(a) This section shall apply to Medicare Select policies, certificates and plans of operation, as defined in this section. (b) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section. (c) The following words and terms, when used in this section, shall have the following meanings, unless the context indicates otherwise. These words and terms shall be defined and included in all Medicare Select policies, certificates and plans of operation.   (1) Complaint--Any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers.   (2) Emergency Care--Bona fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in:     (A) placing the patient's health in serious jeopardy;     (B) serious impairment to bodily functions; or     (C) serious dysfunction of any bodily organ or part.   (3) 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.   (4) Medicare Select Issuer--An issuer offering, or seeking to offer, a Medicare Select policy or certificate.   (5) Medicare Select Policy or Medicare Select Certificate--A Medicare supplement policy or certificate, respectively, that contains restricted network provisions.   (6) 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 covered under a Medicare Select policy.   (7) Non-network Provider--A provider of health care, or a group of providers of health care, that has not entered into a written agreement with the issuer to provide benefits covered under a Medicare Select policy.   (8) Restricted Network Provisions--Any provision which conditions the payment of benefits, in whole or in part, on the use of network providers.   (9) Service Area--The geographic area approved by the commissioner as part of the plan of operation or amended plan of operation, 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, pursuant to this section and the Omnibus Budget Reconciliation Act (OBRA) of 1990, §4358, if the commissioner finds that the issuer has satisfied all of the requirements of this subchapter. (e) 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. A Medicare Select issuer may not file a Medicare Select policy under the Insurance Code, Article 3.42(c), 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 Department, the form and content of which shall be subject to approval by the commissioner. The plan of operation shall contain, at a minimum, the information in paragraphs (1) - (7) of this subsection, and at the time of submission shall have a form number printed or typed on the lower left hand corner of the face page.   (1) The plan must contain evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration of each of the items referenced in subparagraphs (A) - (E) of this paragraph.     (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 must be documented by credible statistics to be 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) Written agreements with network providers describing specific responsibilities must be included.     (D) Emergency care availability 24 hours per day and seven days a week must be demonstrated.     (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 the providers from billing or otherwise seeking reimbursement from or recourse against any individual covered under a Medicare Select policy or certificate. This subparagraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate.   (2) A clear description of the service area must be provided by narrative statement and/or a map.   (3) The grievance procedure to be utilized must be described.   (4) The quality assurance program must be described, 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) Network providers must be listed and described, by specialty.   (6) Copies of the written information proposed to be used by the issuer to comply with subsection (k) of this section must be provided.   (7) Any other information requested by the commissioner must be provided. (g) 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 60 days prior to implementing such changes. Such changes shall be considered approved by the commissioner after 30 days unless specifically disapproved or unless issuer requests an extension of the 30-day period and the commissioner grants the requested extension. (h) An updated list of network providers shall be filed with the commissioner at least quarterly. If there is no change to the list of network providers within a particular calendar quarter, correspondence indicating no change from the prior reporting period to the current reporting period must, at a minimum, be filed to meet the reporting requirements of this subchapter. (i) 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. (j) 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. (k) 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 other Medicare supplement policies or certificates offered by the issuer and with 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; and   (7) a description of the Medicare Select issuer's quality assurance program and grievance procedure.   (8) For hospital network providers, the statement in 12-point bold-face type: "Only certain hospitals are network providers under this policy. Check with your physician to determine if he or she has admitting privileges at the network hospital. If he or she does not, you may be required to use another physician at time of hospitalization or you will be required to pay for all expenses." This statement shall also be included in the "invitation to contract" advertisement, as that term is defined in §21.113(b) of this title (relating to Rules Pertaining Specifically to Accident and Health Insurance Advertising and Health Maintenance Organization Advertising). (l) 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 (k) of this section and that the applicant understands the restrictions of the Medicare Select policy or certificate. (m) A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. Such procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures. If a binding arbitration procedure is included, the insured must have made an informed choice to accept binding arbitration after having been advised of the right to reject this method of dispute or claim resolution.   (1) The grievance procedure shall be described in the policy and certificates and in the outline of coverage. The in-hospital grievance procedure shall be outlined separately from the grievance procedures for other treatments and/or services. All grievances should be addressed immediately and resolved as soon as possible. Grievances relating to ongoing hospital treatment should be addressed immediately on receipt of any written or oral grievance, and resolved as quickly as possible in a manner which does not interfere with, obstruct or interrupt continued proper medical treatment and care of the patient. The timetable for their resolution shall comply with all applicable provisions of the Insurance Code.   (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, both during the period of care and after care.   (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 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. (n) 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. (o) At the request of an individual covered under a Medicare Select policy or certificate, a Medicare Select issuer shall make available to the individual covered 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 or certificates available without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for six months. (p) 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. (q) 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. Cont'd...