Section 71.21 - Medicare Select(1) 211 CMR 71.21 shall apply to Medicare Select Policies, as defined in 211 CMR 71.21.(2) No policy may be advertised as a Medicare Select Policy, unless it meets the requirements of 211 CMR 71.21.(3) No Issuer may offer a Medicare Select Policy, unless that Issuer also offers a Medicare Supplement Core plan that is not a network plan.(4) For the purposes of 211 CMR 71.21: (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 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.(d)Medicare Select Policy means a Medicare Supplement Insurance Policy 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 or 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.(5) The Commissioner may authorize an Issuer to offer a Medicare Select Policy, pursuant to 211 CMR 71.21 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 211 CMR 71.00.(6) A Medicare Select Issuer shall not issue a Medicare Select Policy in Massachusetts until its plan of operation has been approved by the Commissioner.(7) A Medicare Select Issuer shall be accredited according to the provisions of M.G.L. c. 176O, and 211 CMR 52.00: Managed Care Consumer Protections and Accreditation of Carriers and such Medicare Select Issuer shall file a proposed plan of operation and copies of all standard provider contracts according to the provisions of 211 CMR 52.12: Standards for Provider Contracts. The plan of operation shall contain at least information that follows, and the carrier may satisfy any or all of the following requirements by documenting that the information was filed previously as part of the accreditation process under 211 CMR 52.06: Application for Accreditation and by providing the location of the information within that accreditation application:(a) Evidence, according to the provisions of 211 CMR 52.13: Evidences of Coverage, that all covered services that are subject to Restricted Network Provisions are available and accessible through Network Providers, including a demonstration that:1. The number of Network Providers in the Service Area is sufficient, with respect to current and expected Policyholders, either:a. To deliver adequately all services that are subject to Restricted Network Provisions; orb. To make appropriate referrals.2. The Issuer has written agreements with Network Providers describing specific responsibilities.3. Emergency care is available 24 hours per day and seven days per week.4. In the case of covered services that are subject to a Restricted Network Provision and are provided on a prepaid basis, the Issuer has 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. 211 CMR 71.21(7)(a)4. shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select Policy.(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; and3. 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 written information proposed to be used by the Issuer to comply with 211 CMR 71.21(10).(g) Any other information requested by the Commissioner.(8) A Medicare Select Issuer shall file any proposed changes to the plan of operation according to the process for filing material changes to the accreditation application under 211 CMR 52.06: Application for Accreditation.(9) A Medicare Select Policy shall have a network, and the in network benefits provided under such Medicare Select Policy shall be identical to either the Medicare Supplement Core benefits, or the Medicare Supplement 1 benefits, or the Medicare Supplement 1A benefits. A Medicare Select Policy may offer a tiered network, but the benefits offered in each in network tier shall be identical to either the Medicare Supplement Core benefits, the Medicare Supplement 1 benefits, or the Medicare Supplement 1A benefits.(10) A Medicare Select Policy 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.(11) A Medicare Select Policy shall provide payment for full coverage under the Policy for covered services that are not available through Network Providers.(12) A Medicare Select Issuer shall make full and fair disclosure in writing of the provisions, restrictions and limitations of the Medicare Select Policy 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 with: 1. Other Medicare Supplement Insurance Policies offered by the Issuer; and2. Other Medicare Select Policies or Certificates.(b) A description (including address, phone number and hours of operation) of the Network Providers, including primary care providers, specialty providers, 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.(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 Insurance Policy otherwise offered by the Issuer.(g) A description of the Medicare Select Issuer's quality assurance program and grievance procedure.(13) Prior to the sale of a Medicare Select Policy, 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 211 CMR 71.21(10) and that the applicant understands the restrictions of the Medicare Select Policy. (a) A Medicare Select Issuer shall have and use procedures for hearing complaints and resolving written grievances from the Insureds, and such procedures shall be in accordance with M.G.L. c. 176O, M.G.L. c. 6D, and any other applicable provision of law.(b) The grievance procedure shall be described in the Policy and in the outline of coverage.(c) At the time the Policy is issued, the Issuer shall provide detailed information to the Insured describing the way that a grievance may be registered with the Issuer.(d) Grievances shall be handled in accordance with M.G.L. c. 176O, M.G.L. c. 6D, and any other applicable provision of law.(e) If a grievance is found to be valid, corrective action will be taken in accordance with M.G.L. c. 176O, M.G.L. c. 6D, and any other applicable provision of law.(f) All concerned parties shall be notified about the results of a grievance in accordance with M.G.L. c. 176O, M.G.L. c. 6D, and any other applicable provision of law.(g) The Issuer shall report no later than each March 31st to the Commissioner regarding its grievance procedure. The report shall be in accordance with M.G.L. c. 176O, M.G.L. c. 6D, and any other applicable provision of law in a format as prescribed at the discretion of the Commissioner.(14) At the time of the initial purchase, a Medicare Select Issuer shall make available to each applicant for a Medicare Select Policy the opportunity to purchase any Medicare Supplement Policy offered by the Issuer.(15) At the request of an individual Insured under a Medicare Select Policy, a Medicare Select Issuer shall make available to the individual Insured the opportunity to purchase a Medicare Supplement Policy offered by the Issuer which has comparable or lesser benefits and which does not contain a Restricted Network Provision. For the purposes of 211 CMR 71.21(16), a Medicare Supplement Policy will be considered to have comparable or lesser benefits, unless it contains one or more significant benefits not included in the Medicare Select Policy being replaced. For the purposes of 211 CMR 71.21(16), a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges,
(16) Medicare Select policies shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select Policies issued pursuant to 211 CMR 71.21(16) 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 the opportunity to purchase any Medicare Select Policy offered by the Issuer for which the individual Insured is eligible which has comparable or lesser benefits and which does not contain a restricted Network Provision. The Issuer shall make the policies and available without evidence of insurability.(b) For the purposes of 211 CMR 71.21(17), a Medicare Select Policy will be considered to have comparable or lesser benefits, unless it contains one or more significant benefits not included in the Medicare Select Policy being replaced. For the purposes of 211 CMR 71.21(17)(b), a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.(17) 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.Amended by Mass Register Issue 1397, eff. 8/9/2019.