Tenn. Comp. R. & Regs. 0780-01-58-.13 - MEDICARE SELECT POLICIES AND CERTIFICATES
(1)
(a) This Rule shall apply to Medicare Select
policies and certificates, as defined in this Rule.
(b) No policy or certificate may be
advertised as a Medicare Select policy or certificate unless it meets the
requirements of this Rule.
(2) For the purposes of this Rule:
(a) "Complaint" means any dissatisfaction
expressed by an individual concerning a Medicare Select issuer or its network
providers.
(b) "Grievance" means
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.
(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 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.
(f) "Restricted network provision" means any
provision which conditions the payment of benefits, in whole or in part, on the
use of network providers.
(g)
"Service area" means the geographic area approved by the commissioner within
which an issuer is authorized to offer a Medicare Select policy.
(3) The commissioner may authorize
an issuer to offer a Medicare Select policy or certificate, pursuant to this
Rule 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 Chapter.
(4) 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.
(5) 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:
(a) Evidence
that all covered services that are subject to restricted network provisions are
available and accessible through network providers, including a demonstration
that:
1. 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.
2. 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.
3. There are
written agreements with network providers describing specific
responsibilities.
4. Emergency care
is available twenty-four (24) hours per day and seven (7) days per
week.
5. 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 any individual insured under a Medicare Select policy or
certificate. This part shall not apply to supplemental charges or coinsurance
amounts as stated in the Medicare Select policy or certificate.
(b) A statement or map providing a
clear description of the service area.
(c) A description of the grievance procedure
to be utilized.
(d) A description
of the quality assurance program, including:
1. The formal organizational
structure;
2. The written criteria
for selection, retention and removal of network providers; and
3. The procedures for evaluating quality of
care provided by network providers, and the process to initiate corrective
action when warranted.
(e) A list and description, by specialty, of
the network providers.
(f) Copies
of the written information proposed to be used by the issuer to comply with
Paragraph (9).
(g) Any other
information requested by the commissioner.
(6)
(a) 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 the changes. Changes shall be considered
approved by the commissioner after thirty (30) days unless specifically
disapproved.
(b) An updated list of
network providers shall be filed with the commissioner at least
quarterly.
(7) A
Medicare Select policy or certificate shall not restrict payment for covered
services provided by non-network providers if:
(a) The services are for symptoms requiring
emergency care or are immediately required for an unforeseen illness, injury or
a condition; and
(b) It is not
reasonable to obtain services through a network provider.
(8) 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.
(9) 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:
(a) An
outline of coverage sufficient to permit the applicant to compare the coverage
and premiums of the Medicare Select policy or certificate with:
1. Other Medicare supplement policies or
certificates offered by the issuer; and
2. Other Medicare Select policies or
certificates.
(b) A
description (including address, phone number and hours of operation) of the
network providers, 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 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.
(d) A description of coverage for emergency
and urgently needed care and other out-of-service area coverage.
(e) A description of limitations on referrals
to restricted network providers and to other providers.
(f) A description of the policyholder's
rights to purchase any other Medicare supplement policy or certificate
otherwise offered by the issuer.
(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 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 Paragraph (9) and that the
applicant understands the restrictions of the Medicare Select policy or
certificate.
(11) 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 arbitration procedures.
(a) The grievance procedure shall be
described in the policy and certificates and in the outline of
coverage.
(b) 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.
(c) 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.
(d) If a
grievance is found to be valid, corrective action shall be taken
promptly.
(e) All concerned parties
shall be notified about the results of a grievance.
(f) 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.
(12) 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.
(13)
(a) 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 the policies
or certificates available without requiring evidence of insurability after the
Medicare Select policy or certificate has been in force for six (6)
months.
(b) For the purposes of
this Paragraph, 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 subparagraph, a significant benefit
means coverage for the Medicare Part A deductible, coverage for at-home
recovery services or coverage for Part B excess charges.
(14) 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 Rule should be discontinued due to
either the failure of the Medicare Select Program to be reauthorized under law
or its substantial amendment.
(a) 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.
(b) For
the purposes of this Paragraph, 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 subparagraph, a
significant benefit means coverage for the Medicare Part A deductible, coverage
for at-home recovery services or coverage for Part B excess charges.
(15) 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.
Notes
Authority: T.C.A. ยงยง
56-1-701;
56-2-301; 56-6-112; 56-6-124(a); 56-7-1401, et seq.; 56-7-1453; 56-7-1454;
56-7-1455; 56-7-1457; 56-7-1501, et seq.; 56-7-1503; 56-7-1504; 56-7-1505;
56-7-1507; and 56-32-118(a); Omnibus Budget Reconciliation Act of 1990,
Pub. L. No.
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