Md. Code Regs. 31.10.06.25

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.06.25 - Medicare Select-Consumer Protection

A. Applicability.

(1) This regulation shall apply to Medicare Select policies and certificates, as defined in Regulation .02 of this chapter.

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

B. Required Disclosure.

(1) 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.

(2) The disclosure required by §B(1) of this regulation 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:

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

(ii) 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 if 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 policy or certificate otherwise offered by the issuer; and

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

(3) With regard to the description of restricted network provisions required by §B(2)(c) of this regulation, expenses incurred when using out-of-network providers may not count toward the out-of-pocket annual limit contained in plans K and L, except to the extent specified in the policy or certificate.

C. Before 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 under §B of this regulation and that the applicant understands the restrictions of the Medicare Select policy or certificate.

D. Complaints and Grievances.

(1) Procedures Required.

(a) A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers.

(b) The procedures for hearing complaints and resolving written grievances from subscribers shall be aimed at mutual agreement for settlement.

(2) The grievance procedure shall be described in the policy and certificates and in the outline of coverage.

(3) Any grievance procedure involving coverage decisions shall comply with the requirements found in Insurance Article, Title 15, Subtitle 10D, Annotated Code of Maryland.

(4) Any grievance procedure involving adverse decisions shall comply with the requirements found in Insurance Article, Title 15, Subtitle 10A, Annotated Code of Maryland.

(5) 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.

(6) An issuer shall consider grievances in a timely manner and shall transmit the grievances to appropriate decision-makers who have authority to fully investigate the issue and take corrective action.

(7) If a grievance is found to be valid, an issuer shall take corrective action promptly.

(8) An issuer shall notify all concerned parties about the results of a grievance.

(9) Annual Report.

(a) The issuer shall report not later than March 31 of each year to the Commissioner regarding its grievance procedure.

(b) The report required by §D(9)(a) of this regulation 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 the grievances.

E. 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.

F. Right to Purchase Medicare Supplement Policy or Certificate.

(1) 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.

(2) The issuer shall make available the policies or certificates described in §F(1) of this regulation without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for 6 months.

(3) For the purposes of §F(1) of this regulation, a Medicare supplement policy or certificate shall be considered to have comparable or lesser benefits unless the Medicare supplement policy or certificate contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced.

(4) A benefit shall be considered a significant benefit under §F(3) of this regulation if the benefit includes coverage for the Medicare Part A deductible, coverage for at-home recovery services, or coverage for Part B excess charges.

G. Options if the Medicare Select Program is Discontinued.

(1) Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary determines that Medicare Select policies and certificates issued under this regulation shall be discontinued due to either the:

(a) Failure of the Medicare Select Program to be reauthorized under law; or

(b) Substantial amendment of the Medicare Select Program.

(2) If the Secretary determines that Medicare Select policies and certificates should be discontinued as described in §G(1) of this regulation, 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.

(3) The issuer referenced in §G(2) of this regulation shall make available the policies and certificates without requiring evidence of insurability.

(4) For the purposes of §G(2) of this regulation, a Medicare supplement policy or certificate shall 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.

(5) A benefit shall be considered a significant benefit under §G(4) of this regulation if the benefit includes coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.

Md. Code Regs. 31.10.06.25