Rule: 6.6.5908 Prev     Up     Next    
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Subchapter: Network Adequacy
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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(1) When an insured's provider is dropped for any reason from the network, an insurer shall establish reasonable procedures to transition the insured to a preferred provider in a manner that ensures continuity of care.

(2) If the insured requests it and the treating provider agrees that the insured is in an active course of treatment, the treating provider may:

(a) request that the insured be permitted to continue treatment under the provider's care;

(b) agree to accept the same reimbursement from the insurer for that patient as provided for under that insurer's provider contract; and

(c) agree not to seek payment from the insured of any amount for which the insured would not be responsible if the provider were still a preferred provider.

(3) As used in this rule, "active course of treatment" means a condition which a provider reasonably believes could cause harm to an insured if care by the treating provider is suddenly discontinued, such as pregnancy or an ongoing course of treatment for an episode of cancer or other condition for which discontinuing care by the current treating physician may worsen the condition and interfere with anticipated outcomes.

(a) In a case involving an active course of treatment, an insurer must ensure continuity of care until the later of the following:

(i) the ongoing course of treatment is completed; or

(ii) through the postpartum period for a covered person in her second or third trimester of pregnancy.

(b) Except in the case of pregnancy, the continuity of care period may not last longer than 90 days, or the next renewal date for that policy, whichever is longer, without insurer consent; and

(c) Continuity of care protections are not required for routine primary and preventive care.

(4) An insurer shall agree to extend its obligation to reimburse the treating provider for ongoing treatment at the in-network rate if:

(a) the insurer agrees that the insured is in an "active course of treatment" as identified by the treating physician; and

(b) the provider contract termination was not "for cause."

(5) If the insurer does not agree to extend ongoing treatment at the in-network rate, the insured may appeal that decision under the appeal rights outlined in the insurance contract. An expedited appeal process must be available.

(6) This rule is effective for policies issued or renewed on or after January 1, 2016.

History: 33-22-1707, MCA; IMP, 33-22-1706, MCA; NEW, 2015 MAR p. 565, Eff. 5/15/15.


MAR Notices Effective From Effective To History Notes
6-208 5/15/2015 Current History: 33-22-1707, MCA; IMP, 33-22-1706, MCA; NEW, 2015 MAR p. 565, Eff. 5/15/15.
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