.), (r) 12., and (s) 12. are amended to read:
Ins 3.39 (30m) (i) 1. An outline of coverage in substantially the same format as Appendices 22m and 55m sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate to the following:
8. A designation: MEDICARE SELECT POLICY. This designation shall be immediately below and in the same type size as the designation required in sub. (4s)(4m) (a) 10.
(n) Medicare select policies and certificates shall provide for continuation of coverage in the event the Secretary 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 program to be reauthorized under law or its substantial amendment.
(q) Permissible additional coverage may only be added to the policy or certificate as separate riders. The issuer shall issue a separate rider for each additional coverage offered. Issuers shall ensure that the riders offered are compliant with MMA, each rider is priced separately, available for purchase separately at any time, subject to underwriting and the preexisting limitation allowed in sub. (4s)(4m) (a) 2., and may consist of the following:
(r) 12. Coverage for 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 [$4,440] in 2010, indexed each year by the appropriate inflation adjustment specified by the Secretary secretary.
(s) 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 [$2,220] in 2010, indexed each year by the appropriate inflation adjustment specified by the Secretary secretary.
SECTION 71. Ins 3.39 (30t) is created to read:
Ins 3.39 (30t) Medicare select policies and certificates. (a) 1. This subsection shall apply to Medicare select policies and certificates issued on or after January 1, 2020.
2. No policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requirements of this subsection.
(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.
(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.
(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 all of the following information:
1. Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration of all of the following:
a. That covered 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.
b. That 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.
c. That there are written agreements with network providers describing specific responsibilities.
d. Emergency care is available 24 hours per day and 7 days per week.
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.
2. A statement or map providing a clear description of the service area.
3. A description of the grievance procedure to be utilized.
4. A description of the quality assurance program, including all of the following:
a. The formal organizational structure.
b. The written criteria for selection, retention, and removal of network providers.
c. The procedures for evaluating quality of care provided by network providers.
d. The process to initiate corrective action when warranted.
5. A list and description, by specialty, of the network providers.
6. Copies of the written information proposed to be used by the issuer to comply with par. (i).
7. Any other information requested by the commissioner.
(f) 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 after filing unless specifically disapproved.
2. An updated list of network providers shall be filed with the commissioner at least quarterly.
(g) A Medicare select policy or certificate may not restrict payment for covered services provided by non-network providers if all of the following occur:
1. The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition.
2. It is not reasonable to obtain services described in subd. 1. through a network provider.
(h) A Medicare select policy or certificate shall provide payment for full coverage under the policy or certificate for covered services that are not available through network providers.
(i) A Medicare select issuer shall make full and fair disclosure in writing of the provisions, coinsurance, or copayments, restrictions, and limitations of the Medicare select policy or certificate to each applicant. This disclosure shall include at least the following:
1. An outline of coverage in substantially the same format as Appendices 2t and 5t sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate to the following:
a. Other Medicare supplement policies or certificates offered by the issuer.
b. 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 copayments or 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 under pars. (r) and (s).
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 or certificateholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.
7. A description of the Medicare select issuer’s quality assurance program and grievance procedure.
8. A designation: MEDICARE SELECT POLICY. This designation shall be immediately below and in the same type size as the designation required in sub. (4t) (a) 10.
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."
(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.
(k) A Medicare select issuer shall have and use procedures for hearing complaints and resolving written grievances from its subscribers for Wisconsin mandated benefits. These grievance procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures and include all of the following.
1. The grievance procedure shall be described in the policy and certificate and in the outline of coverage.
2. At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder or certificateholder describing how a grievance may be registered with the issuer.
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.
4. If a grievance is found to be valid, corrective action shall be taken promptly.
