20:06:13:66Filing plan of operation.

A Medicare select issuer shall file a proposed plan of operation with the director in a format prescribed by the director. The plan of operation must 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) Such services can be provided by network providers with reasonable promptness regarding geographic location, hours of operation, and after-hour care. The hours of operation and availability of after-hour care must reflect the usual practice in the local area. Geographic availability must reflect the usual travel times within the community; (b) The number of network providers in the service area is sufficient for current and expected policyholders either to deliver adequately all services that are subject to a restricted network provision or to make appropriate referrals. (c) There are written agreements with network providers describing specific responsibilities; (d) Emergency care is available 24 hours a day and 7 days a 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 subsection does 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 used; (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 § 20:06:13:70; and (7) Any other information requested by the director.

Source: 22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13, 1997.