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OAC 365:10

INSURANCE DEPARTMENT

policy or certificate in this state until its plan of operation has been approved by the Commissioner. (e) Plan of operation requirements. 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:

      • (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 is 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)

        There are written agreements with network providers describing specific responsibilities.

      • (D)

        Emergency care is available twenty-four (24) hours per day and seven (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 the providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate. This paragraph shall not apply to supplemental charges 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:

      • (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)

      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 Subsection (i).

    • (7)

      Any other information requested by the Commissioner.

  • (f)

    Plan of operation amendments. 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 the changes. Changes shall be considered approved by the Commissioner after thirty (30) days unless specifically disapproved. An updated list of network providers shall be filed with the Commissioner at least quarterly.

(g)

Non-network providers. A Medicare Select policy or certificate shall not restrict payment

for covered services provided by non-network providers if:

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