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| Montana Administrative Register Notice 6-285 | No. 3 02/09/2024 | |
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BEFORE THE COMMISSIONER OF SECURITIES AND INSURANCE OFFICE OF THE MONTANA STATE AUDITOR
TO: All Concerned Persons
1. The Commissioner of Securities and Insurance, Office of the Montana State Auditor (CSI) proposes to amend and repeal the above-stated rules.
2. The 68th Montana Legislature passed House Bill 156, which transferred the authority and operation of the Managed Care Plan Network Adequacy and Quality Assurance Act from the Department of Public Health and Human Services (DPHHS) to CSI. The first step in implementing the relevant sections of HB 156 occurred on October 20, 2023, when the commissioner published MAR Notice No. 6-282, which transferred rules pertaining to Network Adequacy for Managed Care Plans from DPHHS to CSI. The second step in implementing the relevant sections of HB 156 is amending the rules to conform to the changes made by HB 156 and to CSI operations, which is accomplished by the amendments proposed in this notice.
3. CSI will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require accommodation, contact CSI no later than 5:00 p.m. on February 20, 2024, to advise us of the nature of the accommodation that you need. Please contact Laura Shirtliff, Digital and Creative Services Director, 840 Helena Avenue, Helena, Montana, 59601; telephone (406) 444-2040 or 1-800-3326148; fax (406) 444-3413; TDD (406) 444-3246; or e-mail [email protected].
4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
6.6.8801 DEFINITIONS The following definitions, in addition to those contained in 33-36-103, MCA, apply to this chapter: (1) "Access plan" means a document filed by a health carrier with the (2) "Advanced practice registered nurse" means a nurse midwife, a nurse anesthetist, a nurse practitioner, or a clinical nurse specialist. (3) "Geographic service area" means a geographic area of Montana in which a health carrier has a network that has been deemed adequate by the
(4) "Mid-level provider" means a physician assistant-certified or an advanced practice registered nurse. (5) "Non-urgent care with symptoms" means care required for an illness, injury, or condition with symptoms that do not require care within 24 hours to prevent a serious risk of harm but do require care that is neither routine nor preventive in nature. (6) "Primary care provider (PCP)" means a physician, mid-level provider, federally qualified health center or rural health clinic as defined in ARM (7) "Specialty provider" or "specialist" means a physician or other provider whose area of specialization is an area other than general medicine, family medicine, general internal medicine, or general pediatrics. A provider whose area of specialization is obstetrics and/or gynecology may be either a PCP or a specialist within the meaning of this rule. (8) "Urgent care" means those health care services that are not emergency services but that are necessary to treat a condition or illness that could reasonably be expected to present a serious risk of harm if not treated within 24 hours.
AUTH: 33-36-105, MCA IMP: 33-36-103, 33-36-105, MCA
6.6.8805 ACCESS PLAN FILING AND REVIEW GUIDELINES (1) When a health carrier submits a proposed access plan to the (2) During the (3) The total number of days allowed for the review of a given proposed access plan may not exceed 120 calendar days, including both time spent by the
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-201, MCA
6.6.8806 ACCESS PLAN UPDATES (1) Health carriers shall be responsible for monitoring the status of their networks and must submit an updated access plan to the (2) In addition to the requirement in (1): (a) the health carrier must submit an updated access plan to the (b) health carriers must file an updated access plan with the commissioner if the number of providers in the overall provider network or in any specialty provider network decreases by more than 5% during the year in any single geographic service area or in the overall network. The carrier must file the plan within 30 days of the date the carrier learns of the decrease.
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-201, MCA
6.6.8807 ACCESS PLAN SPECIFICATIONS (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 (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 (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 (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 (iii) the procedures in place for selecting and changing providers;
(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 (g) a process for enabling enrollees to change primary care professionals that meets the standards of ARM (h) a process for transfer of enrollees to other providers must include a provision for transitional care as described in ARM (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 (j) the health carrier's procedures for complying with geographic accessibility requirements as outlined in ARM
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-201, MCA
6.6.8808 ACCESS CRITERIA (1) The
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-201, MCA
6.6.8820 EXCEPTIONS TO GEOGRAPHIC ACCESS CRITERIA (1) The (2) Good cause includes but is not limited to the circumstance where the health carrier has documented a good faith effort to negotiate a contract with local providers but has failed to reach an agreement within 60 days after the offer of a written contract from the health carrier. A good faith effort means an honest effort with the intent to deal fairly with providers and includes offering terms and conditions at least as favorable as those offered to other entities providing the same or similar services.
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-201, MCA
6.6.8841 LETTERS OF INTENT (1) In order to demonstrate that its network is adequate, a health carrier may utilize letters of intent from individual providers with whom it does not yet have a contract, so long as the providers do not constitute more than 15% of the total network. If letters of intent from providers are utilized, within 6 months after the access plan is submitted to the
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-201, MCA
5. CSI proposes to repeal the following rules:
6.6.8850 CORRECTIVE ACTION
AUTH: 33-36-105, MCA IMP: 33-36-105, MCA
6.6.8851 APPEAL FROM DEPARTMENT DECISION
6. REASON: The Commissioner of Securities and Insurance, Montana State Auditor, Troy Downing (commissioner) is the statewide elected official responsible for administering the Montana Insurance Code and regulating business of insurance. These amendments are necessary to ensure compliance with the Managed Care Plan Network Adequacy and Quality Assurance Act, the administration of which was transferred from DPHHS to CSI by House Bill 156, enacted by the 68th Montana Legislature. The above-stated amendments conform the already-existing rules to the changes made by HB 156 and to CSI's operations.
7. Concerned persons may submit their data, views, or arguments concerning the proposed actions in writing to: Laura Shirtliff, Digital and Creative Services Director, 840 Helena Avenue, Helena, Montana, 59601; telephone (406) 444-2040 or 1-800-332-6148; fax (406) 444-3413; TDD (406) 444-3246; or e-mail [email protected], and must be received no later than 5:00 p.m., March 8, 2024.
8. If persons who are directly affected by the proposed actions wish to express their data, views, or arguments orally or in writing at a public hearing, they must make written request for a hearing and submit this request along with any written comments to Laura Shirtliff at the above address no later than 5:00 p.m., March 8, 2024.
9. If the agency receives requests for a public hearing on the proposed actions from either 10 or 25 percent, whichever is less, of the persons directly affected by the proposed actions; from the appropriate administrative rule review committee of the Legislature; from a governmental subdivision or agency; or from an association having not less than 25 members who will be directly affected, a hearing will be held at a later date. Notice of the hearing will be published in the Montana Administrative Register. Ten percent of those directly affected has been determined to be 10 persons based on a conservative estimate of managed care members.
10. CSI maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list must make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Written request may be mailed or delivered to the contact person in paragraph 8 or made by completing a request form at any rules hearing held by CSI.
11. An electronic copy of this proposal notice is available through the Secretary of State's website at http://sosmt.gov/ARM/Register.
12. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
13. With regard to the requirements of 2-4-111, MCA, CSI has determined that the amendment and repeal of the above-referenced rules will not significantly and directly impact small businesses.
/s/ Ole Olson /s/ Mary Belcher Ole Olson Mary Belcher Rule Reviewer Deputy Auditor Commissioner of Securities and Insurance, Office of the Montana State Auditor
Certified to the Secretary of State January 30, 2024.
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A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
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