BEFORE THE COMMISSIONER OF SECURITIES AND INSURANCE

MONTANA STATE AUDITOR

 

In the matter of the amendment of ARM 6.6.2503, 6.6.2504, 6.6.2505, 6.6.2506, 6.6.2507, 6.6.2508, and 6.6.2509, relating to health maintenance organizations

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NOTICE OF AMENDMENT

 

TO: All Concerned Persons

 

1. On February 23, 2018, the Commissioner of Securities and Insurance, Montana State Auditor published MAR Notice No. 6-243 pertaining to the public hearing on the proposed amendment of the above-stated rules at page 369 of the 2018 Montana Administrative Register, Issue Number 4.

 

2. The department has amended the following rules as proposed: ARM 6.6.2504 and 6.6.2505.

 

3. After consideration of the comments received, the department amends the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:

 

6.6.2503 DEFINITIONS (1) and (2) remain as proposed.

(3) "Emergency care services" means: the same as "emergency services," and incorporating "emergency medical condition," as defined in 33-36-103, MCA.

(a) if within the service area:

(i) covered health care services rendered by affiliated providers under unforeseen conditions that require immediate medical attention; and

(ii) covered health care services from non-affiliated providers under unforeseen conditions that require immediate medical attention, but only when delay in receiving care from the health maintenance organization could reasonably be expected to cause severe jeopardy to the enrollee's condition; and

(b) medically necessary health care services that are immediately required because of unforeseen illness or injury while the enrollee is outside the service area.

(4) through (12) remain as proposed.

 

6.6.2506 REQUIREMENTS FOR CONTRACTS AND EVIDENCES OF COVERAGE  (1) and (2) remain as proposed.

(3) In addition to the requirements under (2), a group contract and evidence of coverage must contain:

(a) a provision that the coverage shall not be cancelled or terminated without giving the enrollee at least 15 days from the day written notice of termination is mailed to the enrollee; and

(b) remains as proposed, but is renumbered (a).

(4) through (6) remain as proposed. 

(7) A contract or evidence of coverage delivered or issued for delivery to any person by a health maintenance organization required to obtain a certificate of authority in this state may not contain any definitions that extend, modify, or conflict with those definitions contained in the Montana Health Maintenance Organization Act or ARM 6.6.2503 6.10.2503. A contract or evidence of coverage may include definitions of additional terms, so long as those additional definitions do not extend, modify, or conflict with the definitions contained in the Montana Health Maintenance Organization Act or ARM 6.6.2503. In addition, all definitions used in the contract and evidence of coverage must be in alphabetical order. 

 

6.6.2507 PROHIBITED PRACTICES (1) through (4) remain as proposed. 

 

AUTH: 33-31-103, MCA

           IMP: 33-18-203, 33-22-1811, 33-31-111, 33-31-301, 33-31-312, MCA

 

6.6.2508 SERVICES (1) through (5) remain as proposed.

(6) When an enrollee is traveling or temporarily residing out of a health maintenance organization's service area, the health maintenance organization must provide benefits for reimbursement for emergency care services, without regard to whether the health care provider furnishing the emergency care services is a participating network provider with respect to the emergency care services. and transportation that is medically necessary and appropriate under the circumstances to return the enrollee to a health maintenance organization provider. These out-of-area emergency care services and transportation may only be subject to some or all of the following requirements:

(a) the condition could not have been reasonably foreseen;

(b) the enrollee could not reasonably arrange to return to the service area to receive treatment from a health maintenance organization provider; or

(c) the travel or temporary residence must be for some purpose other than the receipt of medical treatments.

(7) remains as proposed.

 

6.6.2509 OTHER REQUIREMENTS  (1) through (3) remain as proposed. 

(4) Health maintenance organizations, unless operated by an insurer or a health service corporation as a plan, are required to file annual audited financial reports, as set forth in ARM 6.6.3501 through 6.6.3521.

 

4. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:

 

COMMENT No. 1: The commenter requested that the definition of "emergency care services" be struck and the definitions of "emergency services" and "emergency medical condition" as defined in 33-36-103, MCA, be used in its place. The commenter noted that the definition of "emergency care services" was old language from the 1990's. The commenter argued that since multiple current state and federal requirements use definitions more similar to 33-36-103, MCA, for consistency with other health plans it would be better to use the more current definitions.

 

RESPONSE No. 1: The CSI agrees with this comment; however the term "emergency care services" is used in multiple rules in this subchapter, and some of those rules were not being amended by this notice. So for internal consistency, the CSI has kept the phrase "emergency care services," but has adopted the more current definition used in the Insurance Code.

 

COMMENT No. 2: The commenter requested the removal of proposed new subsection (3)(a) in ARM 6.6.2506, because it required group health contract language from a statute that the legislature has not applied to health maintenance organizations.

 

RESPONSE No. 2: The CSI agrees with this comment, and has removed proposed ARM 6.6.2506(3)(a).

 

COMMENT No. 3: The commenter objected to the removal of language in previous ARM 6.6.2506(2)(m) allowing a limitation of hospital or inpatient benefits if disclosed in the group contract. The commenter stated that the reasonable necessity statement did not properly explain the substantive change, and requested that the provision stay the same.

 

RESPONSE No. 3: The CSI disagrees with this comment, but does acknowledge that the reasonable necessity statement could have been confusing. To remove any doubt, the deletion of the clause allowing the limitation on hospital or inpatient benefits was intentional. The justification that the change "was to conform to NAIC model law" in the reasonable necessity statement was meant to apply to both changes to proposed ARM 6.6.2506(3).

 

COMMENT No. 4: The commenter requested additional language be included in proposed ARM 6.6.2506(7) to make clear that HMO policy contracts may define additional terms, so long as they do not conflict with the definitions provided in rule.

 

RESPONSE No. 4: The CSI believes that was implied in the proposed language, but has added a clarifying sentence for the removal of any doubt.

 

COMMENT No. 5: The commenter noted that ARM 6.6.2507 as proposed cited to 33-22-1811, MCA, even though that statute does not apply to HMOs.

 

RESPONSE No. 5: The CSI agrees with this comment, and has removed the reference to 33-22-1811, MCA.

 

COMMENT No. 6: The commenter requested removal of proposed language in 6.6.2508(6) because it was different from current Montana and federal requirements for "emergency services," similar to comment 1.

 

RESPONSE No. 6: The CSI agrees that these requirements should be consistent, and has modified the language in ARM 6.6.2508(6) accordingly. 

 

COMMENT No. 7: The commenter requested the addition of language to proposed ARM 6.6.2509(4) that was in 33-31-211, MCA.

 

RESPONSE No. 7: The CSI agrees with this comment, and has modified ARM 6.6.2509(4) accordingly.

 

 

/s/ Michael A. Kakuk                                   /s/ Kristin Hansen                          

Michael A. Kakuk                                        Kristin Hansen

Rule Reviewer                                            Chief Counsel

                                                                                   

            Certified to the Secretary of State May 29, 2018.