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OAC 365:10

INSURANCE DEPARTMENT

    • (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 services through a network provider.

  • (h)

    Unavailable services. 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. (i) Full disclosure. 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:

      • (A)

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

      • (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 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.

    • (7)

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

  • (j)

    Proof of full disclosure. 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 (i) of this Section and that the applicant understands the restrictions of the Medicare Select policy or certificate. (k) Grievance procedures. A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. The procedures shall be aimed at

mutual agreement for settlement.

(1)

The grievance procedure shall be described in the policy and certificates 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 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.

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