Montana Code 33-22-1706. Permissible and mandatory provisions in provider agreements, insurance policies, and subscriber contracts
33-22-1706. Permissible and mandatory provisions in provider agreements, insurance policies, and subscriber contracts. (1) A provider agreement, insurance policy, or subscriber contract issued or delivered in this state may contain components designed to control the cost and improve the quality of health care for insureds and subscribers as provided in this part.
Terms Used In Montana Code 33-22-1706
- Contract: A legal written agreement that becomes binding when signed.
- Health benefit plan: means the health insurance policy or subscriber arrangement between the insured or subscriber and the health care insurer that defines the covered services and benefit levels available. See Montana Code 33-22-1703
- Preferred provider: means a provider or group of providers who have contracted to provide specified health care services. See Montana Code 33-22-1703
- Provider: means an individual or entity licensed or legally authorized to provide health care services or services covered within Title 33, chapter 22, part 7. See Montana Code 33-22-1703
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
- Subscriber: means a certificate holder or other person on whose behalf the health care insurer is providing or paying for health care coverage. See Montana Code 33-22-1703
(2)All terms or conditions of an insurance policy or subscriber contract, except those already approved by the commissioner, are subject to the prior approval of the commissioner.
(3)Provisions designed to control cost and improve the quality of health care under this section include but are not limited to those that set a payment difference for reimbursement of a nonpreferred provider as compared to a preferred provider and those designed to give policyholders or subscribers an incentive to choose a particular provider consistent with the other provisions of this part.
(4)(a) A health benefit plan that contains a payment difference provision and that the commissioner has determined to have an adequate provider network is not subject to subsection (4)(b).
(b)A health benefit plan that contains a payment difference provision and has not been determined to have an adequate provider network may not exceed a 25% payment difference in the reimbursement level for a preferred provider, and the commissioner shall review differences between copayments, deductibles, and other cost-sharing arrangements under this subsection (4)(b).
(c)For the purposes of this subsection (4), a provider network is adequate if:
(i)the network includes at least 80% of the licensed individual physicians actively practicing in the state of Montana;
(ii)the network includes at least 80% of the licensed individual nonphysician health care providers actively practicing in the state of Montana; and
(iii)the network includes at least 90% of those facilities licensed and operating as hospitals in the state of Montana.
(5)A health benefit plan or other plan offering prepaid dental services under this part shall offer its insureds the right to obtain dental care from any licensed dental care provider of their choice subject to the same terms and conditions imposed under this section.