California Insurance Code § 10192.10

(a) (1) This section shall apply to Medicare Select policies and certificates, as defined in this section. (2) A policy or certificate shall not be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section. (b) For the purposes of this section: (1) “Appeal” means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers. (2) “Complaint” means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers. (3) “Medicare Select issuer” means an issuer offering, seeking to offer, advertising, marketing, soliciting, or issuing a Medicare Select policy or certificate. (4) “Medicare Select policy” or “Medicare Select certificate” means respectively a Medicare supplement policy or certificate that contains restricted network provisions. (5) “Network provider” means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer or other entity to provide benefits insured under a Medicare Select policy. (6) “Restricted network provision” means any provision that conditions the payment of benefits, in whole or in part, on the use of network providers. (7) “Service area” means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare Select policy. (8) “Grievance” means a written complaint registered by an individual for resolution under the formal grievance procedure, which may involve, but is not limited to, the administration, claims practices, or provision of services by the issuer or its network providers. (9) “Medicare Select coverage” means Medicare supplement coverage through a preferred provider organization or any other type of restricted network, which coverage has been approved by the commissioner under this section. (10) “Preferred provider organization” means a health care provider or an entity contracting with health care providers that (A) establishes alternative or discounted rates of payment, (B) offers the insureds certain advantages for selecting the member providers, or (C) withholds from the insureds certain advantages if they choose providers other than the member providers. Organizations regulated as Medicare Select include, but are not limited to, provider groups, hospital marketing plans, and organizations that are formed or operated by insurers or third-party administrators. (c) The commissioner may authorize an issuer to offer a Medicare Select policy or certificate pursuant to this section if the commissioner finds that the issuer has satisfied all of the requirements of this section. (d) A Medicare Select issuer shall not issue a Medicare Select policy or certificate in this state until its plan of operation has been approved by the commissioner. (e) A Medicare Select issuer shall file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation shall 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 of all of the following: (A) That services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation, and afterhour care. The hours of operation and availability of afterhour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community. (B) That the number of network providers in the service area is sufficient, with respect to current and expected policyholders, as to either of the following: (i) To deliver adequately all services that are subjec

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