6.6.5901    APPLICABILITY AND IDENTIFICATION OF DIFFERENT LEVELS OF ADEQUACY

(1) A health care insurer who issues disability benefits and meets the requirements of 33-22-1706(4)(c), MCA, is deemed to have an adequate network, for that category of health care providers, provided that the insurer submits the information and follows the requirements set forth in this chapter.

(2) The commissioner may also determine a network to be adequate pursuant to 33-22-1706(4)(a), MCA, and ARM 6.6.5902(1) and (3).

(3) If the commissioner determines an insurer's network to be "not adequate," the cost sharing may be adjusted to no greater than a 25% payment differential.

(a) The commissioner shall determine whether the payment difference between in- and out-of-network is 25% or less, based on the utilization of actuarial data developed by actuarial experts, such as the information found in the Tillinghast Manual.

(b) Even if the commissioner determines that the insurer utilizes an acceptable payment differential under (3), that insurer shall submit the information and follow the requirements set forth in this chapter.

(4) If the commissioner determines that the network is so inadequate that representing it to the public as a network constitutes a misrepresentation under 33-1-502, MCA, the insurer may not issue a network plan under this chapter.

(5) ARM 6.6.5902(4)(b) through (f), ARM 6.6.5903(2)(b), ARM 6.6.5905(1)(b), and ARM 6.6.5906(4)(b) do not apply to dental and vision insurers.

History: 33-22-1707, MCA; IMP, 33-22-1706, MCA; NEW, 2015 MAR p. 565, Eff. 5/15/15.