S.D. Admin. R. 20:06:13:66

Current through Register Vol. 51, page 67, December 16, 2024

Section 20:06:13:66 - Filing plan of operation

A Medicare select issuer shall file a proposed plan of operation with the director in a format prescribed by the director. The plan of operation must 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) Such services can be provided by network providers with reasonable promptness regarding geographic location, hours of operation, and after-hour care. The hours of operation and availability of after-hour care must reflect the usual practice in the local area. Geographic availability must reflect the usual travel times within the community;

(b) The number of network providers in the service area is sufficient for current and expected policyholders either to deliver adequately all services that are subject to a restricted network provision or to make appropriate referrals.

(c) There are written agreements with network providers describing specific responsibilities;

(d) Emergency care is available 24 hours a day and 7 days a 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 subsection does 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 description of the grievance procedure to be used;

(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;

(6) Copies of the written information proposed to be used by the issuer to comply with § 20:06:13:70; and

(7) Any other information requested by the director.

S.D. Admin. R. 20:06:13:66

22 SDR 107, effective 2/18/1996; 23 SDR 236, effective 7/13/1997.

General Authority: SDCL 58-17A-2(12), 58-17A-2, 58-17A-7.

Law Implemented: SDCL 58-17A-2.