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(1) A medicare select issuer shall file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation shall contain at least the following information:

(a) evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

(i) such services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care. The hours of operation and availability of after-hour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community;

(ii) the number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:

(A) to deliver adequately all services that are subject to a restricted network provision; or

(B) to make appropriate referrals;

(iii) there are written agreements with network providers describing specific responsibilities;

(iv) emergency care is available 24 hours per day and 7 days per week;

(v) in the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting such providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a medicare select policy or certificate. (1) (a) (v) shall not apply to supplemental charges or coinsurance amounts as stated in the medicare select policy or certificate;

(b) a statement or map providing a clear description of the service area;

(c) a description of the grievance procedure to be utilized;

(d) a description of the quality assurance program, including:

(i) the formal organizational structure;

(ii) the written criteria for selection, retention and removal of network providers; and

(iii) the procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted;

(e) a list and description, by specialty, of the network providers;

(f) copies of the written information proposed to be used by the issuer to comply with (1) ; and

(g) any other information requested by the commissioner.

History: 33-22-904 and 33-22-905, MCA; IMP, 33-22-901 through 33-22-924, MCA; NEW, 1996 MAR p. 907, Eff. 4/5/96.

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