NAC687B.368. Written disclosure of provisions, restrictions and limitations.

     1. A Medicare select issuer shall disclose in writing the provisions, restrictions and limitations of the Medicare select policy or certificate to each applicant. The disclosure must include:

     (a) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare select policy or certificate with:

          (1) Other policies or certificates to supplement Medicare offered by the Medicare select issuer; and

          (2) Other Medicare select policies.

     (b) A description of the primary care physicians, specialty physicians, hospitals and other network providers, including their addresses, phone numbers and hours of operation.

     (c) A description of the provisions for a restricted network, including those provisions addressing 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.

     (d) A description of coverage for emergency and urgently needed care and coverage for care provided outside the service area.

     (e) A description of any limitations on referrals by network providers to persons other than network providers.

     (f) A description of the policyholder’s or certificate holder’s rights to purchase other policies or certificates to supplement Medicare that the Medicare select issuer offers.

     (g) A description of the program for quality assurance and the procedure for addressing grievances that the Medicare select issuer utilizes.

     2. Before the sale of a Medicare select policy or certificate, a Medicare select issuer must obtain from the applicant a signed and dated form stating that the applicant has received the written disclosure required by subsection 1 and that the applicant understands the restrictions of the Medicare select policy or certificate.

     (Added to NAC by Comm’r of Insurance, eff. 5-13-96; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit)