La. Admin. Code tit. 37 § XIII-525

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-525 - Medicare Select Policies and Certificates

1. This Section shall apply to Medicare select policies and certificates, as defined in this Section.

2. No policy or certificate may be advertised as a Medicare select policy or certificate unless it meets the requirements of this Section.

B. For the purposes of this Section:

Complaint-any dissatisfaction expressed by an individual concerning a Medicare select issuer or its network providers.

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.

Medicare Select Issuer-an issuer offering, or seeking to offer, a Medicare select policy or certificate.

Medicare Select Policy or Medicare Select Certificate-respectively a Medicare supplement policy or certificate that contains restricted network provisions.

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 insured under a Medicare select policy.

Primary Residence-the policyholder's residence as listed on the policyholder's application for insurance or any other residence given by the policyholder to the issuer subsequent to the application date for the purpose of changing the policyholder's residence.

Restricted Network Provision-any provision, which conditions the payment of benefits, in whole or in part, on the use of network providers.

Service Area-the 50 mile geographical radius or area approved by the commissioner within which a policyholder's primary residence must be located in relation to an issuer's network provider and within which an issuer is authorized to offer a Medicare select policy.

C. The commissioner may authorize an issuer to offer a Medicare select policy or certificate, pursuant to this Section and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the commissioner finds that the issuer has satisfied all of the requirements of this regulation.

1. 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.

2. After September 1, 2006, issuers shall be prohibited from selling new Medicare select policies to those persons whose primary residence is located outside of the issuer's service area.

3. Medicare select issuers shall provide notice, within 30 days after the publication of this rule, to all Medicare select policyholders that:

a. if the policyholder changes his primary residence to a residence located outside of the issuer's service area:

i. the policyholder shall have the right to convert his current Medicare select policy to a Medicare supplement policy; and

ii. the issuer cannot cancel the policyholder's Medicare select policy on the basis that the policyholder did not convert his Medicare select policy to a Medicare supplement policy;

iii. the terms of the policy shall govern with respect to benefits available to the policyholder after moving his primary residence outside of the service area;

b. the policyholder may incur a penalty in the form of some or all of the benefits under the Medicare select policy not being payable if the policyholder requires medical services outside of the service area after the policyholder changes his primary residence to a residence located outside of the service area without converting his policy to a Medicare supplement policy.

4. After October 1, 2006, upon the Medicare select issuer obtaining actual knowledge that a policyholder has changed his primary residence to a residence located outside of the service area, the issuer shall mail to the policyholder the same notice, or one substantially similar, required in the above Paragraph D.3. The issuer shall mail this notice within 30 days after obtaining actual knowledge of the policyholder's change of residence.

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:

1. evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

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 shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community;

b. the number of network providers in the service area is 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. there are written agreements and/or contracts with network providers describing specific responsibilities;

d. emergency care is available 24 hours per day and seven 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 and/or contracts with network providers prohibiting the 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;

2. a statement or map providing a clear description of the service area;

3. a detailed description and the method utilized by the Medicare select insurer of informing policyholders of the plan's service and features, including but not limited to, the plan's grievance procedures, its process for choosing and changing in-network providers, and the procedures for providing and approving emergency and specialty care;

4. a description of the quality assurance program, including:

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 when warranted;

5. a list and description, by specialty, of the network providers, including the Medicare select issuer's procedures for making referrals within and outside its network;

6. copies of the written information proposed to be used by the issuer to comply with §525 I;

7. the listing of hospitals and the number of hospital beds available for the policyholders at an in-network hospital;

8. any other information requested by the commissioner.

1. A Medicare select issuer shall file for approval any proposed changes, material or otherwise, to the plan of operation or contracts, except for changes to the listing of network providers, with the commissioner prior to implementation of any changes. The removal or withdrawal of any hospital from a Medicare select issuer's network shall constitute a material change to the plan of operation or contract and shall be filed with the commissioner in accordance with the provisions of this Subsection. Changes shall be considered approved by the commissioner after 30 days unless specifically disapproved.

2. All filings of proposed changes, material or otherwise, to the plan of operation or contracts as required by this Section shall include, but not be limited to the following:

a. the listing of hospitals and the number of hospital beds available for the policyholders at an in-network hospital;

b. any other information requested by the commissioner.

3. An updated list of network providers shall be filed with the commissioner at least quarterly.

G. A Medicare select policy or certificate shall not restrict payment for covered services provided by non-network providers if:

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 such services through a network provider.

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.

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:

1. an outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate with:

a. other Medicare supplement policies or certificates offered by the issuer; and

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 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;

7. a description of the Medicare select issuer's quality assurance program and grievance procedure.

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 Subsection I of this Section 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 the subscribers. The procedures shall be aimed at mutual agreement for settlement and may include non-binding arbitration procedures.

1. The grievance procedure shall be described in the policy and certificates 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 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.

5. All concerned parties shall be notified about the results of a grievance.

6. The issuer shall report no later than each March 31 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.

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.

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 six months.

2. 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.

N. Medicare select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services 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.

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 the policies and certificates available without requiring evidence of insurability.

O. A Medicare select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select Program.

La. Admin. Code tit. 37, § XIII-525

Promulgated by the Department of Insurance, Office of the Commissioner, LR 25:1108 (June 1999), repromulgated LR 25:1488 (August 1999), amended LR 29:2442 (November 2003), LR 31:2910 (November 2005), LR 32:1462 (August 2006), LR:35:1120 (June 2009).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:1111 (re-designated from LSA-R.S. 22:224 pursuant to Acts 2008, No. 415, effective January 1, 2009) and 42 U.S.C. 1395 et seq.