reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 10 - Regulation to Implement the Medicare Supplement Insurance Minimum Standards Model Act, as amended › Rule 19-3-10.27 - Appendix A- Reporting Form for Calculation of Loss Ratios

Current through June 25, 2024
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4 For the calendar year on the
				  appropriate line in column (a), the premium earned during that year for
				  policies issued in that year.
5 These loss ratios are not
				  explicitly used in computing the benchmark loss ratios. They are the loss
				  ratios, on a policy year basis, which result in the cumulative loss ratios
				  displayed on this worksheet. They are shown here for informational purposes
				  only.
6 To include the earned premium
				  for all years prior to as well as the 15th year prior to the current
				  year.
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Benchmark Ratio Since Inception: (l + n)/(k + m):
1 Individual, Group, Individual
				  Medicare Select, or Group Medicare Select Only.
2 "SMSBP" = Standardized Medicare
				  Supplement Benefit Plan - Use "P" for pre-standardized plans
3 Year 1 is the current calendar
				  year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the
				  current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
4For the calendar year on the
				  appropriate line in column (a), the premium earned during that year for
				  policies issued in that year.
5These loss ratios are not
				  explicitly used in computing the benchmark loss ratios. They are the loss
				  ratios, on a policy year basis, which result in the cumulative loss ratios
				  displayed on this worksheet. They are shown here for informational purposes
				  only.
6 To include the earned premium
				  for all years prior to as well as the 15 th year
				  prior to the current year.
Miss Code Ann §
										83-9-107(Rev.
				  2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 10 - Regulation to Implement the Medicare Supplement Insurance Minimum Standards Model Act, as amended › Rule 19-3-10.28 - Appendix B- Form for Reporting Duplicate Policies

Current through June 25, 2024
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Miss Code Ann
				  §839-103(Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 10 - Regulation to Implement the Medicare Supplement Insurance Minimum Standards Model Act, as amended › Rule 19-3-10.29 - Disclosure Statements Appendix C

Current through June 25, 2024
DISCLOSURE STATEMENTS
Instructions for Use of the Disclosure Statements for
				  Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate
				  Medicare
1. Section 1882 (d)
				of the federal Social Security Act [
				42 U.S.C.
				1395 ss] prohibits the sale of a health
				insurance policy (the term policy includes certificate) to Medicare
				beneficiaries that duplicates Medicare benefits unless it will pay benefits
				without regard to a beneficiary's other health coverage and it includes the
				prescribed disclosure statement on or together with the application for the
				policy.
2. All types of health
				insurance policies that duplicate Medicare shall include one of the attached
				disclosure statements, according to the particular policy type involved, on the
				application or together with the application. The disclosure statement may not
				vary from the attached statements in terms of language or format (type size,
				type proportional spacing, bold character, line spacing, and usage of boxes
				around text).
3. State and federal
				law prohibits insurers from selling a Medicare supplement policy to a person
				that already has a Medicare supplement policy except as a replacement policy.
4. Property/casualty and life
				insurance policies are not considered health insurance.
5. Disability income policies are not
				considered to provide benefits that duplicate Medicare.
6. Long term care insurance policies that
				coordinate with Medicare and other health insurance are not considered to
				provide benefits that duplicate Medicare.
7. The federal law does not preempt state
				laws that are more stringent than the federal requirements.
8. The federal law does not preempt existing
				state form filing requirements.
9.
				Section 1882 of the federal Social Security Act was amended in Subsection
				(d)(3)(A) to allow for alternative disclosure statements. The disclosure
				statements already in Appendix C remain. Carriers may use either disclosure
				statement with the requisite insurance product. However, carriers should use
				either the original disclosure statements or the alternative disclosure
				statements and not use both simultaneously.
Miss Code Ann
				  §839-103(Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.01 - Authority

Current through June 25, 2024
This Regulation is promulgated pursuant to the authority
				  vested in the Commissioner of Insurance under Article 7 and Article 9 of
				  Chapter 41 of Title 83 of the Mississippi Code of 1972, Annotated, and is
				  promulgated in accordance with Mississippi Insurance Department Regulation No.
				  88-101, being the Rules of Practice and Procedure Before the Mississippi
				  Insurance Department.
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.02 - Purpose and Intent

Current through June 25, 2024
This Regulation requires a managed care entity to establish a
				  comprehensive health care professional credentialing verification program to
				  ensure that its participating health care professionals meet specific minimum
				  standards of professional qualification. The standards set out in this
				  Regulation address the initial credentialing verification and subsequent
				  recredentialing process
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.04 - Applicability And Scope

Current through June 25, 2024
This Regulation shall apply to managed care entities that
				  offer, operate or participate in managed care plans.
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.05 - General Responsibilities Of The Managed Care Entity

Current through June 25, 2024
A. A managed care entity shall:
1. Establish written policies and procedures
				for credentialing verification of all health care professionals with whom the
				managed care entity contracts and apply these standards consistently;
2. Verify the credentials of a health care
				professional when entering into a contract with that health care professional.
				The medical director of the managed care entity or other designated health care
				professional shall have responsibility for, and shall participate in, health
				care professional credentialing verification;
3. Establish a credentialing verification
				committee consisting of licensed physicians and other health care professionals
				to review credentialing verification information and supporting documents and
				make decisions regarding credentialing verification;
4. Make available for review by the applying
				health care professional upon written request all application and credentialing
				verification policies and procedures; and
5. Keep confidential all information obtained
				in the credentialing verification process, except as otherwise provided by
				law.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.06 - Verification Responsibilities of the Managed Care Entity

Current through June 25, 2024
A managed care entity shall:
A. Obtain primary verification of at least
				the following information about the applicant:
1. Current license or certification to
				practice in this and all other states and history of licensure or
				certification;
2. Status of primary
				admitting hospital privileges, if applicable;
3. Specialty board certification status, or,
				if not board certified, the highest level of education obtained;
4. Malpractice history within the last five
				(5) years.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.07 - Uniform Application for Physician Credentialing and Recredentialing

Current through June 25, 2024
A. In order to simplify the application
				process for physicians who are applying to multiple managed care entities, the
				Commissioner hereby adopts a basic uniform credentialing application which
				shall be used by all managed care entities performing physician credentialing
				and recredentialing activities in Mississippi. The uniform application is
				attached hereto as Exhibit "A" and hereby made a part of this
				Regulation.
B. The uniform
				application may be augmented by an individual managed care entity for the
				purpose of obtaining additional necessary and material information which is not
				requested in the uniform application, and further, for the purpose of providing
				more detailed instructions regarding the completion and submission of the
				application. The additional information/instructions may only be
				requested/provided on supplemental sheets which are attached to the uniform
				application. Any proposed supplemental sheets must be submitted by the managed
				care entity to the Commissioner for prior approval.
C. The form prescribed by this Section shall
				apply only to the credentialing and recredentialing of physicians.
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.08 - Health Care Professional's Right to Review Credentialing Verification Information

Current through June 25, 2024
Subject to the provisions of Subsections A., B., C., and D.
				  of this Section, a managed care entity shall provide a health care professional
				  with the sources from which credentialing information is received, notification
				  of any information that varies substantially from the information the health
				  care professional provided, and the opportunity to correct information received
				  from a third party that is incorrect or misleading.
A. Each health care professional who is
				subject to the credentialing verification process shall have the right to
				request information regarding the sources utilized by the managed care entity
				to verify credentialing information, including a summary of information
				obtained by the managed care entity to satisfy the requirements of this
				Regulation.
B. A managed care
				entity shall notify a health care professional of any information obtained
				during the managed care entity's credentialing verification process that does
				not meet the managed care entity's credentialing verification standards or that
				varies substantially from the information provided to the managed care entity
				by the health care professional, except, that the managed care entity shall not
				be required to allow the health care professional to (1) review the contents of
				a verification, (2) identify the source of information, or (3) provide a
				summary of differing information, if the information is not obtained to meet
				the requirements of this Regulation or if disclosure is prohibited by law.
				Responses provided by personal or professional references shall not be
				available to the health care professional.
C. A health care professional shall have the
				right to correct any erroneous information submitted by a third party when the
				health care professional feels that the managed care entity's credentialing
				verification committee has received information that is incorrect or
				misleading. The managed care entity shall have a formal process by which the
				health care professional may submit supplemental or corrected information to
				the managed care entity's credentialing verification committee. Supplemental
				information shall be subject to confirmation by the managed care
				entity.
D. Nothing in this Section
				8 shall prohibit a managed care entity from denying an application or
				reapplication or terminating privileges, employment or a provider participation
				agreement where a health care professional intentionally withholds material
				information, intentionally omits material information, or intentionally submits
				material false or misleading information in a credentialing or re-credentialing
				application which is submitted to a managed care entity.
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.09 - Contracting

Current through June 25, 2024
Whenever a managed care entity delegates the credentialing
				  functions required by this Regulation to another entity, the commissioner shall
				  hold the managed care entity responsible for monitoring the activities of the
				  delegatee entity in order to ensure that the requirements of this Regulation
				  are met.
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.10 - Separability

Current through June 25, 2024
If any provision of the Regulation, or the application of the
				  provision to any person or circumstance, shall be held invalid, the remainder
				  of the Regulation, and the application of the provision to persons or
				  circumstances other than those to which it is held invalid, shall not be
				  affected.
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.11 - Effective Date

Current through June 25, 2024
This Regulation shall become effective thirty (30) days after
				  filing with the Office of the Secretary of State of the State of
				  Mississippi.
Miss Code Ann §
										25-43-3.113(Rev.
				  2010)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.12 - Instructions for Completing the Mississippi Participating Physician Application

Current through June 25, 2024
To effectively use the Application, the following is
				  suggested:
Type or legibly complete the Application in
black
				  ink.
A. Complete all of the
				Application except for line 1, "This application is submitted to,___". Do not
				sign and date the original. Keep the completed original on file and keep a
				blank original for future up-dates. Sign and date as directed below.
B. When submitting the Mississippi
				Participating Physician Application to a credentialing entity:
1. copy the original Application and any
				addenda the credentialing entity has requested;
2. fill in the name of the IPA, medical
				group, health plan, hospital, etc., to which the Application is being submitted
				on the top of page 1;
3. sign and
				date the copy in the spaces provided;
4. mail the signed and dated copy to the
				requesting organization.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.13 - Mississippi Participating Physician Application

Current through June 25, 2024
(See below.)
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Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.01 - Authority

Current through June 25, 2024
This Regulation is promulgated pursuant to the authority
				  vested in the Commissioner of Insurance under Miss. Code Ann. §§
									83-1-43
				  and
				  83-5-1
				  (Rev. 1999), and is promulgated in accordance with Mississippi Insurance
				  Department Regulation No. 88-101, said Regulation being the Rules of Practice
				  and Procedure Before the Mississippi Insurance Department.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.02 - Purpose and Intent

Current through June 25, 2024
In order to fully comply with the Health Insurance
				  Portability and Accountability Act of 1996, as Amended, including information
				  issued by the Health Care Financing Administration to the Mississippi
				  Department of Insurance regarding the enforcement thereof, this Regulation is
				  promulgated to prevent health insurance issuers in the group or individual
				  market that cover hospitalization in connection with childbirth for mothers
				  and/or their newborns from restricting coverage to less than forty-eight (48)
				  hours following a vaginal delivery and ninety-six (96) hours following a
				  Cesarean section.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.03 - Definition of Health Insurance Issuer

Current through June 25, 2024
As used in this Regulation, the term "health insurance
				  issuer" shall mean any insurance company, hospital or medical service plan or
				  any entity defined in Miss. Code Ann. §
									83-41-303(n)(Rev.
				  1999), which offers group or individual insurance coverage in the State of
				  Mississippi.
Miss. Code Ann. §
										83-5-1;
				  83-1-43 (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.04 - Benefit Requirements for Minimum Hospital Stay

Current through June 25, 2024
A. A
				health insurance issuer shall not, except as provided in subsection B. of this
				Section:
1. Restrict benefits for any
				hospital length of stay in connection with childbirth for the mother or newborn
				child following a normal vaginal delivery to less than forty-eight (48) hours;
				or
2. Restrict benefits for any
				hospital length of stay in connection with childbirth for the mother or newborn
				child following a Caesarean section to less than ninety-six (96) hours;
				or
3. Require that a provider
				obtain authorization from the health insurance issuer for prescribing any
				length of stay required in this Section 4.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.05 - Prohibited Practices

Current through June 25, 2024
A health insurance issuer offering a group or individual
				  health insurance coverage shall not:
A.
				Deny to the mother or her newborn child eligibility, or continued eligibility,
				to enroll or to renew coverage under the terms of the policy solely for the
				purpose of avoiding the requirements of this Regulation;
B. Provide monetary payments or rebates to
				mothers to encourage such mothers to accept less than the minimum protections
				available under this Regulation;
C.
				Penalize or otherwise reduce or limit the reimbursement of an attending
				provider because such provider provided care to an insured or enrollee in
				accordance with this Regulation;
D.
				Provide incentives, monetary or otherwise, to an attending provider to induce
				such provider to provide care to an insured or enrollee in a manner
				inconsistent with this Regulation; or
E. Subject to subsection C. of Section 6. of
				this Regulation, restrict benefits for any portion of a period within a
				hospital length of stay required under subsections (1) and (2) of Section 4. of
				this Regulation in a manner which is less favorable than the benefits provided
				for any preceding portion of such stay.
Source:Miss. Code Ann.
				  §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.06 - Exceptions

Current through June 25, 2024
A. Nothing in this Regulation shall be
				construed to require a mother who is an insured or enrollee:
1. To give birth in a hospital; or
2. To stay in the hospital for a fixed period
				of time following the birth of her child.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.07 - Notice

Current through June 25, 2024
A health insurance issuer providing group or individual
				  health insurance coverage shall provide notice to the named insured in the case
				  of an individual policy, and to each certificate holder in the case of a group
				  policy, regarding the coverage required by this Regulation. Such notice shall
				  be in writing and prominently positioned in any literature or correspondence
				  made available or distributed by the health insurance issuer and shall be
				  transmitted to the named insured or certificate holder not later than October
				  1, 2000. The notice prescribed by this Section 7. shall be filed with and
				  approved by the Commissioner of Insurance before distribution by the health
				  insurance issuer.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 12 - (2000-2) Newborns' and Mothers' Health Protection › Rule 19-3-12.08 - Effective Date

Current through June 25, 2024
The effective date of this Regulation shall be thirty (30)
				  days from and after its adoption and filing with the Secretary of State of the
				  State of Mississippi.
Miss. Code Ann. §
										25-43-3.113
				  (Rev. 2010)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.01 - Authority

Current through June 25, 2024
This Regulation is promulgated pursuant to the authority
				  vested in the Commissioner of Insurance under
Miss. Code
				  Ann
. §§
									83-1-43
				  and
				  83-5-1
				  (Rev. 1999).and is promulgated in accordance with Mississippi Insurance
				  Department Regulation No. 88-101, said Regulation being the Rules of Practice
				  and Procedure Before the Mississippi Insurance Department.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.02 - Purpose and Intent

Current through June 25, 2024
In order to fully comply with the Health Insurance
				  Portability and Accountability Act of 1996, as Amended, including instructions
				  issued by the Health Care Financing Administration regarding the enforcement
				  thereof, this Regulation is promulgated to require health insurance issuers in
				  the group and individual markets that cover medical and surgical benefits with
				  respect to a mastectomy to cover, for patients who so elect:
A. Reconstruction of the breast on which the
				mastectomy has been preformed;
B.
				Surgery and reconstruction of the other breast to produce a symmetrical
				appearance;
C. Prosthesis, and
				physical complications of mastectomy, including lymphedema.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.03 - Definition of Health Insurance Issuer

Current through June 25, 2024
As used in this Regulation, the term "health insurance
				  issuer" shall mean any insurance company, hospital or medical service plan or
				  any entity defined in
Miss. Code Ann
. §
									83-41-303(n)(Rev.
				  1999), which offers group or individual health insurance coverage in the State
				  of Mississippi.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.04 - Benefit Requirements

Current through June 25, 2024
A health insurance issuer providing group or individual
				  health insurance coverage that provides medical and surgical benefits with
				  respect to a mastectomy shall provide an insured or enrollee who is receiving
				  benefits in connection with a mastectomy and whoelects breast reconstruction in
				  connection with such mastectomy, coverage for all stages of reconstruction of
				  the breast on which the mastectomy has been performed; surgery and
				  reconstruction of the other breast to produce a symmetrical appearance; and
				  prostheses and physical complications of mastectomy, including lymphedema in a
				  manner determined in consultation with the attending physician and the patient.
				  Such coverage may be subject to annual deductibles and coinsurance provisions
				  as may be deemed appropriate and as are consistent with those established for
				  other benefits under the coverage. Written notice of the availability of such
				  coverage shall be delivered to the insured in the case of an individual policy,
				  and to the certificate holder in the case of a group policy, upon enrollment
				  and annually thereafter.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.05 - Prohibited Practices

Current through June 25, 2024
A. A health
				insurance issuer offering group or individual health insurance coverage may
				not:
1. Deny to a patient eligibility, or
				continued eligibility, to enroll or to renew coverage under the terms of the
				policy solely for the purpose of avoiding the requirements of this Regulation;
				or
2. Penalize or otherwise reduce
				or limit the reimbursement of an attending provider or provide incentives
				(monetary or otherwise) to an attending provider to induce such provider to
				provide care to an insured or enrollee in a manner inconsistent with this
				Regulation.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.06 - Notice

Current through June 25, 2024
A health insurance issuer providing group or individual
				  health insurance coverage shall provide notice to the named insured in the case
				  of an individual policy, and to each certificate holder in the case of a group
				  policy, regarding the coverage required by this Regulation. Such notice shall
				  be in writing and prominently positioned in any literature or correspondence
				  made available or distributed by the health insurance issuer and shall be
				  transmitted to the named insured or certificate holder not later than October
				  1, 2000. The notice prescribed by the Section 6. shall be filed with and
				  approved by the Commissioner of Insurance before distribution by the health
				  insurance issuer.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.07 - Exceptions

Current through June 25, 2024
This Regulation does not apply to any group health insurance
				  coverage in relation to its provision of excepted benefits described in 42
				  U.S.C. § 300gg-21(c) and (d), and does not apply to any individual health
				  insurance coverage in relation to its provision of expected benefits described
				  in 42 U.S.G. § 300gg-63.
Miss. Code Ann. §
										83-1-43
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 13 - (2000-3) Women's Health and Cancer Rights › Rule 19-3-13.08 - Effective Date

Current through June 25, 2024
The effective date of this Regulation shall be thirty (30)
				  days from and after its adoption and filing with the Secretary of State of the
				  State of Mississippi.
Miss. Code Ann. §
										25-43-3.113
				  (Rev. 2010)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.1 - Title

Current through June 25, 2024
This Regulation shall be known and may be cited as the
				  Managed Care Plan Network Adequacy Regulation and is promulgated by the
				  Commissioner of Insurance pursuant to the authority granted to him by Title 83,
				  the Mississippi Insurance Code; the requirements of Mississippi Code Annotated,
				  Section
				  25-43-1.101,
				  et seq., in accordance with the Mississippi Administrative Procedures Law; and
				  the requirements of Mississippi Code Annotated, Section 83-41-101, et seq., the
				  Mississippi Patient Protection Act of 1995.
Miss. Code Ann.
				  §§
										25-43-1.101,
				  et seq.; §
										83-5-1;
				  §§ 83-41-101, et seq. (Rev.
				  2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.2 - Purpose

Current through June 25, 2024
The purpose and intent of this Regulation are to establish
				  standards for the creation and maintenance of networks by health carriers and
				  to assure 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.
Miss. Code Ann. §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.4 - Applicability and Scope

Current through June 25, 2024
This Regulation shall apply to all health carriers that offer
				  managed care plans.
Miss. Code Ann. §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.5 - Network Adequacy

Current through June 25, 2024
A. A health carrier
				providing a managed care plan shall maintain a network that is sufficient in
				numbers and types of participating providers to assure that all services to
				covered persons will be accessible without unreasonable delay. In the case of
				emergency facility services, covered persons shall have access twenty-four (24)
				hours per day, seven (7) days per week. Sufficiency shall be determined in
				accordance with the requirements of this section, and may be established by
				reference to any reasonable criteria used by the health carrier, including but
				not limited to: provider-covered person ratios by specialty; primary care
				provider-covered person ratios; geographic accessibility; waiting times for
				appointments with participating providers; hours of operation; and the volume
				of technological and specialty services available to serve the needs of covered
				persons requiring technologically advanced or specialty care.
(1) In any case where the health carrier has
				an insufficient number or type of participating provider to provide a covered
				benefit, the health carrier shall ensure that the covered person obtains the
				covered benefit at no greater cost to the covered person than if the benefit
				were obtained from participating providers, or shall make other arrangements
				acceptable to the commissioner.
(2)
				The health carrier shall establish and maintain adequate arrangements to ensure
				reasonable proximity of participating providers to the business or personal
				residence of covered persons. In determining whether a health carrier has
				complied with this provision, the commissioner shall give due consideration to
				the relative availability of health care providers in the service area under
				consideration.
(3) A health carrier
				shall monitor, on an ongoing basis, the ability, clinical capacity, financial
				capability and legal authority of its providers to furnish all contracted
				benefits to covered persons.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.7 - Intermediaries

Current through June 25, 2024
A contract between a health carrier and an intermediary shall
				  satisfy all the requirements contained in this section.
A. Intermediaries and participating providers
				with whom they contract shall comply with all the applicable requirements of
				Section 16.06.
B. A health
				carrier's statutory responsibility to monitor the offering of covered benefits
				to covered persons shall not be delegated or assigned to the
				intermediary.
C. A health carrier
				shall have the right to approve or disapprove participation status of a
				subcontracted provider in its own or a contracted network for the purpose of
				delivering covered benefits to the carrier's covered persons.
D. A health carrier shall maintain copies of
				all intermediary health care subcontracts at its principal place of business in
				the state, or ensure that it has access to all intermediary subcontracts,
				including the right to make copies to facilitate regulatory review, upon twenty
				(20) days prior written notice from the health carrier.
E. If applicable, an intermediary shall
				transmit utilization documentation and claims paid documentation to the health
				carrier. The carrier shall monitor the timeliness and appropriateness of
				payments made to providers and health care services received by covered
				persons.
F. If applicable, 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 in a manner that facilitates regulatory
				review.
G. An intermediary shall
				allow the commissioner access to the intermediary's books, records, financial
				information and any documentation of services provided to covered persons, as
				necessary to determine compliance with this Regulation.
H. A health carrier shall have the right, in
				the event of the intermediary's insolvency, to require the assignment to the
				health carrier of the provisions of a provider's contract addressing the
				provider's obligation to furnish covered services.
Miss. Code Ann. §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.8 - Filing Requirements and State Administration

Current through June 25, 2024
A.
				Beginning August 1, 2014, a health carrier shall file with the commissioner
				sample contract forms proposed for use with its participating providers and
				intermediaries.
B. A health carrier
				shall submit material changes to a contract that would affect a provision
				required by this regulation to the commissioner for approval prior to use.
				Changes in provider payment rates, coinsurance, copayments or deductibles, or
				other plan benefit modifications are not considered material changes for the
				purpose of this subsection.
C. If
				the commissioner takes no action within sixty (60) days after submission of a
				material change to a contract by a health carrier, the change is deemed
				approved.
D. The health carrier
				shall maintain provider and intermediary contracts at its principal place of
				business in the state, or the health carrier shall have access to all contracts
				and provide copies to facilitate regulatory review upon twenty (20) days prior
				written notice from the commissioner.
Miss. Code Ann. §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.9 - Contracting

Current through June 25, 2024
A. The execution of a contract by a health
				carrier shall not relieve the health carrier of its liability to any person
				with whom it has contracted for the provision of services, nor of its
				responsibility for compliance with the law or applicable regulations.
B. All contracts shall be in writing and
				subject to review.
C. All contracts
				shall comply with applicable requirements of the law and applicable
				regulations.
Miss. Code Ann. §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.10 - Enforcement

Current through June 25, 2024
A. If the commissioner determines that a
				health carrier has not contracted with enough participating providers to assure
				that covered persons have accessible health care services in a geographic area,
				or that a health carrier's access plan does not assure reasonable access to
				covered benefits, or that a health carrier has entered into a contract that
				does not comply with this Regulation, or that a health carrier has not complied
				with a provision of this Regulation, the commissioner may institute a
				corrective action that shall be followed by the health carrier, or may use any
				of the commissioner's other enforcement powers to obtain the health carrier's
				compliance with this Regulation.
B.
				The commissioner will not act to arbitrate, mediate or settle disputes
				regarding a decision not to include a provider in a managed care plan or in a
				provider network or regarding any other dispute between a health carrier, its
				intermediaries or a provider network arising under or by reason of a provider
				contract or its termination.
Miss. Code Ann. §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.11 - Penalties

Current through June 25, 2024
A violation of this Regulation shall be subject to the
				  penalty provisions set forth in
Miss. Code Ann.
§
									83-5-17,
				  as well as other penalty provisions under applicable law.
Miss. Code Ann. §
										83-5-17;
				  §
										83-41-405;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.12 - Severability

Current through June 25, 2024
If any provision of this Regulation, or the application of
				  the provision to any person or circumstance shall be held invalid, the
				  remainder of the Regulation, and the application of the provision to persons or
				  circumstances other than those to which it is held invalid, shall not be
				  affected.
Miss. Code Ann. §
										83-5-1;
				  §
										83-41-413
				  (Rev. 2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 14 - Managed Care Plan Network Adequacy › Rule 19-3-14.13 - Effective Date

Current through June 25, 2024
This Regulation shall be effective thirty (30) days after
				  final adoption with the Office of the Secretary of State.
A. All provider and intermediary contracts in
				effect on the effective date of this Regulation shall comply with this
				Regulation no later than eighteen (18) months after the effective date of this
				Regulation. The commissioner may extend the eighteen (18) months for an
				additional period not to exceed six (6) months if the health carrier
				demonstrates good cause for an extension.
B. A new provider or intermediary contract
				that is issued or put in force on or after August 1, 2014, shall comply with
				this Regulation.
C. A provider
				contract or intermediary contract not described in Subsection A or Subsection B
				shall comply with this Regulation no later than eighteen (18) months after the
				effective date of this Regulation.
Miss. Code Ann. §
										25-43-3.112 (Rev.
				  2011)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.01 - Purpose and Intent

Current through June 25, 2024
The purpose of this Regulation is to provide uniform
				  standards for the establishment and maintenance of external review procedures
				  to assure that covered persons have the opportunity for an independent review
				  of an adverse determination or final adverse determination, as defined in this
				  Regulation.
Miss. Code Ann. §
										83-5-1
				  (Rev. 2011); Public Law
				  111-148 -Mar. 23, 2010 (Patient Protection and
				  Affordable Care Act)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.03 - Applicability and Scope

Current through June 25, 2024
A. Except as
				provided in subsection B, this Regulation shall apply to all health
				carriers.
B. The provisions of this
				Regulation shall not apply to a policy or certificate that provides coverage
				only for a specified disease, specified accident or accident-only coverage,
				credit, dental, disability income, hospital indemnity, long-term care
				insurance, as defined by the Commissioner by regulation, vision care or any
				other limited supplemental benefit or to a Medicare supplement policy of
				insurance, as defined by the Commissioner by regulation, coverage under a plan
				through Medicare, Medicaid, or the federal employees health benefits program,
				any coverage issued under Chapter 55 of Title 10, U.S. Code and any coverage
				issued as supplement to that coverage, any coverage issued as supplemental to
				liability insurance, workers' compensation or similar insurance, automobile
				medical-payment insurance or any insurance under which benefits are payable
				with or without regard to fault, whether written on a group blanket or
				individual basis.
Miss. Code Ann. §
										83-5-1
				  (Rev. 2011); Public Law
				  111-148 -Mar. 23, 2010 (Patient Protection and
				  Affordable Care Act)
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.04 - Notice of Right to External Review

Current through June 25, 2024
A.
1. A health carrier shall notify the covered
				person in writing of the covered person's right to request an external review
				to be conducted pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this
				Regulation and include the appropriate statements and information set forth in
				subsection B at the same time the health carrier sends written notice of:
a. An adverse determination upon completion
				of the health carrier's utilization review process; and
b. A final adverse
				determination.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.05 - Request for External Review

Current through June 25, 2024
A.
1. Except for a request for an expedited
				external review as set forth Rule 15.08 of this Regulation, all requests for
				external review shall be made in writing to the Commissioner.
2. The External Review Request Form, attached
				hereto as Rule 15.21 -Appendix "B", meets the form and requirements of this
				section and may be used to submit a request for External Review.
Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.06 - Exhaustion of Internal Grievance Process

Current through June 25, 2024
A.
1. Except as provided in subsection B, a
				request for an external review pursuant to Rule 15.07, Rule 15.08 or Rule 15.09
				of this Regulation shall not be made until the covered person has exhausted the
				health carrier's internal grievance process.
2. A covered person shall be considered to
				have exhausted the health carrier's internal grievance process for purposes of
				this section, if the covered person or the covered person's authorized
				representative:
a. Has filed a grievance
				involving an adverse determination with the health carrier; and
b. Except to the extent the covered person or
				the covered person's authorized representative requested or agreed to a delay,
				has not received a written decision on the grievance from the health carrier
				within thirty (30) days following the date the covered person or the covered
				person's authorized representative filed the grievance with the health
				carrier.
3.
				Notwithstanding paragraph (2), a covered person or the covered person's
				authorized representative may not make a request for an external review of an
				adverse determination involving a retrospective review determination until the
				covered person has exhausted the health carrier's internal grievance
				process.