Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.6 - Requirements for Health Carriers and Participating Providers

Current through June 25, 2024
A health carrier offering a managed care plan shall include
				  the following requirements contained in this section, in addition to any other
				  requirements required under Mississippi law.
A. A health carrier shall establish a
				mechanism by which the participating provider will be notified on an ongoing
				basis of the specific covered or non-covered health services for which the
				provider will be responsible, including any limitations or conditions on
				services.
B. Every contract between
				a health carrier and a participating provider shall set forth a hold harmless
				provision specifying protection for covered persons. This requirement shall be
				met by including a provision substantially similar to the following:
"Provider agrees that in no event, including but not limited
				  to nonpayment by the health carrier or intermediary, insolvency of the health
				  carrier or intermediary, or breach of this agreement, shall the provider bill,
				  charge, collect a deposit from, seek compensation, remuneration or
				  reimbursement from, or have any recourse against a covered person or a person
				  (other than the health carrier or intermediary) acting on behalf of the covered
				  person for services provided pursuant to this agreement. This agreement does
				  not prohibit the provider from collecting coinsurance, deductibles or
				  copayments, as specifically provided in the evidence of coverage, or fees for
				  uncovered services delivered on a fee-for-service basis to covered persons. Nor
				  does this agreement prohibit a provider (except for a health care professional
				  who is employed full-time on the staff of a health carrier and has agreed to
				  provide services exclusively to that health carrier's covered persons and no
				  others) and a covered person from agreeing to continue services solely at the
				  expense of the covered person, as long as the provider has clearly informed the
				  covered person that the health carrier may not cover or continue to cover a
				  specific service or services. Except as provided herein, this agreement does
				  not prohibit the provider from pursuing any available legal remedy."
C. Every contract between a health
				carrier and a participating provider shall set forth that in the event of a
				health carrier or intermediary insolvency or other cessation of operations,
				covered services to covered persons will continue through the period for which
				a premium has been paid to the health carrier on behalf of the covered person
				or until the covered person's discharge from an inpatient facility, whichever
				time is greater. Covered benefits to covered persons confined in an inpatient
				facility on the date of insolvency or other cessation of operations will
				continue until their continued confinement in an inpatient facility is no
				longer medically necessary.
D. The
				contract provisions that satisfy the requirements of Subsections B and C shall
				be construed in favor of the covered person, shall survive the termination of
				the contract regardless of the reason for termination, including the insolvency
				of the health carrier, and shall supersede any oral or written contrary
				agreement between a participating provider and a covered person or the
				representative of a covered person if the contrary agreement is inconsistent
				with the hold harmless and continuation of covered services provisions required
				by Subsections B and C of this section.
E. In no event shall a participating provider
				collect or attempt to collect from a covered person any money owed to the
				provider by the health carrier.
F.
(1) Health carrier selection standards for
				participating providers shall be developed for primary care professionals and
				each health care professional specialty. The standards shall be used in
				determining the selection of health care professionals by the health carrier,
				its intermediaries and any provider networks with which it contracts. As to
				physicians, the standards shall meet the requirements of 19 Miss. Admin. Code,
				Part 3, Rule 11, "Health Care Professional Credentialing Verification".
				Selection criteria shall not be established in a manner:
(a) That would allow a health carrier to
				avoid high-risk populations by excluding providers because they are located in
				geographic areas that contain populations or providers presenting a risk of
				higher than average claims, losses or health services utilization; or
(b) That would exclude providers because they
				treat or specialize in treating populations presenting a risk of higher than
				average claims, losses or health services utilization.