Montana Administrative Code

6.6.8503 ANNUAL FEE AND REPORTING FORMS On or before March 1 of each year, viatical settlement providers shall submit to the department an annual fee in the amount of $1900. Forms for annual reporting required in 33-20-1309 , MCA, are available at the commissioner's office. Autho…

6.6.8504 FORMS AND MATERIALS FILINGS, APPROVALS AND REVISIONS A viatical settlement provider shall file and have approved by the commissioner application forms, contracts and other forms as required by 33-1-501 and 33-20-1308, MCA. A viatical settlement provider or broker shall f…

6.6.8505 DISCLOSURE A disclosure document containing the disclosures required in 33-20-1311, MCA, and this rule, shall be provided when an application for a viatical settlement contract is taken. The disclosure document must contain the following language: "All medical, financial…

6.6.8506 TRADE PRACTICE STANDARDS FOR REGULATING ADVERTISING AND SOLICITATION (REPEALED) Authorizing statute(s): 33-20-1315, MCA Implementing statute(s): 33-20-1315, MCA History: NEW, 2000 MAR p. 3155, Eff. 11/10/00; REP, 2005 MAR p. 71, Eff. 1/14/05.

6.6.8507 STANDARDS FOR EVALUATION OF REASONABLE PAYMENTS In order to assure that viators receive a reasonable return for viaticating an insurance policy, the following shall be minimum discounts when the insured is terminally ill: Insured's Life Expectancy Minimum Percentage of N…

6.6.8508 GENERAL RULES With respect to policies containing a provision for double or additional indemnity for accidental death, the additional payment must remain payable to the beneficiary last named by a viator prior to entering into a viatical settlement contract, or to such o…

6.6.8509 REGULATION AS A SECURITY A viatical settlement broker or a viatical settlement provider may not solicit, enter into, or negotiate viatical settlement contracts unless a broker or provider, through the exercise of due diligence, ensures that: the method of funding the fin…

6.6.8510 REPORTING REQUIREMENT On or before March 1 of each calendar year, each viatical settlement provider licensed in this state shall submit the following related to the licensee's activities for the previous calendar year: a report of the viatical settlement transactions in …

6.6.8511 PROHIBITED PRACTICES A viatical settlement provider or viatical settlement broker shall not provide patient identifying information to any person, unless the insured provides written consent to the release of the information at or before the time the viator enters into a…

6.6.8512 INSURANCE COMPANY PRACTICES Life insurance companies authorized to do business in this state shall respond to a request for verification of coverage from a viatical settlement provider or a viatical settlement broker within 30 calendar days of the date a request is recei…

6.6.8601 PURPOSE AND SCOPE These rules are intended to establish an expedient and economical process for resolving billing disputes between insurers or health plans and air ambulance services. The independent reviewer shall conduct all aspects of the dispute resolution process in…

6.6.8602 MAPA INAPPLICABLE A dispute resolution process subject to this subchapter: is not a contested case as defined in 2-4-102, MCA; is not a proceeding before the commissioner; and is not subject to the Montana Administrative Procedure Act, Title 2, chapter 4, MCA. The indepe…

6.6.8603 CONFIDENTIALITY The parties and independent reviewer shall maintain the confidentiality of all information protected under applicable law, including protected health information under the Health Insurance Portability and Accountability Act of 1996, trade secret informati…

6.6.8604 NOTICE OF DISPUTE – CONTENT After determining that an insurer or health plan and an air ambulance service cannot resolve a billing dispute, either party may communicate in writing to the other party its intent to submit the dispute to this arbitration process. Within 30 …

6.6.8605 INDEPENDENT REVIEWER SELECTION–SUBSTITUTION If the parties to a dispute agree upon an independent reviewer, the independent reviewer is presumed to be qualified without further verification by the commissioner. If a party believes an assigned independent reviewer has a c…

6.6.8606 PRELIMINARY CONFERENCE Unless otherwise ordered by the independent reviewer or agreed to by the parties, within 30 days of appointment the independent reviewer shall hold a telephonic preliminary conference. During the preliminary conference, the parties and independent …

6.6.8607 DISCOVERY Within 14 days after the preliminary conference, the parties shall exchange all documents upon which they intend to rely at hearing, a list of all witnesses they intend to call, and a summary of the expected testimony from each identified witness. The parties s…

6.6.8608 EVIDENCE AND PROCEDURE The Montana Rules of Evidence and Montana Rules of Civil Procedure do not apply to the independent dispute resolution process. The parties may offer such evidence as is relevant and material to the dispute. The independent reviewer shall determine …

6.6.8609 PREPARATION FOR HEARING No less than 14 days prior to the adjudicatory hearing, the parties shall jointly submit a stipulation identifying all facts not in dispute, including as applicable: distance and method of transportation; actual rates of air ambulance billing and …

6.6.8610 HEARING Unless otherwise requested by either party, all hearings during the independent dispute resolution process should be held telephonically. Each party shall present evidence, which may include witness testimony in support of its fair market price determination. Wit…

6.6.8611 NON-COMPLIANCE WITH ORDER An independent reviewer may order sanctions as necessary to address a party's willful or repeated non-compliance with its obligations under statute, these rules, or an order of the independent reviewer. Sanctions may include: disallowing testimo…

6.6.8612 FINAL DETERMINATION An independent reviewer shall issue a written final determination of the fair market price of the services provided no later than 60 days following the hearing. The final determination must provide a reasoned basis for the fair market price with suppo…

6.6.8701 PURPOSE The purpose of these rules is to set forth the procedures for filing and the required contents of the CGAD necessary to carry out the provisions of the Corporate Governance Disclosure Act, 33-2-2101 through 33-2-2109, MCA. Authorizing statute(s): 33-2-2105, MCA I…

6.6.8702 DEFINITIONS The following definitions apply to this subchapter: "CGAD" means the corporate governance annual disclosure required under Title 33, chapter 2, part 21, MCA. "Insurance group" means those insurers and affiliates included within an insurance holding company sy…

6.6.8703 FILING PROCEDURES An insurer, or the insurance group of which the insurer is a member, required to file a CGAD by Title 33, chapter 2, part 21, MCA, shall, no later than June 1 of each calendar year, submit to the commissioner a CGAD that contains the information describ…

6.6.8704 CONTENTS OF CORPORATE GOVERNANCE ANNUAL DISCLOSURE The insurer or insurance group shall be as descriptive as possible in completing the CGAD, and shall include any relevant attachments or example documents that are used in the governance process. The CGAD shall describe …

6.6.8705 ADOPTION OF NAIC FINANCIAL ANALYSIS HANDBOOK For purposes of review of holding company systems and corporate governance disclosures, the commissioner adopts the financial analysis handbook, volumes one and two, most recently published on January 2, 2017 by the National A…

6.6.8801 DEFINITIONS The following definitions, in addition to those contained in 33-36-103.htm" target="MCA" style="text-decoration:none">33-36-103 , MCA, apply to this chapter: "Access plan" means a document filed by a health carrier with thecommissioner that complies with the …

6.6.8805 ACCESS PLAN FILING AND REVIEW GUIDELINES When a health carrier submits a proposed access plan to thecommissioner for review and approval, thecommissioner will either approve, disapprove, or request additional information on the proposed plan within 60 calendar days. Thec…

6.6.8806 ACCESS PLAN UPDATES Health carriers shall be responsible for monitoring the status of their networks and must submit an updated access plan to thecommissioner within 30 calendar days after amaterial change in the status of their network. For the purposes of this rule, am…

6.6.8807 ACCESS PLAN SPECIFICATIONS In addition to meeting the requirements of 33-36-201.htm" target="MCA" style="text-decoration:none">33-36-201 (6) , MCA, an access plan for each health carrier offered in Montana must describe or contain the following: a list of participating p…

6.6.8808 ACCESS CRITERIA Thecommissioner will utilize the criteria set forth in this chapter and Title 33, chapter 36, MCA, to determine whether the network maintained by a health carrier offering a managed care plan in Montana is sufficient in numbers and type of providers. Auth…

6.6.8814 MANDATORY COVERAGE The following must be reimbursed without regard to either prior authorization or the contractual relationship between the health carrier and the provider: emergency services as defined in 33-36-103.htm" target="MCA" style="text-decoration:none">33-36-1…

6.6.8815 PROVIDER-ENROLLEE RATIO REQUIREMENTS In order to be deemed adequate, a health carrier's network must include one mid-level PCP per 1,500 projected enrollees or one physician PCP per 2,500 projected enrollees. Authorizing statute(s): 33-36-105, MCA Implementing statute(s)…

6.6.8816 VERIFICATION OF PROVIDER CREDENTIALS Each health carrier shall establish and describe in its access plan the criteria utilized to review the credentials of the providers in its network. A health carrier must require a provider's credentials to be reviewed prior to the he…

6.6.8819 GEOGRAPHIC ACCESS CRITERIA In order to be deemed adequate, a provider network must fulfill all access criteria of the rules in this chapter within the following geographic restrictions: to the extent that services are covered by the health carrier, the health carrier mus…

6.6.8820 EXCEPTIONS TO GEOGRAPHIC ACCESS CRITERIA Thecommissioner may grant exceptions to the geographic accessibility standard in ARM 6.6.8819 if good cause to do so exists. Good cause includes but is not limited to the circumstance where the health carrier has documented a good…

6.6.8821 SERVICE AREAS A network's service area may encompass more than one geographic service area provided the network in all such areas meets the network adequacy criteria. Authorizing statute(s): 33-36-105, MCA Implementing statute(s): 33-36-105, 33-36-201, MCA History: NEW, …

6.6.8827 MAXIMUM WAIT TIMES FOR APPOINTMENTS An adequate network must meet the following criteria for all enrollees: emergency services must be available and accessible at all times; urgent care appointments must be available within 24 hours; appointments for non-urgent care with…

6.6.8828 REFERRAL AND SPECIALTY CARE REQUIREMENTS Procedures for referrals must be clearly outlined in the access plan, in literature provided to all enrollees, and in literature or contracts provided to all participating providers. Women and adolescent females who do not designa…

6.6.8829 CONTINUITY OF CARE AND TRANSITIONAL CARE A health carrier must allow the following new enrollees to continue to receive services from their previous providers for the time periods noted below, so long as those providers agree to abide by the payment rates, credentialing,…

6.6.8835 SELECTING AND CHANGING PROVIDERS Enrollees must be allowed to change primary care providers at least once per benefit year. The health carrier will monitor the frequency of enrollees' requests to change primary care providers and shall have in place a policy to address s…

6.6.8836 REMOVAL OF BARRIERS TO ACCESS The health carrier must have a policy in place 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 orde…

6.6.8840 MONITORING THE NETWORK The health carrier must establish methods for periodically assessing the sufficiency of the network to meet the health care needs of covered persons as well as assessing their satisfaction with services. The following must be included in this asses…

6.6.8841 LETTERS OF INTENT In order to demonstrate that its network is adequate, a health carrier may utilize letters of intent from individual providers with whom it does not yet have a contract, so long as the providers do not constitute more than 15% of the total network. If l…

6.6.8842 RESPONSIBILITY FOR CONTRACTED SERVICES A health carrier offering a managed care plan that uses a contractual arrangement to provide services to covered persons remains responsible for meeting the requirements of this chapter, including documentation requirements. Authori…

6.6.8850 CORRECTIVE ACTION (REPEALED) (REPEALED) Authorizing statute(s): 33-36-105, MCA Implementing statute(s): 33-36-105, MCA History: NEW, 1999 MAR p. 2052, Eff. 9/24/99; TRANS, from 37.108.250, 2023 MAR p. 1401, Eff. 10/21/23; REP, 2024 MAR p. 713, Eff. 4/13/24.