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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 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 ยง 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.

          General Authority: SDCL 58-17A-2(12), 58-17A-2, 58-17A-7.

          Law Implemented: SDCL 58-17A-2.


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