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Rule Title: OTHER REQUIREMENTS
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Department: STATE AUDITOR
Chapter: INSURANCE DEPARTMENT
Subchapter: Health Maintenance Organizations
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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6.6.2509    OTHER REQUIREMENTS

(1) A health maintenance organization shall provide its subscribers with a list of the names and locations of all of its providers no later than the time of enrollment or the time the contract and evidence of coverage are issued and upon request thereafter. 

(a) If a provider is no longer affiliated with a health maintenance organization, the health maintenance organization shall provide notice of such change to its affected subscribers in a timely manner.

(b) Subject to the approval of the commissioner, a health maintenance organization may provide its subscribers with a list of providers or provider groups for a segment of the service area. However, a health maintenance organization must make a list of all providers available to subscribers upon request.

(c) Any list of providers must contain a notice regarding the availability of the listed primary care physicians. The notice must be in not less than 12-point type and be placed in a prominent place on the list of providers. The notice must contain the following or similar language: "Enrolling in [name of health maintenance organization] does not guarantee services by a particular provider on this list. If you wish to be sure of receiving care from specific providers listed, you should contact those providers to be sure that they are accepting additional patients for [name of health maintenance organization]."

(2) A health maintenance organization shall provide its subscribers with a description of its service area no later than the time of enrollment or the time the contract and evidence of coverage is issued and upon request thereafter. If the description of the service area is changed, the health maintenance organization shall provide at such time a new description of the service area to its subscribers.

(3) A health maintenance organization may require copayments of enrollees as a condition for the receipt of specific health care services. Copayments for basic health care services must be shown in the contract and evidence of coverage. Copayments and deductibles are the only charges that a health maintenance organization may assess to subscribers for basic and supplemental health care services.

(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.

 

History: 33-31-103 MCA; IMP, 33-31-202, 33-21-211, 33-31-301 MCA; NEW, 1987 MAR p. 1770, Eff. 10/16/87; AMD, 2018 MAR p. 1102, Eff. 6/9/18.


 

 
MAR Notices Effective From Effective To History Notes
6-243 6/9/2018 Current History: 33-31-103 MCA; IMP, 33-31-202, 33-21-211, 33-31-301 MCA; NEW, 1987 MAR p. 1770, Eff. 10/16/87; AMD, 2018 MAR p. 1102, Eff. 6/9/18.
10/16/1987 6/9/2018 History: Sec. 33-31-103 MCA; IMP, 33-31-202(3) (c), 33-31-301(3) (a), 33-31-301(3) (c), 33-31-301(5) (a), and 33-31-303 MCA; NEW, 1987 MAR p. 1770, Eff. 10/16/87.
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