Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.88 - Network Adequacy for Managed Care Plans › Rule 6.6.8807 - ACCESS PLAN SPECIFICATIONS

Current through Register Vol. 13, July 5, 2024
(1) In addition
				to meeting the requirements of
				33-36-201(6),
				MCA, an access plan for each health carrier offered in Montana must describe or
				contain the following:
(a) a list of
				participating providers which describes the type of provider, their specialty
				or credentials, and also their names, business addresses, zip codes, and phone
				numbers. The list must indicate which providers are accepting new
				patients;
(b) the health carrier's
				policy for making referrals within and outside of the network including, at a
				minimum, the health carrier's method for complying with each of the standards
				set forth in ARM
				6.6.8828,
				6.6.8829, and
				6.6.8835;
(c) the health carrier's process for
				monitoring on a periodic basis the need for and satisfaction with health care
				services of the enrolled population and ensuring on an ongoing basis, the
				sufficiency of the network to meet those needs and, at a minimum, the health
				carrier's methods for complying with each of the standards set forth in ARM
				6.6.8840;
(d) the health carrier's policy to address
				the needs of enrollees with limited English proficiency and/or illiteracy,
				those with diverse cultural and ethnic backgrounds, and those with physical and
				mental disabilities, in order to ensure that these characteristics do not pose
				barriers to gaining access to services. The policy shall, at a minimum,
				describe the health carrier's methods for complying with each of the standards
				set forth in ARM
				6.6.8836; and
(e) a copy of the health benefit plan's
				booklet or policy or certificate of coverage, a summary of benefits for each
				policy (if available), the list of network providers for each policy, and any
				other important information about the health carrier's services and features
				which must be provided by the health carrier to either potential enrollees or
				covered enrollees. This information must be presented in language that is
				comprehensible to the average layperson. The information to be provided
				includes, but is not limited to:
(i) a listing
				of participating providers, as described in (1)(a);
(ii) a summary description of the health
				carrier's standards for provider credentials and methodology for reviewing
				provider credentials on an ongoing basis required by ARM
				6.6.8816;
(iii) the procedures in place for selecting
				and changing providers;
(iv) the
				health carrier's policy regarding enrollee responsibility for co-insurance,
				copayments, and deductibles;
(v) a
				detailed description of the health carrier's procedures along with
				authorization for specialty care that comply with ARM 6.6.8828, a schedule of
				the fees, including co-insurance, copayments, and deductibles, for which an
				enrollee will be responsible;
(vi)
				policies pertaining to approval of and access to emergency services that meet
				the requirements of ARM
				6.6.8814;
(vii) telephone numbers and procedures for
				contacting an authorized representative of the health carrier who can
				facilitate review of post-evaluation or post-stabilization services required
				immediately after receipt of emergency services;
(viii) a description of the health carrier's
				grievance procedures, including specific instructions and guidelines for filing
				and appealing grievances;
(ix) a
				policy regarding use of and payment for in-network services; and
(x) a policy regarding use of and payment for
				out-of-network services;
(f) the health carrier's method of providing
				and paying for emergency screening and services 24 hours a day, 7 days a week,
				in accordance with ARM 6.6.8814;
(g) a process for enabling enrollees to
				change primary care professionals that meets the standards of ARM
				6.6.8835;
(h) a process for
				transfer of enrollees to other providers must include a provision for
				transitional care as described in ARM 6.6.8829;
(i) the process used to address and correct
				instances where a health carrier has an insufficient number or type of
				participating providers accessible to enrollees to provide a covered benefit.
				This process must comply with the requirements of ARM
				6.6.8819 and
				6.6.8820; and
(j) the health carrier's procedures for
				complying with geographic accessibility requirements as outlined in ARM
				6.6.8819 and
				6.6.8820.