Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.25 - Health Maintenance Organizations › Rule 6.6.2506 - REQUIREMENTS FOR CONTRACTS AND EVIDENCES OF COVERAGE

Current through Register Vol. 13, July 5, 2024
(1) Each subscriber is entitled to a contract
				or evidence of coverage as approved by the commissioner. The contract or
				evidence of coverage must be delivered or issued fox delivery to a subscriber
				within a reasonable time after enrollment, but not more than 15 days from the
				later of the effective date of coverage or the date on which the health
				maintenance organization is notified of enrollment.
(2) A health maintenance organization
				contract and evidence of coverage must contain:
(a) the name, address, and telephone number
				of the health maintenance organization and the location of and the manner in
				which information is available as to how services may be obtained;
(b) a statement that the contract, all
				applications, and any amendments thereto constitute the entire agreement
				between the parties. No portion of the charter, bylaws, or other document of
				the health maintenance organization may be part of the contract and evidence of
				coverage unless set forth in full in the contract and evidence of coverage or
				attached thereto.
(c) the time and
				date or occurrence upon which coverage takes effect, including any applicable
				waiting or affiliation periods, or describe how the time and date or occurrence
				upon with coverage takes effect is determined. The contract and evidence of
				coverage must contain the time and date or occurrence upon which coverage will
				terminate.
(d) eligibility
				requirements indicating the conditions that must be met to enroll as a
				subscriber or eligible dependent; the limiting age for subscribers and eligible
				dependents, including the effects of medicare eligibility; and a clear
				statement regarding coverage of newborn children. However, a health maintenance
				organization contract and evidence of coverage may not contain any provision
				excluding or limiting coverage for a newborn child. Medically diagnosed
				congenital defects and birth abnormalities must be treated the same as any
				other illness or injury for which coverage is provided.
(e) a specific description of benefits and
				services available within the service area and out of the service area;
(f) a specific description of
				benefits available for emergency care services 24 hours a day, seven days a
				week, including disclosure of any restrictions on emergency care
				services.
(g) a description of any
				copayments, limitations, or exclusions on the services, kind of services,
				benefits, or kind of benefits to be provided, such as any lawful copayments,
				limitations, or exclusions due to preexisting conditions, waiting or
				affiliation periods, or an enrollee's refusal of treatment;
(h) the conditions upon which the health
				maintenance organization or the subscriber may cancel coverage;
(i) the conditions for, and any restrictions
				upon, the subscriber's right to renewal and right to reinstatement;
(j) a grace period of not less than 10 days
				for the payment of any premium except the first, during which coverage remains
				in effect if payment is made during the grace period. During the grace period,
				the health maintenance organization remains liable for providing the services
				and benefits contracted for, the contract holder remains liable for paying the
				premium for the time coverage was in effect during the grace period, and the
				subscriber remains liable for any copayments owed.
(k) procedures for filing claims that
				include:
(i) required notice to the health
				maintenance organization;
(ii) if
				any claim forms are required, how, when, and where to obtain and submit them;
(iii) requirements for filing
				proper proofs of loss;
(iv) time
				limit of payment of claims;
(v)
				notice of requirements for resolving disputed claims including arbitration;
				and
(vi) a statement of
				restrictions, if any, on assignment of sums payable to the enrollee by the
				health maintenance organization.
(l) in compliance with Title 33, chapter 32,
				MCA and ARM
				6.6.2509(4),
				a description of the health maintenance organization's method for resolving
				enrollee complaints, incorporating procedures to be followed by the enrollee if
				a dispute arises under the contract; and
(m) a provision that a subscriber may return
				the contract within 10 days of receiving it and receive a refund of the premium
				paid if the person is not satisfied with the contract for any reason. If the
				contract or evidence of coverage is returned to the health maintenance
				organization or to the agent through whom it was purchased, it is considered
				void from the beginning.