Montana Administrative Register Notice 6-286 No. 3   02/09/2024    
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In the matter of the amendment of ARM 6.6.8901, 6.6.8905, 6.6.8906, 6.6.8907, 6.6.8910, 6.6.8911, 6.6.8915, and 6.6.8916, the repeal of ARM 6.6.8920 and 6.6.8921, and the adoption of NEW RULE I pertaining to Quality Assurance for Managed Care Plans













TO: All Concerned Persons


           1. The Commissioner of Securities and Insurance, Office of the Montana State Auditor (CSI) proposes to amend, repeal, and adopt 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. 6-283, which, effective January 1, 2024, transferred rules pertaining to Quality Assurance 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 csi@mt.gov. 


            4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:


6.6.8901  PURPOSE  (1) The purpose of these rules is to implement the quality assurance provisions of the Montana Managed Care Plan Network Adequacy and Quality Assurance Act specified in Title 33, chapter 36, part 3, MCA.  These rules establish mechanisms for the department commissioner to evaluate quality assurance activities of health carriers providing managed care plans in Montana.


AUTH: 33-36-105, MCA

IMP: 33-36-102, MCA 



(1)  The health carrier shall appoint, prior to commencing operation, a medical physician licensed to practice in the state of Montana to advise, oversee, and actively participate in the implementation and operation of the quality assurance program.

(2)  The health carrier may delegate quality assurance activities.  The health carrier shall retain responsibility for the performance of all delegated activities and shall develop and implement review and reporting requirements to assure ensure that the delegated entity performs all delegated quality assurance activities.

(3)  A health carrier whose managed care quality assurance plan has been accredited by a nationally recognized accrediting organization shall initially provide a copy of the accreditation certificate or outcome report and the accrediting standards used by the accrediting organization to the department commissioner.

(a)  If the department commissioner finds that the standards of the nationally recognized accrediting organization meet or exceed the department's commissioner's standards, the department commissioner will approve the health carrier's quality assurance program.

(b)  After approval by the department commissioner, the accredited health carrier shall provide proof of its continued accreditation annually to the department commissioner.

(c)  An accredited health carrier whose quality assurance plan is approved by the department is not required to comply with ARM 37.108.505.  If the accredited health carrier offers a closed or combination managed care plan, the health carrier must comply with ARM 37.108.510 and 37.108.515.  All accredited health carriers, regardless of their offering of closed, combination, or open plans, must comply with ARM 37.108.50737.108.51537.108.516, and 37.108.520 6.6.8907, 6.6.8910, 6.6.8915, and 6.6.8916.

(d)  The department commissioner will maintain a list of its approved accrediting organizations whose standards have been determined by the department commissioner to meet or exceed the department's commissioner's quality assurance standards.


AUTH: 33-36-105, MCA

IMP: 33-36-10533-36-302, MCA 



(1)  The health carrier shall implement a written quality assessment plan that is evaluated annually and updated as necessary.  The plan must be submitted to the department commissioner by October June 1 of each year.  The plan must describe:

(a)  the plan's mission, goals, and objectives;

(b)  the plan's organizational structure and the job titles of the personnel responsible for quality assessment;

(c)  the scope of the quality assessment plan's activities, including:

(i)  specific diagnoses, conditions, or treatments targeted for review to improve health care services and health outcomes;

(ii)  mechanisms to evaluate enrollees' health and health care services in relation to current medical research, knowledge, standards, and practices;

(iii)  communication processes by which the findings generated by the quality assessment program are communicated to providers and consumers to improve the health of enrollees; and

(iv)  mechanisms to evaluate the service performance of the health carrier and primary care physicians.

(2)  The written quality assessment plan must be signed by the health carrier's corporate officer certifying that the plan meets the department's commissioner's requirements.

(3)  The department commissioner and each health carrier will meet annually to review and approve the written quality assessment plans and their outcomes.


AUTH: 33-36-105, MCA

IMP:  33-36-10533-36-302, MCA



(1)  Annually, the health carrier shall evaluate its quality assessment activities by using the following 2020 2024 HEDIS measures:

(a)  childhood immunization;

(b)  breast cancer screening;

(c)  cervical cancer screening;

(d)  comprehensive diabetes care; and

(e)  HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for adults.

(2)  The health carrier shall record organizational components that affect accessibility, availability, comprehensiveness, and continuity of care, including:

(a)  referrals;

(b)  case management;

(c)  discharge planning;

(d)  appointment scheduling and waiting periods for all types of health care services;

(e)  second opinions, as applicable;

(f)  prior authorizations, as applicable;

(g)  provider reimbursement arrangements that contain financial incentives that may affect the care provided; and

(h)  other systems, procedures, or administrative requirements used by the health carrier that affect the delivery of care.

(3)  The health carrier may meet the requirements in (2) by submitting information to the department commissioner regarding network adequacy as specified in ARM 37.108.201 6.6.8801, et seq., as long as the information is consistent with what is required in (2).

(4)  The department commissioner adopts and incorporates by reference the HEDIS 2020 2024 measures for the categories listed in (1)(a) through (e).  The HEDIS 2020 2024 measures are developed by the National Committee for Quality Assurance and provide a standardized mechanism for measuring and comparing the quality of services offered by managed care health plans.  Copies of the HEDIS 2020 2024 measures are available from the National Committee for Quality Assurance, 1100 13th St. NW, Suite 1000, Washington, D.C. 20005 or at www.ncqa.org


AUTH: 33-36-105, MCA

IMP: 33-36-105, 33-36-302, MCA


6.6.8910  QUALITY IMPROVEMENT  (1)  By October 1 of each year At the commissioner's request, the health carrier shall provide documentation on its quality improvement activities and an evaluation of the effectiveness of the previous year's quality improvement activities.  Such documentation must include the health carrier's identification of quality assessment problems and opportunities for improving care through:

(a)  ongoing monitoring of process, structure, and outcomes of patient care or clinical performance;

(b)  evaluation of the data collected from ongoing monitoring activities to identify problems in patient care or clinical performance using criteria developed and applied by health care professionals;

(c)  measurable objectives for each improvement action within the reporting year, including the degree of expected change in persons or situations;

(d)  time frames for quality improvement action; and

(e)  parties responsible for implementing quality improvement action.


AUTH: 33-36-105, MCA

IMP:  33-36-10533-36-303, MCA


6.6.8911  CLINICAL FOCUSED STUDY  (1)  The health carrier shall conduct a focused study relevant to the quality of its services for enrollee care.  The health carrier must document the clinical focused study and submit it to the department commissioner at the commissioner's request by October 1 of each year.

(2)  The health carrier shall select topics for the focused study that are justified based on any of the following considerations:

(a)  areas of high volume;

(b)  areas of high risk;

(c)  areas where problems are expected or where they have occurred in the past;

(d)  areas that can be corrected or where prevention may have an impact;

(e)  areas that have potential adverse health outcomes; and

(f)  areas where enrollee complaints have occurred.

(3)  The health carrier shall document the study methodology employed, including:

(a)  the focused study question;

(b)  the sample selection;

(c)  data collection;

(d)  evaluation criteria; and

(e)  measurement techniques.


AUTH:  33-36-105, MCA

IMP: 33-36-303, MCA 


6.6.8915  ENROLLEE COMPLAINT SYSTEM  (1)  The health carrier shall have an internal complaint system for enrollees.  Such a system shall comply with the requirements of 33-31-303, MCA, and ARM 6.6.2509(4).

(2)  The health carrier shall conduct ongoing evaluations of all enrollee complaints, including complaints about the health carrier's services filed with participating providers.  Ongoing evaluations must be conducted in accordance with ARM 37.108.510 6.6.8910.  The data on complaints must be reported and evaluated by the health carrier at least quarterly.

(3)  Evaluation methods must permit the health carrier to track specific complaints, assess trends, and establish that corrective action is implemented and effective in improving the identified problem(s).

(4)  The health carrier shall document and monitor the effectiveness of its evaluation of the enrollee complaint system and communicate it to the involved providers, enrollees, and the department commissioner upon request.  The information is subject to the confidentiality requirements provided in 33-36-305, MCA.


AUTH: 33-36-105, MCA

IMP: 33-36-303, MCA 


6.6.8916  RECORDING CONSUMER SATISFACTION  (1)  The health carrier shall record consumer components that identify enrollees' perceptions on the quality of the health carrier's services, including:

(a)  enrollee satisfaction surveys; and

(b)  enrollee complaints, including:

(i)  the health carrier's resolution of the complaints through its internal procedures;

(ii)  independent peer reviewers' decision pursuant to 33-37-103, et seq., MCA, and ARM 37.108.301, et seq.;

(iii) (ii)  arbitration decisions; and

(iv) (iii)  court decisions.

(2)  The health carrier shall submit documentation of its handling of consumer satisfaction to the department commissioner at the commissioner's request by October 1 of each year.

(3)  The health carrier may meet the requirements in (1)(a) of this rule regarding enrollee satisfaction surveys by submitting to the department commissioner the information required for network adequacy as specified in ARM 37.108.201 6.6.8801, et seq., as long as the information is consistent with what is required in (1) (a) of this rule.

(4)  The identities of enrollees involved in recording consumer satisfaction are subject to the confidentiality requirements provided in 33-36-305, MCA.


AUTH:  33-36-105, MCA

IMP: 33-36-303, MCA 


5. CSI proposes to repeal the following rules:




AUTH: 33-36-105, MCA

IMP: 33-36-105, 33-36-401, MCA




AUTH: 33-36-105, MCA

IMP: 33-36-401, MCA


            6. The rule proposed to be adopted is as follows:


NEW RULE I  NOTICE OF DISAGREEMENT AND PROGRESSION TO ENFORCEMENT ACTION  (1)  If a health carrier disagrees with a corrective action recommended by the commissioner pursuant to 33-36-401(1), MCA, the health carrier must provide a written notice to the commissioner containing a short and plain statement of the grounds for disagreement with the corrective action. 

(2)  Once the carrier provides written notice to the commissioner pursuant to this rule, the matter proceeds as an enforcement action for non-compliance pursuant to 33-36-401(2)(a), MCA. The enforcement action will be held in accordance with the Montana Administrative Procedure Act, Title 2, chapter 4, part 6, MCA, and ARM 6.2.101


AUTH: 33-36-105, MCA

IMP: 33-36-401, MCA


7. 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. 


8. 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 CSI@mt.gov, and must be received no later than 5:00 p.m., March 8, 2024. 


9. 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.  


10. 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.


11. 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 requests 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. 


12. An electronic copy of this proposal notice is available through the Secretary of State's website at http://sosmt.gov/ARM/Register


13. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.   


14. With regard to the requirements of 2-4-111, MCA, CSI has determined that the amendment, repeal, and adoption 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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