Details for 3772678.pdf

(c) An issuer shall comply with section 1882 (c) (3) of the
social security act, 42 U.S.C. 1395ss, by complying with all of
the following:
1. Accepting a notice from a Medicare issuer on dually
assigned claims submitted by participating physicians and
suppliers as a claim for benefits in place of any other claim form
otherwise required and making a payment determination on the
basis of the information contained in that notice.
2. Notifying the participating physician or supplier and the
beneficiary of the payment determination.
3. Paying the participating physician or supplier directly.
4. Furnishing, at the time of enrollment, each insured with a
card listing the policy or certificate name, number and a central
mailing address to which notices from a Medicare issuer may be
sent.
5. Paying user fees for claim notices that are transmitted
electronically or otherwise.
6. Providing to the secretary, at least annually, a central
mailing address to which all claims may be sent by Medicare
issuers.
7. Certifying compliance with the requirements set forth in this
subsection on the Medicare supplement insurance experience
reporting form.
(d) 1. Except as provided in subd. 2., an issuer shall continue
to make available for purchase any policy or certificate form
issued after December 31, 2019, that has been approved by the
commissioner. A policy or certificate form shall not be considered
to be available for purchase unless the issuer has actively offered
it for sale in the previous 12 months.
2. An issuer may discontinue the availability of a policy or
certificate form if the issuer provides to the commissioner in
writing its decision at least 30 days prior to discontinuing the
availability of the form of the policy or certificate. After receipt of
the notice by the commissioner, the issuer shall no longer offer for
sale the policy or certificate form in this state.
3. An issuer that discontinues the availability of a policy or
certificate form pursuant to subd. 2., shall not file for approval a
new policy or certificate form of the same type, as defined at subd.
(3) (zar), as the discontinued form for a period of 5 years after the
issuer provides notice to the commissioner of the discontinuance.
The period of discontinuance may be reduced if the commissioner
determines that a shorter period is appropriate.
4. This subsection shall not apply to the riders permitted in
sub. (5t) (e).
(e) The sale or other transfer of Medicare supplement
business to another issuer shall be considered a discontinuance
for the purposes of this subsection.
(f) A change in the rating structure or methodology shall be
considered a discontinuance under par. (d) 1., unless the issuer
complies with the following requirements:
1. The issuer provides an actuarial memorandum, in a form
and manner prescribed by the commissioner, describing the
manner in which the revised rating methodology and resultant
rates differ from the existing rating methodology and resultant
rates.
2. The issuer does not subsequently put into effect a change of
rates or rating factors that would cause the percentage differential
between the discontinued and subsequent rates as described in
the actuarial memorandum to change. The commissioner may
approve a change to the differential that is in the public interest.
(g) Except as provided in par. (h), the experience of all
policy or certificate forms of the same type, as defined in sub.
(3) (zar), in a standard Medicare supplement benefit plan shall
be combined for purposes of the refund or credit calculation
prescribed in sub. (31).
(h) Forms assumed under an assumption reinsurance
agreement shall not be combined with the experience of other
forms for purposes of the refund or credit calculation.
(i) No issuer may issue a Medicare supplement policy or
certificate, Medicare select policy or certificate, or Medicare
cost policy to an applicant 75 years of age or older, unless the
applicant is subject to sub. (3r) or, prior to issuing coverage, the
issuer either agrees not to rescind or void the policy or certificate
except for intentional fraud in the application, or obtains one of
the following:
1. A copy of a physical examination.
2. An assessment of functional capacity.
3. An attending physician’s statement.
4. Copies of medical records.
(j) Notwithstanding par. (a), an issuer may file and use
only one individual Medicare select policy form and one group
Medicare select certificate form. These policy or certificate
forms shall not be aggregated with non-Medicare select forms in
calculating premium rates, loss ratios and premium refunds.
(k) If an issuer nonrenews an insured who has a nonguaranteed
renewable Medicare supplement policy or certificate with the
issuer, the issuer shall at the time any notice of nonrenewal is sent
to the insured, offer a currently available individual replacement
Medicare supplement policy or certificate and those currently
available riders resulting in coverage substantially similar to
coverage provided by the replaced policy or certificate without
underwriting. This replacement shall comply with sub. (27).
(L) For policies or certificates issued to persons newly eligible
for Medicare on or after January 1, 2020, issuers shall combine
the Wisconsin experience of all policy or certificate forms of
the same type, as defined at sub. (3) (zar), for the purpose of
calculating the loss ratio under sub. (16) (d), and rates. The rates
for all policies or certificates of the same type shall be adjusted by
the same percentage. If the Wisconsin experience is not credible,
then national experience can be considered.
(m) If Medicare determines the eligibility of a covered service,
then the issuer shall use Medicare’s determination in processing
claims.
Section 59. INS 3.39 (15) is amended to read:
INS 3.39 (15) Prior to use in this state, every issuer shall
file with the commissioner a copy of any advertisement used
in connection with the sale of Medicare supplement policy or
certificate, Medicare select policy or certificate, or Medicare cost
policies issued with an effective date after December 31, 1989.
If the advertisement does not reference a particular issuer or
Medicare supplement policy or certificate, Medicare select policy
or certificate, or Medicare cost policy or certificate, each agent
utilizing the advertisement shall file the advertisement with the
commissioner on a form specified by the commissioner in the
manner compliant with the commissioner’s instructions. The
advertisements shall comply with all applicable laws and rules of
this state, including s. Ins 3.27 (9).
SECTION 60. INS 3.39 (15) (Note) is repealed.
SECTION 61. INS 3.39 (16) (a), (c), and (d) (intro.) and 1.
are amended to read:
INS 3.39 (16) (a) Every issuer providing Medicare supplement
or Medicare select Medicare cost coverage on a group or individual
basis on policies or certificates issued before or after August 1,
1992 in this state shall file annually its rates, rating schedule and
supporting documentation including ratios of incurred losses
or incurred health care expenses where coverage is provided
by a health maintenance organization on a service rather than
reimbursement basis to earned premiums by policy duration
for approval by the commissioner in accordance with the filing
requirements and procedures prescribed by the commissioner.
All filings of rates and rating schedules shall demonstrate
that expected claims in relation to premiums comply with the
requirements of par. (d) when combined with actual experience
to date. Filings of rate revisions shall also demonstrate that the
anticipated loss ratio over the entire future period for which the
revised rates are computed to provide coverage can be expected
to meet the appropriate loss ratio standards.
(c) As soon as practicable, but no later than October 1 of the
year prior to the effective date of enhancements in Medicare
benefits, every issuer providing Medicare supplement or
Medicare select cost policies or certificates in this state shall
file with the commissioner in accordance with the applicable
filing procedures of this state appropriate premium adjustments
necessary to produce loss ratios as originally anticipated for
the current premium for the applicable policies or certificates.
Supporting documents as necessary to justify the adjustment
shall accompany the filing.
(d) (intro.) For purposes of subs. (4) (e), (4m) (e), (4t) (e),
(14) (L), (14m) (L), (14t) (L) and this subsection, the loss ratio
standards shall be:
1. At least 65% in the case of individual policies.;
SECTION 62. INS 3.39 (16) (d) 3. is renumbered INS 3.39
(16) (d) 3. (intro.) and amended to read:
INS 3.39 (16) (d) 3. For existing policies subject to this
subsection, the loss ratio shall be calculated on the basis of
incurred claims experience or incurred health care expenses
where coverage is provided by a health maintenance organization
on a service rather than reimbursement basis and earned
premiums for such period and in accordance with accepted
actuarial principles and practices. Incurred health care expenses
when coverage is provided by a health maintenance organization
may not include any of the following:
SECTION 63. INS 3.39 (16) (d) 3. a. to g. are created to
read:
INS 3.39 (16) (d) 3. a. Home office and overhead costs.
b. Advertising costs.
c. Commissions and other acquisition costs.
d. Taxes.
e. Capital costs.
f. Administrative costs.
g. Claims processing costs.
SECTION 64. INS 3.39 (16) (e), and (17) are amended to
read:
INS 3.39 (16) (e) An issuer may not use or change any
premium rates for an individual or group Medicare supplement
or Medicare cost policy or certificate unless the rates, rating
schedule, and supporting documentation have been filed with and
approved not disapproved by the commissioner in accordance
with the filing requirements and procedures prescribed by the
commissioner and in accordance with sub. subs. (4) (g), (4m) (f),
and (4t) (f) as applicable.
(17) An issuer may offer policies or certificates with new or
innovative benefits, in addition to the standardized benefits
provided in a policy or certificate that otherwise complies with
the applicable standards and is filed and approved by the
commissioner. The new or innovative benefits may include only
benefits that are appropriate to Medicare supplement insurance,
are new or innovative, are not otherwise available and are costeffective. New or innovative benefits may not include an outpatient
prescription drug benefit. New or innovative benefits may not be
used to change or reduce benefits, including a change of any
cost-sharing provision. Approval of new or innovative benefits
must not adversely impact the goal of Medicare supplement
simplification.
SECTION 65. INS 3.39 (21) (a) is amended to read:
INS 3.39 (21) (a) An issuer may provide and an agent or other
representative may accept commission or other compensation
for the sale of a Medicare supplement policy or certificate, or
Medicare cost select policy or certificate only if the first year
commission or other first year compensation is at least 100%
and no more than 150% no more than 200% of the commission
or other compensation paid for selling or servicing the policy or
certificate in the 2nd year.
SECTION 66. INS 3.39 (21) (f) is created to read:
INS 3.39 (21) (f) No issuer may provide an agent or other
representative commission or compensation for the sale of any
other Medicare supplement policy or certificate, or Medicare
select policy or certificate to an individual who is eligible for
guaranteed issue under sub. (34), calculated on a different basis
of the commissions paid for the sale of a Medicare supplement
policy or certificate, or Medicare select policy or certificate to an
individual who is eligible for open enrollment under sub. (3r).
SECTION 67. INS 3.39 (22) (d), (f) (intro.) and 1., (23) (a)
(intro.), (c) and (e), and (24) (a) (intro.) and 3. are amended
to read:
INS 3.39 (22) (d) If a Medicare supplement or Medicare cost
policy or certificate, Medicare select policy or certificate contains
any limitations with respect to pre-existing preexisting conditions,
such limitations shall may appear on the first page. or as a
separate paragraph of the policy and be labeled as “Preexisting
Condition Limitations.”
(f) As soon as practicable, but no later than 30 days prior
to the annual effective date of any Medicare benefit changes,
an issuer shall notify its policyholders and certificateholders of
modifications it has made to Medicare supplement, Medicare
select, or Medicare cost insurance policies or certificates in the
format similar to Appendix 4, Appendix 4m, or Appendix 4t. The
notice shall contain all of the following:
1. Include a description of revisions to the Medicare program
and a description of each modification made to the coverage
provided under the Medicare supplement policy or certificate,
Medicare select policy or certificate, or Medicare cost policy or
certificate,; and
(23) (a) Application forms for a Medicare supplement policy or
certificate, a Medicare select policy or certificate, and a Medicare
cost coverage policy shall comply with all relevant statutes and
rules. The application form, or a supplementary form signed by
the applicant and agent, shall include the following statements
and questions:
(c) Upon determining that a sale will involve replacement,
an issuer, other than a direct response issuer, or its agent, shall
furnish the applicant, prior to issuance or delivery of the Medicare
supplement, Medicare select policy or certificate, or Medicare
cost policy or certificate, a notice regarding the replacement of
accident and sickness Medicare supplement coverage in no less
than 12 point type. One copy of the notice signed by the applicant
and the agent, except where the coverage is sold without an
agent, shall be provided to the applicant and an additional signed
copy shall be retained by the issuer. A direct response issuer
shall deliver to the applicant at the time of the solicitation of the
policy the notice regarding replacement of accident and sickness
Medicare supplement coverage.
(e) If the application contains questions regarding health and
tobacco usage, include a statement that health questions should
not be answered if the applicant is in the open-enrollment period
described in sub. (4m)(3r), or during a guaranteed issue period

under sub. (34).
(24) (a) Every issuer marketing Medicare supplement
insurance coverage in this state, directly or through its producers,
shall do all of the following:
3. Inquire and otherwise make every reasonable effort to
identify whether a prospective applicant or enrollee insured
for Medicare supplement insurance already has accident and
sickness insurance and the types and amounts of any such
insurance.
SECTION 68. INS 3.39 (24) (a) 4. is created to read:
INS 3.39 (24) (a) 4. Display prominently by type-size, stamp
or other appropriate means, on the first page of the policy the
following: “Notice to buyer: This policy may not cover all of
your medical expenses.”
SECTION 69. INS 3.39 (25) (a), (b), and (c), and (26) (a)
(intro.) and 1. are amended to read:
INS 3.39 (25) (a) In recommending the purchase or
replacement of any Medicare supplement policy or certificate,
Medicare select policy or certificate, or Medicare replacement
cost policy or certificate, an agent shall make reasonable efforts
to determine the appropriateness of a recommended purchase
or replacement.
(b) Any sale of Medicare supplement policy or certificate,
Medicare select policy or certificate, or Medicare replacement
cost policy or certificate that will provide an individual more than
one Medicare supplement policy or certificate, Medicare select
policy or certificate, or Medicare replacement cost policy or
certificate is prohibited.
(c) An agent shall forward each application taken for a
Medicare supplement policy or certificate, Medicare select policy
or certificate, or Medicare replacement cost policy to the issuer
within 7 calendar days after taking the application. An agent shall
mail the portion of any premium collected due the issuer to the
issuer within 7 days after receiving the premium.
(26) (a) On or before March 1 of each year, every issuer
providing Medicare supplement policy or certificate, Medicare
select policy or certificate, or Medicare cost insurance coverage
policy in this state shall report the following information for every
individual resident of this state for which the insurer has in
force more than one Medicare supplement policy or certificate,
Medicare select policy or certificate, or Medicare cost insurance
policy or certificate:
1. Policy and certificate number, and.
SECTION 70. INS 3.39 (26) (a) 3. to 6. are created to read:
INS 3.39 (26) (a) 3. Type of policy.
4. Company name and national association of insurance
commissioners number.
5. Name and contact information of person completing the
form.
6. Other information as requested by the commissioner.
SECTION 71. INS 3.39 (26) (b), (27), (28) (title), (a) (intro.),
(b) 2., and (c), (29) (a) and (b) 1., and (30) (a) are amended
to read:
INS 3.39 (26) (b) The items in par. (a) must be grouped
by individual policyholder or certificateholder and listed on a
form in substantially the same format as made available by the
commissioner. Appendix 9 Issuers shall submit the information in
the manner compliant with the commissioner’s instructions on or
before March 1 of each year.
(27) If a Medicare supplement policy or certificate, Medicare
select policy or certificate, or Medicare cost policy or certificate
replaces another Medicare supplement policy or certificate,
Medicare select policy or certificate or Medicare cost policy
or certificate that has been in effect for at least 6 months, the
replacing issuer shall waive any time periods applicable to
pre-existing condition preexisting conditions, waiting periods,
elimination periods and probationary periods in the new Medicare
supplement, Medicare select, or new Medicare cost policy for
similar benefits to the extent such time was periods were satisfied
under the original policy or certificate.
(28) Group policy certificate continuation and conversion
requirements. (a) If a group Medicare supplement insurance
policy certificate is terminated by the group policyholder issued a
certificate and not replaced as provided in par. (c), the issuer shall
offer certificateholders at least the following choices:
(b) 2. At the option of the group policyholder issued a
certificate, offer the certificateholder continuations of coverage
under the group policy certificate for the time specified in s.
632.897, Stats.
(c) If a group Medicare supplement policy certificate
is replaced by another group Medicare supplement policy
certificate, the issuer of the replacement policy certificate shall
offer coverage to all persons covered under the old group policy
certificate on its date of termination. Coverage under the new
group policy certificate shall not result in any limitation exclusion
for pre-existing preexisting conditions that would have been
covered under the group policy certificate being replaced.
(29) filinG and approval requirements. (a) An issuer shall not
deliver or issue for delivery a Medicare supplement policy or
certificate, Medicare select policy or certificate or Medicare cost
policy to a resident of this state unless the policy form or certificate
form has been filed with and approved by the commissioner in
accordance with filing requirements and procedures prescribed
by the commissioner.
(b) 1. Beginning January 1, 2007, issuers shall replace
existing amended policies and riders for current and renewing
enrollees insureds with filed and approved policy or certificate
forms that are compliant with the MMA. An issuer shall, beginning
January 1, 2007, use filed and approved policy or certificate forms
that are compliant with the MMA for all new business.
(30) (a) 1. This subsection shall apply only to Medicare
select policies and certificates issued to persons first eligible for
Medicare prior to June 1, 2010. This subsection does not apply
to Medicare supplement policies and certificates or Medicare cost
policies.
2. No Medicare select policy or certificate may be advertised
as a Medicare select policy or certificate unless it meets the
requires of this subsection.
SECTION 72. INS 3.39 (30) (b) is repealed.
SECTION 73. INS 3.39 (30) (k) (intro.), (n) (intro.), (q) 12., (r)
12., and (30m) (a) 1. are amended to read:
INS 3.39 (30) (k) A Medicare select issuer shall have and
use procedures for hearing complaints and resolving written
grievances from its subscribers for Wisconsin mandated
benefits. Such The grievance procedures shall be aimed at
mutual agreement for settlement and, may include arbitration
procedures, and may include all of the following.:
(n) Medicare select policies and certificates shall provide for
continuation of coverage in the event the Secretary secretary
determines that Medicare select policies and certificates issued
pursuant to this section should be discontinued due to either the
failure of the Medicare select federal program to be reauthorized
under law or its substantial amendment.
(q) 12. Coverage of 100% of all cost sharing under Medicare
Part A or B for the balance of the calendar year after the individual
has reached the out-of-pocket limitation on annual expenditures
under Medicare Parts A and B of $4,000 in 2006, indexed each
year by the appropriate inflation adjustment specified by the
Secretary secretary.
(r) 12. Coverage for 100% of all cost sharing under Medicare
Parts A and B for the balance of the calendar year after the
individual has reached the out-of-pocket limitation on annual
expenditures under Medicare Parts A and B of $2,000 in 2006,
indexed each year by the appropriate inflation adjustment
specified by the Secretary secretary.
(30m) (a) 1. This subsection shall only apply to Medicare
select policies and certificates issued to persons first eligible for
Medicare on or after June 1, 2010 and prior to January 1, 2020.
This subsection does not apply to Medicare supplement policies
or certificates.
SECTION 74. INS 3.39 (30m) (b) is repealed.
SECTION 75. INS 3.39 (30m) (i) 1. (intro.), and 8., (k) (intro.),
(n) (intro.), (q) (intro.), (r) 12., and (s) 12. are amended to read:
INS 3.39 (30m) (i) 1. An outline of coverage in substantially
the same format as Appendices 22m and 55m sufficient to permit
the applicant to compare the coverage and premiums of the
Medicare select policy or certificate to the following:
8. A designation: MEDICARE SELECT POLICY. This
designation shall be immediately below and in the same type size
as the designation required in sub. (4s)(4m) (a) 10.
(k) A Medicare select issuer shall have and use procedures
for hearing complaints and resolving written grievances from
its subscribers for Wisconsin mandated benefits. Such The
grievance procedures shall be aimed at mutual agreement for
settlement and, may include arbitration procedures, and include
all of the following.:
(n) Medicare select policies and certificates shall provide for
continuation of coverage in the event the Secretary secretary
determines that Medicare select policies and certificates issued
pursuant to this section should be discontinued due to either the
failure of the Medicare select federal program to be reauthorized
under law or its substantial amendment, then the following apply:
(q) Permissible additional coverage may only be added to the
policy or certificate as separate riders. The issuer shall issue a
separate rider for each additional coverage offered. Issuers shall
ensure that the riders offered are compliant with MMA, each rider
is priced separately, available for purchase separately at any
time, subject to underwriting and the preexisting limitation allowed
in sub. (4s)(4m) (a) 2., and may consist of the following:
(r) 12. Coverage for 100% of all cost sharing under Medicare
Part A or B for the balance of the calendar year after the individual
has reached the out-of-pocket limitation on annual expenditures
under Medicare Parts A and B of [$4,440] in 2010, indexed each
year by the appropriate inflation adjustment specified by the
Secretary secretary.
(s) 12. Coverage for 100% of all cost sharing under Medicare
Parts A and B for the balance of the calendar year after the
individual has reached the out-of-pocket limitation on annual
expenditures under Medicare Parts A and B of [$2,220] in
2010, indexed each year by the appropriate inflation adjustment
specified by the Secretary secretary.
SECTION 76. INS 3.39 (30t) is created to read:
INS 3.39 (30t) medicare select policies and certificates. (a) 1.
This subsection shall apply only to Medicare select policies and
certificates issued to persons newly eligible for Medicare on or
after January 1, 2020. This subsection does not apply to Medicare
supplement policies or certificates or to Medicare cost policies.
2. No Medicare select policy or certificate may be advertised
as a Medicare select policy or certificate unless it meets the
requirements of this subsection.
(c) The commissioner may authorize an issuer to offer a
Medicare select policy or certificate, pursuant to this subsection
OBRA, if the commissioner finds that the issuer has satisfied all
of the requirements of this subsection.
(d) 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.
(e) 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 all of
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 of all of the
following:
a. That covered 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 medical
travel times within the community.
b. That the number of network providers in the service area is
sufficient, with respect to current and expected policyholders or
certificateholders, either to deliver adequately all services that are
subject to a restricted network provision or to make appropriate
referrals.
c. That there are written agreements with network providers
describing specific responsibilities.
d. Emergency care is available 24 hours per day and 7 days
per week.
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
such providers from billing or otherwise seeking reimbursement
from or recourse against any individual insured under a Medicare
select policy or certificate. This subd. 1. e. may not apply to
supplemental charges, copayment, or coinsurance amounts as
stated in the Medicare select policy or certificate.
2. A statement or map providing a clear description of the
service area.
3. A description of the grievance procedure to be utilized.
4. A description of the quality assurance program, including
all of the following:
a. The formal organizational structure.
b. The written criteria for selection, retention, and removal of
network providers.
c. The procedures for evaluating quality of care provided by
network providers.
d. The process to initiate corrective action when warranted.
5. A list and description, by specialty, of the network providers.
6. Copies of the written information proposed to be used by
the issuer to comply with par. (i).
7. Any other information requested by the commissioner.
(f) 1. 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
such changes. Such changes shall be considered approved by
the commissioner after 30 days after filing unless specifically
disapproved.
2. An updated list of network providers shall be filed with the
commissioner at least quarterly.
(g) A Medicare select policy or certificate may not restrict
payment for covered services provided by non-network providers
if all of the following occur:
1. The services are for symptoms requiring emergency care
or are immediately required for an unforeseen illness, injury or

a condition.
2. It is not reasonable to obtain services described in subd. 1.
through a network provider.
(h) A Medicare select policy or certificate shall provide
payment for full coverage under the policy or certificate for
covered services that are not available through network providers.
(i) A Medicare select issuer shall make full and fair disclosure
in writing of the provisions, coinsurance, or copayments,
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 in substantially the same format as
Appendices 2t and 5t sufficient to permit the applicant to compare
the coverage and premiums of the Medicare select policy or
certificate to the following:
a. Other Medicare supplement policies or certificates offered
by the issuer.
b. 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 copayments or 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 outof-pocket annual limit contained in the Medicare Select 50% and
25% Coverage Cost-Sharing plans offered by the Medicare select
issuer under pars. (r) and (s).
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 or certificate holder’s
rights to purchase any other Medicare supplement policy or
certificate otherwise offered by the issuer.
7. A description of the Medicare select issuer’s quality
assurance program and grievance procedure.
8. A designation: MEDICARE SELECT POLICY. This
designation shall be immediately below and in the same type size
as the designation required in sub. (4t) (a) 10.
9. The caption, except that the word “certificate” may be used
instead of “policy,” if appropriate: “The Wisconsin Insurance
Commissioner has set standards for Medicare select policies.
This policy meets these standards. It, along with Medicare, may
not cover all of your medical costs. You should review carefully all
policy limitations. For an explanation of these standards and other
important information, see ‘Wisconsin Guide to Health Insurance
for People with Medicare,’ given to you when you applied for this
policy. Do not buy this policy if you did not get this guide.”
(j) 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 par. (i) and that the applicant
understands the restrictions of the Medicare select policy or
certificate.
(k) A Medicare select issuer shall have and use procedures
for hearing complaints and resolving written grievances from its
subscribers for Wisconsin mandated benefits. These grievance
procedures shall be aimed at mutual agreement for settlement,
may include arbitration procedures, and may include all of the
following:
1. The grievance procedure shall be described in the policy
and certificate and in the outline of coverage.
2. At the time the policy or certificate is issued, the issuer shall
provide detailed information to the policyholder or certificateholder
describing how a grievance may be registered with the issuer.
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 to the commissioner no later than
each March 31st 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.
(L) At the time of initial purchase of a Medicare select policy or
certificate, a Medicare select issuer shall make available to each
applicant for the policy or certificate the opportunity to purchase
any Medicare supplement policy or certificate otherwise offered
by the issuer.
(m) 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,
that has comparable or lesser benefits and that does not contain
a restricted network provision. The issuer shall make Medicare
select policies or certificates available without requiring evidence
of insurability after the Medicare select policy or certificate has
been in force for 6 months.
2. For the purposes of this subdivision, 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. 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 Medicare Part B
excess charges.
(n) 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
section should be discontinued due to either the failure of the
Medicare select program to be reauthorized under law or its
substantial amendment, then all of the following apply:
1. 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 Medicare supplement policies
and certificates available without requiring evidence of insurability.
2. For the purposes of this subdivision, 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. 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 Medicare Part B
excess charges.
(o) A Medicare select issuer shall comply with reasonable
requests for data made by state or federal agencies, including the
CMS, for the purpose of evaluating the Medicare select program.
(p) Except as provided in par. (r) or (s), a Medicare select
policy or certificate issued for delivery to individuals newly eligible
for Medicare on or after January 1, 2020, shall contain the
following coverages:
1. The “basic Medicare supplement coverage” as described
in sub. (5t) (d).
2. Coverage for 100% of the Medicare Part A hospital
deductible as described in sub. (5t) (e) 1.
3. Coverage for home health care for an aggregate of 365
visits per policy or certificate year as described in sub. (5t) (e) 3.
4. Coverage for preventive health care services as described
in sub. (5t) (d) 15.
5. Coverage for emergency care obtained outside of the
United States as described in sub. (5t) (e) 6.
(q) Permissible additional coverage may only be added to
the policy or certificate as separate riders. The issuer shall issue
a separate rider for each additional rider offered. Issuers shall
ensure that the riders offered are compliant with MMA, each rider
is priced separately, available for purchase separately at any
time, subject to underwriting and the preexisting limitation allowed
in sub. (4t) (a) 2., and may consist of any of the following:
1. Coverage for 50% of the Medicare Part A hospital deductible
with no out-of-pocket maximum as described in sub. (5t) (e) 2.
2. Coverage for Medicare Part B copayment or coinsurance as
described in sub. (5t) (e) 4.
(r) The Medicare Select 50% Cost-Sharing plans issued
to persons who first became eligible for Medicare on or after
January 1, 2020, shall only contain the following coverages:
1. The designation: MEDICARE SELECT 50% COSTShARINg PLAN.
2. Coverage for 100% of the Medicare Part A hospital
coinsurance or copayment amount for each day used from the
61st through the 90th day in any Medicare benefit period.
3. Coverage for 100% of the Medicare Part A hospital
coinsurance or copayment amount for each Medicare lifetime
inpatient reserve day used from the 91st through the 150th day in
any Medicare benefit period.
4. Upon exhaustion of the Medicare hospital inpatient
coverage, including the lifetime reserve days, coverage for 100%
of the Medicare Part A eligible expenses for hospitalization paid
at the applicable prospective payment system rate, or other
appropriate Medicare standard of payment, subject to a lifetime
limitation benefit of an additional 365 days.
5. Coverage for 50% of the Medicare Part A inpatient hospital
deductible amount per benefit period until the out-of-pocket
limitation as described in subd. 12. is met.
6. Coverage for 50% of the coinsurance or copayment
amount for each day used from the 21st day through the 100th
day in a Medicare benefit period for post-hospital skilled nursing
facility care eligible under Medicare Part A until the out-of-pocket
limitation as described in subd. 12. is met.
7. Coverage for 50% of cost sharing for all Medicare Part
A eligible expenses and respite care until the out-of-pocket
limitation as described in subd. 12. is met.
8. Coverage for 50%, under Medicare Part A or B, of the
reasonable cost of the first 3 pints of blood, or equivalent quantities
of packed red blood cells, as defined under federal regulations,
unless replaced in accordance with federal regulations until the
out-of-pocket limitation as described in subd. 12. is met.
9. Except for coverage provided in subd. 11., coverage for
50% of the cost sharing otherwise applicable under Medicare Part
B after the policyholder or certificateholder pays the Medicare
Part B deductible until the out-of-pocket limitation as described
in subd. 12. is met.
10. Coverage for 100% of the cost sharing for the benefits
described in sub. (5t) (d) 1., 6., 7., 9., 14., 16., and 17., and (e)
3., to the extent the benefits do not duplicate benefits paid by
Medicare and after the policyholder or certificateholder pays the
Medicare Part A and B deductible and the out-of-pocket limitation
described in subd. 12. is met.
11. Coverage for 100% of the cost sharing for Medicare Part B
preventive services after the policyholder or certificateholder pays
the Medicare Part B deductible.
12. Coverage for 100% of all cost sharing under Medicare Part
A or B for the balance of the calendar year after the individual has
reached the out-of-pocket limitation on annual expenditures under
Medicare Parts A and B indexed each year by the appropriate
inflation adjustment specified by the secretary.
(s) The Medicare Select 25% Coverage Cost-Sharing plans
issued to persons who first became eligible for Medicare on
or after January 1, 2020, shall only contain all of the following
phrases and coverages:
1. The designation: MEDICARE SELECT 25% COSTShARINg PLAN.
2. Coverage for 100% of the Medicare Part A hospital
coinsurance or copayment amount for each day used from the
61st through the 90th day in any Medicare benefit period.
3. Coverage for 100% of the Medicare Part A hospital
coinsurance or copayment amount for each Medicare lifetime
inpatient reserve day used from the 91st through the 150th day in
any Medicare benefit period.
4. Upon exhaustion of the Medicare hospital inpatient
coverage, including the lifetime reserve days, coverage for 100%
of the Medicare Part A eligible expenses for hospitalization paid
at the applicable prospective payment system rate, or other
appropriate Medicare standard of payment, subject to a lifetime
limitation benefit of an additional 365 days.
5. Coverage for 75% of the Medicare Part A inpatient hospital
deductible amount per benefit period until the out-of-pocket
limitation as described in subd. 12. is met.
6. Coverage for 75% of the coinsurance or copayment
amount for each day used from the 21st day through the 100th
day in a Medicare benefit period for post-hospital skilled nursing
facility care eligible under Medicare Part A until the out-of-pocket
limitation as described in subd. 12. is met.
7. Coverage for 75% of cost sharing for all Medicare Part
A eligible expenses and respite care until the out-of-pocket
limitation as described in subd. 12. is met.
8. Coverage for 75%, under Medicare Part A or B, of the
reasonable cost of the first 3 pints of blood, or equivalent quantities
of packed red blood cells, as defined under federal regulations,
unless replaced in accordance with federal regulations until the
out-of-pocket limitation as described in subd. 12. is met.
9. Except for coverage provided in subd. 11., coverage for
75% of the cost sharing otherwise applicable under Medicare
Part B, except there shall be no coverage for the Medicare Part B
deductible until the out-of-pocket limitation as described in subd.
12. is met.
10. Coverage for 100% of the cost sharing for the benefits
described in sub. (5t) (d) 1., 6., 7., 9., 14., 16., and 17., and (e)
3., to the extent the benefits do not duplicate benefits paid by
Medicare and after the policyholder or certificateholder pays the
Medicare Part A and B deductible and the out-of-pocket limitation
described in subd. 12. is met.
11. Coverage for 100% of the cost sharing for Medicare Part B
preventive services after the policyholder or certificateholder pays
the Medicare Part B deductible.
12. Coverage for 100% of all cost sharing under Medicare
Parts A and B for the balance of the calendar year after the
individual has reached the out-of-pocket limitation on annual
expenditures under Medicare Parts A and B, indexed each year

by the appropriate inflation adjustment specified by the secretary.
(t) A Medicare select policy or certificate may include
permissible additional coverage as described in sub. (5t) (e) 2.,
4., and 6. These riders, if offered, shall be added to the policy or
certificate as separate riders or amendments and shall be priced
separately and available for purchase separately.
(u) Issuers writing Medicare select policies or certificates shall
additionally comply with subchs. I and III of ch. INS 9.
SECTION 77. INS 3.39 (31) (a) and (b) is repealed and
recreated to read:
INS 3.39 (31) (a) Every issuer providing individual or
group Medicare supplement policies or certificates and every
issuer providing individual or group Medicare select policies or
certificates shall collect and file the following information with
the commissioner. The data must be provided on a form made
available by the commissioner. Issuers shall submit the following
information in the manner compliant with the commissioner’s
instructions on or before May 31 of each year:
1. The actual experience loss ratio of incurred claims to
earned premium net of refunds.
2. A credibility adjustment based on a creditability factor.
3. A comparison to the benchmark loss ratio that is a
cumulative incurred claims divided by the cumulative earned
premiums to date.
4. A calculation of the amount of refund or premium credit,
if any.
5. A certification that the refund calculation is accurate.
(b) 1. For policies or certificates issued between December
31, 1980, and January 1, 1992, issuers shall combine the
Wisconsin experience of all policy or certificate forms of the same
type, as defined at sub. (3) (zar), for purposes of calculating the
amount of refund or premium credit, if any. Issuers may combine
the Wisconsin experience of all policies issued prior to January
1, 1981, with those issued between December 31, 1980, and
January 1, 1992, if the issuer uses the 60% loss ratio for individual
policies and the 70% loss ratio for group certificates renewed prior
to January 1, 1996, and the appropriate loss ratios specified in
sub. (16) (d), thereafter.
2. For policies or certificates issued on or after
January 1, 1992, and prior to June 1, 2010, issuers shall combine
the Wisconsin experience of all policy or certificate forms of
the same type, as defined at sub. (3) (zar), for the purposes of
calculating the amount of the refund or premium credit, if any, if
the issuer uses the 65% loss ratio for individual policies and the
75% loss ratio for group certificates renewed on or after January
1, 1996 and prior to June 1, 2010, and the appropriate loss ratios
specified in sub. (16) (d).
SECTION 78. INS 3.39 (31) (bm) is repealed.
SECTION 79. INS 3.39 (34) (a) 1., 2., (b) (intro.), 1s. and 2.,
(e) 4. and 5. are amended to read:
INS 3.39 (34) (a) 1. Eligible persons Persons eligible for
guarantee issue are those individuals described in par. (b) who
seek to enroll under the policy during the period specified in
par. (c), and who submit evidence of the date of termination or
disenrollment with the application for a Medicare supplement
policy, Medicare select policy or Medicare cost policy, and where
applicable, evidence of enrollment in Medicare Part D.
2. With respect to an eligible person, an issuer may not deny or
condition the issuance or effectiveness of a Medicare supplement
policy, Medicare select policy, or Medicare cost policy described
in par. (e) that is offered and is available for issuance to new
enrollees by the issuer, and shall not discriminate in the pricing
of such a Medicare supplement, Medicare select, or Medicare
cost policy because of health status, claims experience, receipt
of health care, or medical condition and shall not impose an
exclusion of benefits based on condition and shall not impose an
exclusion of benefits based on a pre-existing preexisting condition
under such a Medicare supplement policy, Medicare select policy,
or Medicare cost policy.
(b) Eligible persons. An eligible person for guarantee issue is
an individual described in any of the following subdivisions:
1s. The individual is enrolled in a Medicare select plan policy
and is notified by the issuer, as required in par (f) 3. and s. Ins
9.35, as applicable, that a hospital is leaving the Medicare select
policy network and that there is no other participating network
provider hospital within a 30 minute or 30 mile radius of the
policyholder.
2. The individual is enrolled with a Medicare Advantage
organization under a Medicare Advantage plan under part C
of Medicare, and any of the following circumstances apply, or
the individual is 65 years of age or older and is enrolled with a
Program of All-Inclusive Care for the Elderly (PACE) provider
under Section 1894 of the Social Security Act, and there are
circumstances similar to those described below that would
permit discontinuance of the individual’s enrollment with such the
PACE provider if such the individual were enrolled in a Medicare
Advantage plan including any of the following:
(e) 4. Paragraph (b) 7., is a Medicare supplement policy as
described in sub. (5) along with any riders available or a Medicare
select policy as defined described in sub. (30), that is offered and
is available for issuance to new enrollees by the same issuer that
issued the individual’s Medicare supplement policy or Medicare
select policy with containing the outpatient prescription drug
coverage.
5. Paragraph (b) 3., is a Medicare cost policy as described in
sub. (7) along with any enhancements and riders, that is offered
and is available for issuance to new enrollees by the same issuer
that issued the individual’s Medicare cost policy.
SECTION 80. INS 3.39 (34) (ez) is renumbered INS 3.39 (34)
(em) and amended to read:
INS 3.39 (34) (em) Products to which that persons eligible for
Medicare persons are entitled guarantee issue on or after June 1,
2010, and prior to January 1, 2020, are entitled to enroll into. The
Medicare supplement policy or certificate, Medicare select policy
or certificate, or Medicare cost policy or certificate to which that
the guarantee issue eligible persons are entitled to enroll include
any of the following under:
1. Paragraph (b) 1., 1m., 1r., 1s., 2., 3. and 4. is a Medicare
supplement policy or certificate as defined described in sub. (5m)
along with any riders available or a Medicare select policy or
certificate as defined described in sub. (30m).
2. Paragraph (b) 5. is the same Medicare supplement policy
or certificate in which the individual was most recently previously
enrolled, if available from the same issuer, or, if not so available,
a policy or certificate as described in subd. 1.
3. Paragraph (b) 6. and 8. is a Medicare supplement policy
or certificate as described in sub. (5m) along with any riders
available or a Medicare select policy or certificate as defined in
sub. (30m).
4. Paragraph (b) 7. is a Medicare supplement policy or
certificate as described in sub. (5m) along with any riders available
or a Medicare select policy or certificate as defined described in
sub. (30m), that is offered and is available for issuance to new
enrollees by the same issuer that issued the individual’s Medicare
supplement policy or certificate.
SECTION 81. INS 3.39 (34) (et) is created to read:
INS 3.39 (34) (et) Products that persons eligible for guarantee
issue are entitled to enroll into who first became eligible for
Medicare on or after January 1, 2020. The Medicare supplement
policy or certificate, Medicare select policy or certificate, or
Medicare cost policy that persons are entitled to enroll on the
basis of guarantee issue includes any of the following:
1. Paragraph (b) 1., 1m., 1r., 1s., 2., 3. and 4., is a Medicare
supplement policy or certificate as described in sub. (5t) with
any riders available or a Medicare select policy or certificate as
described in sub. (30t).
2. Paragraph (b) 5. is the same Medicare supplement policy
or certificate in which the individual was most recently enrolled, if
available from the same issuer, or, if not so available, a policy or
certificate as described in subd. 1.
3. Paragraph (b) 6. and 8., is a Medicare supplement policy
or certificate as described in sub. (5t) with any riders available or
a Medicare select policy or certificate as described in sub. (30t).
4. Paragraph (b) 7., is a Medicare supplement policy or
certificate as described in sub. (5t) with any riders available or
a Medicare select policy or certificate as described in sub. (30t),
that is offered and is available for issuance to new enrollees by
the same issuer that issued the individual’s Medicare supplement
policy or certificate.
SECTION 82. INS 3.39 (34) (f) 1. and 2. are amended to
read:
INS 3.39 (34) (f) Notification provisions. 1. At the time of an
event described in par. (b) because of which an individual loses
coverage or benefits due to the termination of a contract or
agreement, policy, or plan, the organization that terminates the
contract or agreement, the issuer terminating the policy, or the
administrator of the plan being terminated, respectively, shall
notify the individual of his or her rights under this section, and of
the obligations of issuers of Medicare supplement policies and
certificates, Medicare select policies or certificates, or Medicare
cost policies under par. (a). The notice shall be communicated
within 10 working days of the issuer receiving notification of
disenrollment.
2. At the time of an event described in par. (b) of this section
because of which an individual ceases enrollment under a contract
or agreement, policy, or plan, the organization that offers the
contract or agreement, regardless of the basis for the cessation
of enrollment, the (30) (k) the policy, or the administrator of the
plan, respectively, shall notify the individual of his or her rights
under this section, and of the obligations of issuers of Medicare
supplement policies or certificates, Medicare select policies or
certificates or Medicare cost polices under par. (a). Such The
notice shall be communicated within 10 working days of the issuer
receiving notification of disenrollment.
SECTION 83. INS 3.39 (35) (intro.) and (a) are amended
to read:
INS 3.39 (35) exchanGe of medicare supplement policy. An
issuer that submits and receives approval to offer a Medicare
supplement insurance policy or certificate that is effective or
issued to persons first eligible for Medicare on or after June 1,
2010, and before June 1, 2011, may offer an exchange subject to
the following requirements:
(a) By or before May 31, 2011, on a one-time basis in writing,
an issuer may offer to all of its existing Medicare supplement
policyholders or certificateholders covered by a policy with an
effective prior to June 1, 2010, the option to exchange the existing
policy to a different policy that complies with subs. (4s) (4m), (5m)
and (30m), as applicable.
SECTION 84. INS 3.39 Appendix 1 is amended to read:
SECTION 85. INS 3.39 Appendix 2 is renumbered INS 3.39
Appendix 2m and amended to read:
SECTION 86. INS 3.39 Appendix 2t is created to read:
SECTION 87. INS 3.39 Appendix 3 is renumbered INS 3.39
Appendix 3m and INS 3.39 Appendix 3m (title) and (subtitle),
as renumbered, are amended to read:
SECTION 89. INS 3.39 Appendix 4 is renumbered INS
3.39 Appendix 4m and INS 3.39 Appendix 4m (title), as
renumbered, is amended to read:
SECTION 90. INS 3.39 Appendix 4t is created to read:
SECTION 91. INS 3.39 Appendix 5 is renumbered INS
3.39 Appendix 5m and INS 3.39 Appendix 5m (title), as
renumbered, is amended to read:
SECTION 92. INS 3.39 Appendix 5t is created to read:
SECTION 93. INS 3.39 Appendix 6 is amended to read:
SECTION 94. INS 3.39 Appendices 6m and 6t are created
to read:
SECTION 95. INS 3.39 Appendix 7 is amended to read:
SECTION 96. INS 3.39 Appendices 8 and 9 are repealed.
SECTION 97. INS 3.55 (title), (1) and (2) are amended to
read:
INS 3.55 (title) Benefit appeals under long-term care
policies, life insurance-long-term care coverage and
Medicare replacement and supplement policies.
(1) purpose. This section implements and interprets s. 632.84,
Stats., for the purpose of establishing minimum requirements
for the internal procedure for benefit appeals that insurers shall
provide in long-term care policies, life insurance-long-term care
coverage and Medicare replacement or supplement policies. This
section also facilitates the review by the commissioner of these
policy forms.
(2) scope. This section applies to individual and group
nursing home insurance policies and Medicare replacement or
supplement policies issued or renewed on or after August 1,
1988, and to long-term care policies and life insurance-long-term
care coverage issued or renewed on and after June 1, 1991,
except for polices or coverage exempt under s. Ins 3.455 (2) (b).
This section does not apply to health maintenance organizations,
limited service health organization or preferred provider plan, as
those are defined in s. 609.01, Stats.
SECTION 98. INS 3.55 (3) (d) and (e) are repealed.
SECTION 99. INS 3.55 (4) (a) and (5) (intro.) are amended
to read:
INS 3.55 (4) (a) Pursuant to s. 632.84 (2), Stats., an insurer
shall include an internal procedure for benefit appeals in any
long-term care policy, or life insurance-long-term care coverage
any Medicare replacement cost or supplement policy an internal
procedure for benefit appeals.
(5) reports to the commissioner. An insurer offering a long-term
care insurance policy or rider shall report to the commissioner
by March 31 of each year a summary of all benefit appeals filed
during the previous calendar year and the disposition of these
appeals, including:
SECTION 100. INS 9.01 (3m) is amended to read:
INS 9.01 (3m) “Defined network plan” has the meaning
provided under s. 609.01 (1b), Stats., and includes Medicare
select policies, Medicare Select policy and certificates as defined
in s. Ins 3.39 (30) (b) 4. (3) (vm) and (ve), respectively, and health
benefit plans that contract for use of participating providers.
SECTION 101. EFFECTIVE DATE. This rule is effective on the
day of publication in the official state newspaper in accordance
with s. 227.24 (2), Stats.
Dated at Madison, Wisconsin, this 10th day of October, 2019.
/s/Mark V. Afable
Commissioner
PUB: WSJ: October 15, 2019
#3772376 WNAXLP

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