Utah Admin. Code 590-146-10

Current through Bulletin 2024-19, October 1, 2024

Section R590-146-10 - Medicare Select Policies and Certificates

(1)

(a) This section applies to a Medicare Select policy and certificate.

(b) A policy or certificate may not be advertised as a Medicare Select policy or Medicare Select certificate unless it meets the requirements of this section.

(2) The definitions in this subsection apply to this section.

(a) "Complaint" means a dissatisfaction expressed by an insured concerning a Medicare Select issuer or its network providers.

(b) "Grievance" means dissatisfaction expressed in writing by an insured under a Medicare Select policy or Medicare Select certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers.

(c) "Medicare Select issuer" means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.

(d) "Medicare Select policy" or "Medicare Select certificate" mean respectively a Medicare supplement policy or certificate that contains restricted network provisions.

(e) "Network provider" means a healthcare provider, or a group of healthcare providers, that enters into a written agreement with an issuer to provide benefits under a Medicare Select policy.

(f) "Restricted network provision" means a provision that conditions the payment of benefits, in whole or in part, on the use of network providers.

(g) "Service area" means a geographic area approved by the commissioner where a Medicare Select issuer is authorized to offer a Medicare Select policy.

(3) The commissioner may authorize an issuer to offer a Medicare Select policy or Medicare Select certificate under this section if the commissioner finds that the issuer has satisfied the requirements of this rule.

(4) A Medicare Select issuer may not issue a Medicare Select policy or Medicare Select certificate in this state until its plan of operation has been approved by the commissioner.

(5) A Medicare Select issuer shall file a proposed plan of operation with the commissioner that includes:

(a) evidence that each covered service that is subject to a restricted network provision is available and accessible through network providers, including a demonstration that:

(i) services may be provided by network providers with reasonable promptness for geographic location, hours of operation, and after-hours care based on the usual practice in the local area and the usual travel times within the community;

(ii) the number of network providers in the service area is sufficient, with respect to current and expected policyholders or certificate holders, either:

(A) to deliver adequate services subject to a restricted network provision; or

(B) to make appropriate referrals;

(iii) there are written agreements with network providers describing specific responsibilities;

(iv) emergency care is available 24 hours per day and seven days per week; and

(v) 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 the providers from billing or otherwise seeking reimbursement from, or recourse against, an insured under a Medicare Select policy or Medicare Select certificate, except that this subsection may not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or Medicare Select certificate;

(b) a statement or map providing a clear description of the service area;

(c) a description of the grievance procedure to be used;

(d) a description of the quality assurance program, including:

(i) the formal organizational structure;

(ii) the written criteria for selection, retention, and removal of a network provider; and

(iii) the procedures for evaluating quality of care provided by a network provider and the process to initiate corrective action when warranted;

(e) a list and description, by specialty, of each network provider;

(f) written information proposed to be used by the issuer to comply with Subsection (9); and

(g) any other information requested by the commissioner.

(6)

(a) A Medicare Select issuer shall file with the commissioner any proposed change to the plan of operation, except for a change to the list of network providers, prior to implementing the changes.

(b) A change to the list of network providers shall be filed with the commissioner within 30 days of the change. The submission shall include each network provider and clearly identify new and discontinued providers.

(7) A Medicare Select policy or Medicare Select certificate may not restrict payment for covered services provided by a non-network provider if:

(a) the services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or condition; and

(b) it is unreasonable to obtain services through a network provider.

(8) A Medicare Select policy or Medicare Select certificate shall provide payment for full coverage under the policy for a covered service that is not available through a network provider.

(9) A Medicare Select issuer shall make full and fair disclosures in writing of each provision, restriction, and limitation of a Medicare Select policy or Medicare Select certificate to an applicant. The disclosure shall include:

(a) an outline of coverage sufficient to permit an applicant to compare the coverage and premiums of the Medicare Select policy or Medicare Select certificate with:

(i) other Medicare supplement insurance policies or certificates offered by the issuer; and

(ii) other Medicare Select policies or Medicare Select certificates;

(b) a description, including address, phone number, and hours of operation, of each network provider, including primary care physicians, specialty physicians, hospitals, and other providers;

(c) 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 Medicare Select policy or Medicare Select certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in a Plan K or L;

(d) a description of coverage for emergency and urgent care and other out-of-service area coverage;

(e) a description of any limitation on a referral to a restricted network provider or other provider;

(f) a description of the Medicare Select policyholder's rights to purchase another Medicare supplement insurance policy or certificate offered by the issuer; and

(g) a description of the Medicare Select issuer's quality assurance program and grievance procedure.

(10) Prior to the sale of a Medicare Select policy or Medicare Select certificate, a Medicare Select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information required under Subsection (9) and that the applicant understands the restrictions of the Medicare Select policy or Medicare Select certificate.

(11) A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from insureds. The procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures.

(a) A grievance procedure shall be described in the Medicare Select policy, Medicare Select certificate, and outline of coverage.

(b) At the time a Medicare Select policy or Medicare Select certificate is issued, a Medicare Select issuer shall provide detailed information to the policyholder or certificate holder describing how a grievance may be registered with the issuer.

(c) An issuer shall consider a grievance in a timely manner and transmit it to an appropriate decision maker who has the authority to fully investigate the issuer and take corrective action.

(d) If a grievance is found to be valid, corrective action shall be promptly taken.

(e) Each concerned party shall be notified about the results of a grievance.

(f) A Medicare Select issuer shall report to the commissioner no lather than March 31 of each year the number of grievances filed in the past year and a summary of the subject, nature, and resolution of the grievances.

(12)

(a) At the request of an insured, a Medicare Select issuer shall provide the insured the opportunity to purchase a Medicare supplement insurance policy or certificate offered by the issuer which has comparable or lesser benefits that does not contain a restricted network provision. The issuer shall make the Medicare supplement insurance policy or certificate available without requiring evidence of insurability after the Medicare Select policy or Medicare Select certificate has been in force for six months.

(b) For the purposes of this subsection, a Medicare supplement policy or certificate is considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or Medicare Select certificate being replaced. A significant benefit includes coverage for the Medicare Part A deductible, at-home recovery services, or the Medicare Part B excess charges.

(13)

(a) A Medicare Select policy or Medicare Select certificate shall provide for continuation of coverage in the event the Secretary determines that Medicare Select policies and Medicare Select certificates should be discontinued due to either failure of the Medicare Select Program to be reauthorized under law or its substantial amendment.

(b) A Medicare Select issuer shall provide an insured under a Medicare Select policy or Medicare Select certificate the opportunity to purchase a Medicare supplement insurance policy or certificate offered by the issuer that has comparable or lesser benefits that does not contain a restricted network provision. The issuer shall make the Medicare supplement insurance policy or certificate available without requiring evidence of insurability.

(c) For the purposes of this subsection, a Medicare supplement insurance policy or certificate is considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or Medicare Select certificate being replaced. For this subsection, a significant benefit includes coverage for the Medicare Part A deductible, at-home recovery services, or the Medicare Part B excess charges.

(14) A Medicare Select issuer shall comply with reasonable requests for data to evaluate the Medicare Select Program.

Utah Admin. Code R590-146-10

Amended by Utah State Bulletin Number 2019-13, effective 6/7/2019

Adopted by Utah State Bulletin Number 2024-16, effective 8/7/2024