State Law

Admin. Rules of Montana-Dept. #37-Subchapter 2-Network Adequacy for Managed Care

08/10/2023 Montana Section 37.108.207

Access Plan Specifications

Network Adequacy

(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 37.108.228, 37.108.229 and 37.108.235;

(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 37.108.240;

(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 insure that these characteristics do not pose barriers to gaining access to services. The policy shall, at a minimum, describe the health carrier’s methods for complying with each of the standards set forth in ARM 37.108.236; and

(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) above;

(ii) a summary description of the health carrier’s standards for provider credentials and methodology for reviewing providers, credentials on an ongoing basis required by ARM 37.108.216;

(iii) the procedures in place for selecting and changing providers;

(iv) a copy of the information filed with the commissioner of insurance detailing the health carrier’s benefits, including a comprehensive list of covered and non-covered services;

(v) the health carrier’s policy regarding enrollee responsibility for co-insurance, copayments, and deductibles;

(vi) a detailed description of the health carrier’s procedures along with authorization for specialty care that comply with ARM 37.108.228, a schedule of the fees, including co-insurance, co-payments and deductibles, for which an enrollee will be responsible;

(vii) policies pertaining to approval of and access to emergency services that meet the requirements of ARM 37.108.214;

(viii) telephone numbers and procedures for contacting an authorized representative of the health carrier who can facilitate review of post-evaluation or post-stabilization services required immediately after receipt of emergency services;

(ix) a description of the health carrier’s grievance procedures, including specific instructions and guidelines for filing and appealing grievances;

(x) a policy regarding use of and payment for in-network services; and

(xi) a policy regarding use of and payment for out-of-network services.

(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 37.108.214;

(g) a process for enabling enrollees to change primary care professionals that meets the standards of ARM 37.108.235;

(h) a process for transfer of enrollees to other providers must include a provision for transitional care as described in ARM 37.108.229;

(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 37.108.219 and 37.108.220; and

(j) the health carrier’s procedures for complying with geographic accessibility requirements as outlined in ARM 37.108.219 and 37.108.220.