Rule 20:06:13:66 Filing plan of operation.
20:06:13:66. Filing 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
(1) Evidence that all
covered services that are subject to restricted network provisions are
available and accessible through network providers, including a demonstration
(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
(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
(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
(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;
(7) Any other information
requested by the director.
22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13, 1997.
Authority: SDCL 58-17A-2(12), 58-17A-2, 58-17A-7.
Implemented: SDCL 58-17A-2.
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