reglab/statecodes huggingface dataset:
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 33. Property and Casualty Utilization Review › Part 1. General Provisions › 33-33-102. Scope -- rulemaking

33-33-102. Scope -- rulemaking.
(1) This chapter applies to property and casualty insurers seeking utilization review opinions and to utilization review organizations that provide opinions with respect to property and casualty insurance contracts issued in this state.
(2) The commissioner may adopt rules to implement the provisions of this chapter, including but not limited to medical privacy requirements.
History: En. Sec. 2, Ch. 335, L. 2001; amd. Sec. 34, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 33. Property and Casualty Utilization Review › Part 1. General Provisions › 33-33-103. Definitions

33-33-103. Definitions.
As used in this chapter, the following definitions apply:
(1) "Utilization review" has the meaning provided in 33-32-102.
(2) "Utilization review organization" means an entity that provides utilization review services.
History: En. Sec. 3, Ch. 335, L. 2001; amd. Sec. 39, Ch. 428, L. 2015.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 33. Property and Casualty Utilization Review › Part 2. Standards › 33-33-201. Standards for utilization review organizations

33-33-201. Standards for utilization review organizations.
(1) A utilization review organization that conducts utilization reviews in this state for property and casualty insurers shall meet the standards set forth in this part.
(2) Utilization review organizations may use only licensed or certified health care professionals to conduct utilization reviews.
(3) Utilization reviews must be conducted by health care professionals who are licensed or certified in the same specialty as the provider whose treatment is being received by the insured or by a health care professional who is qualified to render the treatment being reviewed.
(4) Utilization review organizations shall comply with all applicable state or federal medical privacy laws.
(5) Utilization review evaluations must use generally accepted standards for treatment of the illness, injury, or condition that is being reviewed.
(6) Utilization review opinions must be signed by the health care professional performing the review.
(7) A utilization review organization may not base its fees or charges on any recommendation for a reduction in payment under an insurance contract or on a percentage of claim savings.
History: En. Sec. 4, Ch. 335, L. 2001; amd. Sec. 35, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 33. Property and Casualty Utilization Review › Part 2. Standards › 33-33-202. Standards for property and casualty insurers

33-33-202. Standards for property and casualty insurers.
(1) Property or casualty insurers seeking utilization reviews with respect to insurance contracts issued in this state may use only utilization review organizations that meet the requirements of this part and any rules adopted pursuant to this part.
(2) A property or casualty insurer is responsible for:
(a) monitoring all utilization review activities carried out by or on behalf of the property or casualty insurer;
(b) ensuring that all requirements of this part and rules adopted pursuant to this part are met; and
(c) ensuring that appropriate personnel have operational responsibility for and oversight of the performance of the property or casualty insurer's utilization review program and contracts with utilization review organizations.
(3) A property or casualty insurer that denies, in whole or in part, a policyholder's claim after consideration of a utilization review shall provide the policyholder an opportunity to request reconsideration by the insurer and the opportunity to submit additional information relating to the claim.
History: En. Sec. 5, Ch. 335, L. 2001; amd. Sec. 36, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 1. General Provisions › 33-35-101. Short title

33-35-101. Short title.
This chapter may be cited as the "Self-Funded Multiple Employer Welfare Arrangement Regulation Act".
History: En. Sec. 1, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 1. General Provisions › 33-35-102. Purpose

33-35-102. Purpose.
The purposes of this chapter are to:
(1) provide for the authorization and registration of self-funded multiple employer welfare arrangements;
(2) regulate self-funded multiple employer welfare arrangements in order to ensure the financial integrity of the arrangements;
(3) provide reporting requirements for self-funded multiple employer welfare arrangements; and
(4) provide for sanctions against self-funded multiple employer welfare arrangements organized and maintained in Montana that do not comply with this chapter.
History: En. Sec. 2, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 1. General Provisions › 33-35-103. Definitions

33-35-103. Definitions.
As used in this chapter, unless the context requires otherwise, the following definitions apply:
(1) "Allowable benefit" means a benefit relating to medical, surgical, or hospital care in the event of sickness, accident, disability, or any combination of sickness, accident, or disability.
(2) (a) "Bona fide association" means an association of employers that has been in existence for a period of not less than 5 years prior to sponsoring a self-funded multiple employer welfare arrangement, during which time the association has engaged in substantial activities relating to the common interests of member employers, and that continues to engage in substantial activities in addition to sponsoring an arrangement.
(b) Notwithstanding subsection (2)(a), an association that was formed and began sponsoring an arrangement prior to October 1, 1995, is not subject to the requirement that the association be in existence for 5 years prior to sponsoring an arrangement.
(3) "Claims liability" means the total of all incurred and unpaid claims for allowable benefits under a self-funded multiple employer welfare arrangement that are not reimbursed or reimbursable by excess of loss insurance, subrogation, or other sources.
(4) (a) "Multiple employer welfare arrangement" means a multiple employer welfare arrangement as defined by 29 U.S.C. 1002.
(b) The term does not include an arrangement, plan, program, or interlocal agreement of or between political subdivisions of this state, including school districts, as provided in 33-1-102.
(5) "Reserves" means the excess of the assets of a self-funded multiple employer welfare arrangement minus the liabilities of the arrangement. The liabilities of a self-funded multiple employer welfare arrangement include the claims liability of the arrangement.
(6) "Self-funded multiple employer welfare arrangement" or "arrangement" means a multiple employer welfare arrangement that does not provide for payment of benefits under the arrangement solely through a policy or policies of insurance issued by one or more insurance companies with a certificate of authority under this title.
History: En. Sec. 3, Ch. 420, L. 1995; amd. Sec. 25, Ch. 399, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 2. Certificate of Authority › 33-35-201. Certificate of authority

33-35-201. Certificate of authority.
(1) Except as provided in subsection (3), a person may not establish or maintain a self-funded multiple employer welfare arrangement in Montana unless the arrangement first obtains a certificate of authority from the commissioner.
(2) A self-funded multiple employer welfare arrangement is considered to be established or maintained in Montana if one or more of the employer members participating in the arrangement is either domiciled in or maintains its principal place of business in Montana.
(3) A self-funded multiple employer welfare arrangement established and maintained in Montana prior to January 1, 1995, has until April 1, 1996, to file an application for a certificate of authority. An arrangement that files an application for a certificate of authority by that date is considered to have been issued a certificate of authority unless the commissioner finally denies the arrangement's application for a certificate of authority.
History: En. Sec. 4, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 2. Certificate of Authority › 33-35-202. Eligibility for certificate of authority

33-35-202. Eligibility for certificate of authority.
The commissioner may not issue a certificate of authority to a self-funded multiple employer welfare arrangement unless the arrangement establishes to the reasonable satisfaction of the commissioner that the following requirements have been satisfied by the arrangement:
(1) the employers participating in the self-funded multiple employer welfare arrangement are either engaged in the same trade, profession, or industry or the employers participating in the arrangement are members of a bona fide association;
(2) the employers participating in the arrangement exercise control over the arrangement, as follows:
(a) Subject to subsection (2)(b), control exists if the employers participating in the arrangement have the right to elect at least 75% of the individuals designated in the arrangement's organizational documents as having control over the operations of the arrangement and the individuals designated in the arrangement's organizational documents in fact exercise control over the operation of the arrangement.
(b) The use of a third-party administrator to process claims and to assist in the administration of the arrangement is not evidence of the lack of exercise of control over the operation of the arrangement.
(3) the arrangement provides only allowable benefits. However, an arrangement may provide life insurance coverage to its participants if the coverage is provided pursuant to contracts of insurance that comply with Title 33, chapter 20, parts 10 through 12.
(4) the arrangement provides allowable benefits to not less than 2 employers and not less than 75 employees;
(5) the arrangement may not solicit participation in the arrangement from the general public. However, the arrangement may employ or independently contract with a licensed insurance producer who may be paid a commission or other remuneration to enroll employers in the arrangement, and employees of the arrangement, employees of the association sponsoring the arrangement, or employees of affiliates of the association, other than licensed insurance producers, may enroll employers in the arrangement if the employees do not receive a commission or other remuneration in addition to their customary compensation for enrolling employers.
(6) the arrangement is not organized or maintained solely as a conduit for the collection of premiums and the forwarding of premiums to an insurance company. However, it is permissible for a self-funded multiple employer welfare arrangement to act as a conduit for the collection and forwarding of premiums for life insurance coverage pursuant to subsection (3).
History: En. Sec. 5, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 2. Certificate of Authority › 33-35-205. Application for certificate of authority

33-35-205. Application for certificate of authority.
A self-funded multiple employer welfare arrangement shall apply for a certificate of authority on a form prescribed by the commissioner and shall submit the application, together with the following documents, to the commissioner:
(1) a copy of all articles, bylaws, agreements, trusts, or other documents or instruments describing the rights and obligations of the employers, employees, and beneficiaries of the arrangement;
(2) a copy of the summary plan description or summary plan descriptions of the arrangement filed or required to be filed with the United States department of labor, together with any amendments to the description;
(3) evidence of coverage of or letters of intent to participate executed by at least 2 employers providing allowable benefits to at least 75 employees;
(4) a copy of the arrangement's most recent year's financial statements or, if the arrangement has been in existence for less than 1 year, pro forma financial statements that must include, at a minimum, a balance sheet, an income statement, a statement of changes in financial position, and an actuarial opinion that the unpaid claim liability of the arrangement satisfies the standards of 33-2-514. The commissioner may, in the commissioner's discretion, waive the requirement of an actuarial opinion and require a report by an actuarial firm.
(5) proof that the arrangement maintains or will maintain fidelity bonds required by the United States department of labor pursuant to the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001, et seq.;
(6) a copy of any excess of loss insurance coverage policies maintained or proposed to be maintained by the arrangement;
(7) biographical reports on forms prescribed by the national association of insurance commissioners evidencing the general trustworthiness and competence of each individual who is serving or who will serve as an employee or fiduciary of the arrangement; and
(8) a statement executed by a representative of the arrangement certifying, to the best knowledge and belief of the representative, that:
(a) the arrangement is in compliance with requirements of 33-35-202;
(b) the arrangement is in compliance with the requirements of the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001, et seq., or a statement of any requirements with which the arrangement is not in compliance and a statement of proposed corrective actions; and
(c) the arrangement is in compliance with requirements of 33-35-209 and 33-35-210.
History: En. Sec. 7, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 2. Certificate of Authority › 33-35-209. Minimum reserve requirements

33-35-209. Minimum reserve requirements.
Self-funded multiple employer welfare arrangements shall establish by the end of the first year of operations of the arrangement and shall maintain as of the end of each year of operations reserves equal to at least 30% of the unpaid claims liability of the arrangement. The commissioner may adopt rules regarding the supervision, rehabilitation, and liquidation of self-funded multiple employer welfare arrangements that fail to maintain the level of reserves required by this section.
History: En. Sec. 8, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 2. Certificate of Authority › 33-35-210. Minimum funding levels

33-35-210. Minimum funding levels.
A self-funded multiple employer welfare arrangement shall establish and maintain contribution rates for participation under the arrangement that satisfy either of the following requirements:
(1) contribution rates must equal or exceed the sum of projected claims liability for the year, plus all projected costs of operation of the arrangement for the year, plus an amount equal to any deficiency in the reserves of the arrangement for the prior year, minus an amount equal to the reserves of the arrangement in excess of the minimum required level of reserves; or
(2) contribution rates must equal or exceed a funding level established by a report prepared by an actuarial firm.
History: En. Sec. 9, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 2. Certificate of Authority › 33-35-211. Issuance of certificate of authority

33-35-211. Issuance of certificate of authority.
(1) The commissioner shall grant or deny an application for a certificate of authority within 180 days of the date that a completed application, together with the items designated in 33-35-205, is submitted to the commissioner.
(2) The commissioner shall grant the application of an arrangement that satisfies the applicable requirements of 33-35-202, 33-35-203, 33-35-205, 33-35-209, and 33-35-210.
(3) The commissioner shall deny the application of an arrangement that does not satisfy the applicable requirements of 33-35-202, 33-35-203, 33-35-205, 33-35-209, and 33-35-210. Denial of an application for a certificate of authority is considered a contested case under the Montana Administrative Procedure Act.
(4) A certificate of authority granted to an arrangement is effective unless revoked by the commissioner under 33-35-302.
History: En. Sec. 10, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 3. Enforcement › 33-35-301. Reporting

33-35-301. Reporting.
(1) A self-funded multiple employer welfare arrangement shall comply with the reporting requirements of this section.
(2) Within 3 months following the close of the arrangement's year of operations, the arrangement shall file with the commissioner, on forms prescribed by the commissioner:
(a) a statement of financial condition;
(b) a statement of change in financial conditions accompanied by an actuarial opinion that the unpaid claim liability of the arrangement satisfies the standards of 33-2-514. The commissioner may, in the commissioner's discretion, waive the requirement of an actuarial opinion and require a report prepared by an actuarial firm and, upon a showing of good cause, may extend by 30 days the filing date for the report.
(c) a statement of its contribution rates for the ensuing year;
(d) a statement of operations for the previous year;
(e) if the total payments to the arrangement for participation during the prior year of operations exceeded the sum of $2 million, an audit satisfying the requirements of the commissioner's rules governing annual audited reports, except that an arrangement audit may be prepared using generally accepted accounting principles. The audit must be certified by an independent certified public accountant. The filing date for the audit must be extended by the commissioner upon a showing of good cause.
(f) additional information as the commissioner reasonably determines to be necessary to determine the financial integrity of the management.
(3) An arrangement shall file with the commissioner a copy of the arrangement's internal revenue service form 5500 together with all attachments to the form, at the time required for filing the form.
History: En. Sec. 11, Ch. 420, L. 1995; amd. Sec. 32, Ch. 63, L. 2015.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 3. Enforcement › 33-35-302. Failure to comply

33-35-302. Failure to comply.
(1) Pursuant to 33-1-317 and 33-1-318, the commissioner may impose sanctions against a self-funded multiple employer welfare arrangement that fails to comply with the provisions of this chapter. The maximum fine may not exceed $5,000 for each violation.
(2) The commissioner may issue a notice of intent to revoke the certificate of authority of a self-funded multiple employer welfare arrangement that fails to comply with the provisions of 33-35-209, 33-35-210, or 33-35-301. If, within 60 days of receiving notice under this subsection, the arrangement fails to file with the commissioner a plan to bring the arrangement into compliance with 33-35-209, 33-35-210, or 33-35-301, the commissioner may revoke the arrangement's certificate of authority. A revocation of a certificate of authority is a contested case under the Montana Administrative Procedure Act.
(3) The commissioner shall adopt rules to provide sanctions for an arrangement that fails to maintain the level of reserves required by 33-35-209. The rules must be consistent with the provisions of Title 33, chapter 2, part 13.
History: En. Sec. 12, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 3. Enforcement › 33-35-303. Violation by arrangement failing to obtain or maintain certificate of authority

33-35-303. Violation by arrangement failing to obtain or maintain certificate of authority.
A self-funded multiple employer welfare arrangement organized or maintained in Montana without a certificate of authority is in violation of 33-2-101.
History: En. Sec. 13, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 3. Enforcement › 33-35-306. Application of insurance code to arrangements

33-35-306. Application of insurance code to arrangements.
(1) In addition to this chapter, self-funded multiple employer welfare arrangements are subject to the following provisions:
(a) 33-1-111;
(b) Title 33, chapter 1, part 4, but the examination of a self-funded multiple employer welfare arrangement is limited to those matters to which the arrangement is subject to regulation under this chapter;
(c) Title 33, chapter 1, part 7;
(d) Title 33, chapter 2, parts 23 and 24;
(e) 33-3-308;
(f) Title 33, chapter 7;
(g) Title 33, chapter 18, except 33-18-242;
(h) Title 33, chapter 19;
(i) 33-22-107, 33-22-114, 33-22-128, 33-22-129, 33-22-131, 33-22-134, 33-22-135, 33-22-138, 33-22-139, 33-22-141, 33-22-142, and 33-22-152 through 33-22-155;
(j) 33-22-316;
(k) 33-22-512, 33-22-515, 33-22-525, and 33-22-526;
(l) Title 33, chapter 22, parts 7 and 21; and
(m) 33-22-707.
(2) Except as provided in this chapter, other provisions of Title 33 do not apply to a self-funded multiple employer welfare arrangement that has been issued a certificate of authority that has not been revoked.
History: En. Sec. 14, Ch. 420, L. 1995; amd. Sec. 7, Ch. 410, L. 1997; amd. Sec. 32, Ch. 416, L. 1997; amd. Sec. 5, Ch. 434, L. 1999; amd. Sec. 49, Ch. 380, L. 2003; amd. Sec. 8, Ch. 384, L. 2003; amd. Sec. 2, Ch. 249, L. 2007; amd. Sec. 9, Ch. 356, L. 2007; amd. Sec. 6, Ch. 390, L. 2007; amd. Sec. 26, Ch. 399, L. 2007; amd. Sec. 5, Ch. 359, L. 2009; amd. Sec. 5, Ch. 97, L. 2013; amd. Sec. 4, Ch. 164, L. 2013; amd. Sec. 10, Ch. 363, L. 2013; amd. Sec. 4, Ch. 256, L. 2015; amd. Sec. 10, Ch. 231, L. 2017; amd. Sec. 8, Ch. 245, L. 2017; amd. Sec. 4, Ch. 209, L. 2021; amd. Sec. 4, Ch. 277, L. 2021; amd. Sec. 3, Ch. 323, L. 2021; amd. Sec. 19, Ch. 501, L. 2021; amd. Sec. 3, Ch. 88, L. 2023; amd. Sec. 4, Ch. 179, L. 2023; amd. Sec. 3, Ch. 463, L. 2023; amd. Sec. 4, Ch. 520, L. 2023; amd. Sec. 4, Ch. 600, L. 2023; amd. Sec. 7, Ch. 782, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 35. Multiple Employer Welfare Arrangements › Part 3. Enforcement › 33-35-307. Disclosure

33-35-307. Disclosure.
Each policy issued by a self-funded multiple employer welfare arrangement must contain, in 10-point type on the front page and the declaration page, the following notice:
"NOTICE
This policy is issued by a self-funded multiple employer welfare arrangement. A self-funded multiple employer welfare arrangement may not be subject to all of the insurance laws and regulations of your state. State insurance insolvency guaranty funds are not available for a self-funded multiple employer welfare arrangement."
History: En. Sec. 15, Ch. 420, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 1. General Provisions › 33-36-101. Short title

33-36-101. Short title.
This chapter may be cited as the "Managed Care Plan Network Adequacy and Quality Assurance Act".
History: En. Sec. 8, Ch. 413, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 1. General Provisions › 33-36-102. Purpose

33-36-102. Purpose.
The purpose and intent of this chapter are to:
(1) establish standards for the creation and maintenance of networks by health carriers offering managed care plans and to ensure the adequacy, accessibility, and quality of health care services offered under a managed care plan by establishing requirements for written agreements between health carriers offering managed care plans and participating providers regarding the standards, terms, and provisions under which the participating provider will provide services to covered persons;
(2) provide for the implementation of state network adequacy and quality assurance standards in administrative rules, provide for monitoring compliance with those standards, and provide a mechanism for detecting and reporting violations of those standards to the commissioner;
(3) establish minimum criteria for the quality assessment activities of a health carrier issuing a closed plan or a combination plan and to require that minimum state quality assessment criteria be adopted by rule;
(4) enable health carriers to evaluate, maintain, and improve the quality of health care services provided to covered persons; and
(5) provide a streamlined and simplified process by which managed care network adequacy and quality assurance programs may be monitored for compliance through efforts by the commissioner. It is not the purpose or intent of this chapter to apply quality assurance standards applicable to medicaid or medicare to managed care plans regulated pursuant to this chapter or to create or require the creation of quality assurance programs that are as comprehensive as quality assurance programs applicable to medicaid or medicare.
History: En. Sec. 9, Ch. 413, L. 1997; amd. Sec. 38, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 1. General Provisions › 33-36-104. Applicability and scope

33-36-104. Applicability and scope.
This chapter applies to all health carriers that offer managed care plans. This chapter does not exempt a health carrier from the applicable requirements of federal law when providing a managed care plan to medicare recipients or from the applicable requirements of federal law or Title 53, chapter 6, when providing a managed care plan to medicaid recipients.
History: En. Sec. 11, Ch. 413, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 1. General Provisions › 33-36-105. Commissioner -- general powers and duties -- rulemaking

33-36-105. Commissioner -- general powers and duties -- rulemaking.
(1) The commissioner shall:
(a) adopt rules pursuant to the Montana Administrative Procedure Act establishing minimum state standards for network adequacy and quality assurance and procedures for ensuring compliance with those standards; and
(b) if appropriate, initiate action against a health carrier whose managed care plan does not comply with standards for network adequacy and quality assurance adopted by the commissioner.
(2) Quality assurance standards adopted by the commissioner must consist of some but not all of the health plan employer data and information standards. The commissioner shall select and adopt only standards appropriate for quality assurance in Montana.
(3) The state may contract, through a competitive bidding process, for the development of network adequacy and quality assurance standards.
History: En. Sec. 12, Ch. 413, L. 1997; amd. Sec. 40, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-203. Selection of providers -- professional credentials standards

33-36-203. Selection of providers -- professional credentials standards.
(1) A health carrier shall adopt standards for selecting participating providers who are primary care professionals and for each health care professional specialty within the health carrier's network. The health carrier shall use the standards to select health care professionals, the health carrier's intermediaries, and any provider network with which the health carrier contracts. A health carrier may not adopt selection criteria that allow the health carrier to:
(a) avoid high-risk populations by excluding a provider because the provider is located in a geographic area that contains populations or providers presenting a risk of higher than average claims, losses, or use of health care services; or
(b) exclude a provider because the provider treats or specializes in treating populations presenting a risk of higher than average claims, losses, or use of health care services.
(2) Subsection (1) does not prohibit a health carrier from declining to select a provider who fails to meet the other legitimate selection criteria of the health carrier adopted in compliance with this part and the rules implementing this part.
(3) This part does not require a health carrier, its intermediary, or a provider network with which the health carrier or its intermediary contract to employ specific providers or types of providers who may meet their selection criteria or to contract with or retain more providers or types of providers than are necessary to maintain an adequate network.
(4) A health carrier may use criteria established in accordance with the provisions of this section to select health care professionals allowed to participate in the health carrier's managed care plan. A health carrier shall make its selection standards for participating providers available for review by the commissioner and by each health care professional who is subject to the selection standards.
History: En. Sec. 15, Ch. 413, L. 1997; amd. Sec. 42, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-205. Emergency services

33-36-205. Emergency services.
(1) A health carrier offering a managed care plan shall provide or pay for emergency services screening and emergency services and may not require prior authorization for either of those services. If an emergency services screening determines that emergency services or emergency services of a particular type are unnecessary for a covered person, emergency services or emergency services of the type determined unnecessary by the screening need not be covered by the health carrier unless otherwise covered under the health benefit plan. However, if screening determines that emergency services or emergency services of a particular type are necessary, those services must be covered by the health carrier. A health carrier shall cover emergency services if the health carrier, acting through a participating provider or other authorized representative, has authorized the provision of emergency services.
(2) A health carrier shall provide or pay for emergency services obtained from a nonnetwork provider within the service area of a managed care plan and may not require prior authorization of those services if use of a participating provider would result in a delay that would worsen the medical condition of the covered person or if a provision of federal, state, or local law requires the use of a specific provider.
(3) If a participating provider or other authorized representative of a health carrier authorizes emergency services, the health carrier may not subsequently retract its authorization after the emergency services have been provided or reduce payment for an item or health care services furnished in reliance on approval unless the approval was based on a material misrepresentation about the covered person's medical condition made by the provider of emergency services.
(4) Coverage of emergency services is subject to applicable coinsurance, copayments, and deductibles.
(5) For postevaluation or poststabilization services required immediately after receipt of emergency services, a health carrier shall provide access to an authorized representative 24 hours a day, 7 days a week, to facilitate review.
History: En. Sec. 17, Ch. 413, L. 1997; amd. Sec. 11, Ch. 325, L. 2003.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-209. Use of intermediaries -- responsibilities of health carriers, intermediaries, and providers

33-36-209. Use of intermediaries -- responsibilities of health carriers, intermediaries, and providers.
(1) A health carrier is responsible for complying with applicable provisions of this chapter and contracting with an intermediary for all or some of the services for which a health carrier is responsible does not relieve the health carrier of responsibility for compliance.
(2) A health carrier may determine whether a subcontracted provider participates in the provider's own network or a contracted network for the purpose of providing covered benefits to the health carrier's covered persons.
(3) A health carrier shall maintain copies of all intermediary health care subcontracts at the health carrier's principal place of business in this state or ensure that the health carrier has access to all intermediary subcontracts, including the right to make copies of the contracts, upon 20 days' prior written notice from the health carrier.
(4) If required in a contract or otherwise by a health carrier, an intermediary shall transmit utilization documentation and claims-paid documentation to the health carrier. The health carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by covered persons. This duty may not be delegated to an intermediary by a health carrier.
(5) If required in a contract or otherwise by a health carrier, an intermediary shall maintain the books, records, financial information, and documentation of services provided to covered persons at its principal place of business in the state and preserve them for 5 years in a manner that facilitates regulatory review.
(6) An intermediary shall allow the commissioner access to the intermediary's books, records, claim information, billing information, and other documentation of services provided to covered persons that are required by any of those entities to determine compliance with this part and the rules implementing this part.
(7) A health carrier may, in the event of the intermediary's insolvency, require the assignment to the health carrier of the provisions of a participating provider's contract addressing the participating provider's obligation to furnish covered benefits.
History: En. Sec. 18, Ch. 413, L. 1997; amd. Sec. 43, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-210. Contract filing requirements -- material changes -- state access to contracts

33-36-210. Contract filing requirements -- material changes -- state access to contracts.
(1) A health carrier offering a managed care plan in this state on January 1, 2024, shall file with the commissioner on December 1, 2023, sample contract forms proposed for use with its participating providers and intermediaries. A health carrier offering a managed care plan in this state for the first time after January 1, 2024, shall file with the commissioner sample contract forms proposed for use with its participating providers and intermediaries at least 60 days before offering the managed care plan.
(2) A health carrier shall file with the commissioner a material change to a contract. The change must be filed with the commissioner at least 60 days before use of the proposed change. A change in a participating provider payment rate, coinsurance, copayment, or deductible or other plan benefit is not considered a material change for the purpose of this subsection.
(3) A health carrier shall maintain participating provider and intermediary contracts at its principal place of business in this state, or the health carrier must have access to all contracts and provide copies to the commissioner on 20 days' prior written notice from the commissioner.
History: En. Sec. 19, Ch. 413, L. 1997; amd. Sec. 44, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-211. General contracting requirements

33-36-211. General contracting requirements.
(1) The execution of a contract for health care services with an intermediary by a health carrier does not relieve the health carrier of its duty to provide health care services to a person with whom the health carrier has contracted and does not relieve the health carrier of its responsibility for compliance with this chapter or the rules implementing this chapter.
(2) All contracts by a health carrier for the provision of health care services by a managed care plan must be in writing and are subject to review by the commissioner.
History: En. Sec. 20, Ch. 413, L. 1997; amd. Sec. 45, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-212. Contract compliance dates

33-36-212. Contract compliance dates.
A contract between a health carrier and a participating provider or intermediary must comply with this part and the rules implementing this part on the date the contract is issued or put into effect.
History: En. Sec. 21, Ch. 413, L. 1997; amd. Sec. 46, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 2. Network Adequacy › 33-36-213. Rulemaking authority

33-36-213. Rulemaking authority.
The commissioner may adopt rules to implement this part.
History: En. Sec. 22, Ch. 413, L. 1997; amd. Sec. 47, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 3. Quality Assurance › 33-36-301. Quality assurance -- national accreditation

33-36-301. Quality assurance -- national accreditation.
(1) A health carrier whose managed care plan has been accredited by a nationally recognized accrediting organization shall annually provide a copy of the accreditation and the accrediting standards used by the accrediting organization to the commissioner.
(2) If the commissioner finds that the standards of a nationally recognized accrediting organization meet or exceed state standards and that the health carrier has been accredited by the nationally recognized accrediting organization, the commissioner shall approve the quality assurance standards of the health carrier.
(3) The commissioner shall maintain a list of accrediting organizations whose standards have been determined by the commissioner to meet or exceed state quality assurance standards.
(4) Section 33-36-302 does not apply to a health carrier's managed care plan if the health carrier maintains current accreditation by a nationally recognized accrediting organization whose standards meet or exceed state quality assurance standards adopted pursuant to this part.
(5) This section does not prevent the commissioner from monitoring a health carrier's compliance with this part.
History: En. Sec. 23, Ch. 413, L. 1997; amd. Sec. 48, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 3. Quality Assurance › 33-36-302. Standards for health carrier quality assessment programs

33-36-302. Standards for health carrier quality assessment programs.
A health carrier that issues a closed plan or a combination plan shall adopt and use infrastructure and disclosure systems sufficient to accurately measure the quality of health care services provided to covered persons on a regular basis and appropriate to the types of plans offered by the health carrier. To comply with this requirement, a health carrier shall:
(1) establish and use a system designed to assess the quality of health care provided to covered persons and appropriate to the types of plans offered by the health carrier. The system must include systematic collection, analysis, and reporting of relevant data.
(2) communicate in a timely fashion its findings concerning the quality of health care to regulatory agencies, providers, and consumers as provided in 33-36-304;
(3) report to the appropriate professional or occupational licensing board provided in Title 37 any persistent pattern of problematic care provided by a participating provider that is sufficient to cause the health carrier to terminate or suspend a contractual arrangement with the participating provider; and
(4) file a written description of the quality assessment program and any subsequent material changes with the commissioner in a format that must be prescribed by rules of the commissioner. The description must include a signed certification by a corporate officer of the health carrier that the health carrier's quality assessment program meets the requirements of this part.
History: En. Sec. 24, Ch. 413, L. 1997; amd. Sec. 49, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 3. Quality Assurance › 33-36-303. Standards for health carrier quality improvement programs

33-36-303. Standards for health carrier quality improvement programs.
A health carrier that issues a closed plan or a combination plan shall, in addition to complying with 33-36-302, adopt and use systems and methods necessary to improve the quality of health care provided in the health carrier's managed care plan as indicated by the health carrier's quality assessment program and as required by this section. To comply with this requirement, a health carrier subject to this section shall:
(1) establish an internal system capable of identifying opportunities to improve care;
(2) use the findings generated by the system required by subsection (1) to work on a continuing basis with participating providers and other staff within the closed plan or closed component to improve the health care delivered to covered persons; and
(3) consistent with this part, adopt and use a program for measuring, assessing and improving the outcomes of health care as identified in the health carrier's quality improvement program plan and provide at the commissioner's request a current quality improvement program plan. The quality improvement program plan must:
(a) implement improvement strategies in response to quality assessment findings that indicate improvement is needed; and
(b) evaluate, not less than annually, the effectiveness of the strategies implemented pursuant to subsection (3)(a).
History: En. Sec. 25, Ch. 413, L. 1997; amd. Sec. 50, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 3. Quality Assurance › 33-36-304. Reporting and disclosure requirements

33-36-304. Reporting and disclosure requirements.
(1) A health carrier offering a closed plan or a combination plan shall document and communicate information, as required in this section, about its quality assurance program. The health carrier shall:
(a) include a summary of its quality assurance program in marketing materials;
(b) include a description of its quality assurance program and a statement of patient rights and responsibilities with respect to that program in the certificate of coverage or handbook provided to newly enrolled covered persons; and
(c) make available annually to providers and covered persons a report containing findings from its quality assurance program and information about its progress in meeting internal goals and external standards, when available.
(2) A health carrier shall certify to the commissioner annually that its quality assurance program and the materials provided to providers and consumers in accordance with subsection (1) meet the requirements of this part.
(3) A health carrier shall make available, upon request and payment of a reasonable fee, the materials certified pursuant to subsection (2), except for the materials subject to the confidentiality requirements of 33-36-305 and materials that are proprietary to the managed care plan. A health carrier shall retain all certified materials for at least 3 years from the date that the material was certified or until the material has been examined as part of a market conduct examination, whichever is later.
History: En. Sec. 26, Ch. 413, L. 1997; amd. Sec. 51, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 36. Managed Care Plan Network Adequacy and Quality Assurance › Part 3. Quality Assurance › 33-36-305. Confidentiality of health care and quality assurance records -- disclosure

33-36-305. Confidentiality of health care and quality assurance records -- disclosure.
(1) Except as provided in subsection (2), the following information held by a health carrier offering a closed plan or a combination plan is confidential and may not be disclosed by the carrier to a person:
(a) information pertaining to the diagnosis, treatment, or health of a covered person, regardless of whether the information is in the form of paper, is preserved on microfilm, or is stored in computer-retrievable form;
(b) information considered by a quality assurance program and the records of its actions, including testimony of a member of a quality committee, of an officer, director, or other member of a health carrier or its staff engaged in assisting the quality committee or engaged in the health carrier's quality assessment, quality improvement, or quality assurance activities, or of any person assisting or furnishing information to the quality committee.
(2) The information specified in subsection (1) may be disclosed:
(a) as allowed by Title 33, chapter 19;
(b) as required in proceedings before the commissioner, a professional or occupational licensing board provided in Title 37, or the department of public health and human services pursuant to Title 50, chapter 5, part 2;
(c) in an appeal, if an appeal is permitted, from a quality committee's findings or recommendations; or
(d) as otherwise required by law or court order, including a judicial or administrative subpoena.
(3) Information specified in subsection (1) identifying:
(a) the provider may also be disclosed upon a written, dated, and signed approval of the provider if the information does not identify the covered person;
(b) the covered person may also be disclosed upon a written, dated, and signed approval of the covered person or of the parent or guardian of a covered person if the covered person is a minor and if the information does not identify the provider;
(c) neither the provider nor the covered person may also be disclosed upon request for use for statistical purposes only.
History: En. Sec. 27, Ch. 413, L. 1997; amd. Sec. 52, Ch. 157, L. 2023.