Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.777a - Medicare select policies and certificates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This section applies to Medicare Select
				  policies and certificates, as defined in this section.
(b) A policy or certificate may not be
				  advertised as a Medicare Select policy or certificate unless it meets the
				  requirements of this section.
(c)
				  For the purposes of this section, the following words and terms have the
				  following meanings, unless the context clearly indicates otherwise:
Complaint
-Dissatisfaction expressed orally
					 or in writing by an individual insured under a Medicare Select policy or
					 certificate 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
					 concerning the administration, claims practices or provision of services with 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
-A Medicare supplement policy or certificate,
					 respectively, 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.
Restricted network provision
-A provision
					 which conditions the payment of benefits, in whole or in part, on the use of
					 network providers.
Service area
-The geographic area approved
					 by the Commissioner within which an issuer is authorized to offer a Medicare
					 Select policy.
(d) The
				  Commissioner may authorize an issuer to offer a Medicare Select policy or
				  certificate, under this section, and section 4358 of the Omnibus Budget
				  Reconciliation Act (OBRA) of 1990 (42 U.S.C.A. §
											1395b-2) if the
				  Commissioner finds that the issuer has satisfied the requirements of this
				  section.
(e) 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.
(f) 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:
(i) 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 the usual practice in the local area. Geographic
				  availability shall reflect 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, to either:
(A)
				  Deliver adequately all services that are subject to a restricted network
				  provision.
(B) Make appropriate
				  referrals.
(iii) There
				  are written agreements with network providers describing both parties' specific
				  responsibilities.
(iv) Emergency
				  care is available 24 hours per day and 7 days per week.
(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 any
				  individual insured under a Medicare Select policy or certificate. This
				  subparagraph does not apply to supplemental charges or coinsurance amounts as
				  stated in the Medicare Select policy or certificate.