Mont. Admin. R. 37.86.5010 - HEALTH MAINTENANCE ORGANIZATIONS: CONTRACTS FOR SERVICES
(1) The department may enter into a contract
with an HMO with a certificate of authority under the provisions of
33-31-201,
et seq., MCA, to provide any of the services specified in ARM
37.86.5007.
(2) An HMO, entering into a contract with the
department, must meet the requirements in
53-6-705,
MCA.
(3) A contract for the
provision of services through an HMO must meet the requirements of 42 CFR part
434. The department hereby adopts and incorporates by reference 42 CFR part
434, dated October 1998. A copy of the incorporated provisions may be obtained
through the Department of Public Health and Human Services, Health Policy and
Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT
59620-2951.
(4) An HMO entering
into a contract with the department for the delivery of services assumes the
risk that the costs of performance may exceed the consideration available
through the capitation rate and otherwise.
(5) An HMO must provide the department with
documented assurances to show that the HMO is not likely to become insolvent.
This requirement may be satisfied by documenting compliance with
33-31-216,
MCA.
(6) An HMO may not in any
manner hold an enrollee responsible for the debts of the HMO.
(7) A contract with an HMO must:
(a) list the covered services to be provided
by the HMO;
(b) specify the method
and rate of reimbursement; and
(c)
provide for disclosure of ownership and subcontractor relationship;
and
(d) owners, directors,
officers, or partners of the HMO must certify that they meet federal
nondebarment requirements.
(8) A contract may be terminated for cause,
if the contractor fails to:
(a) perform the
services within the time limits specified in the contract;
(b) perform any requirement of the
contract;
(c) perform its
contractual duties or responsibilities specified in the standards of contractor
performance defined in the contract;
(d) comply with any law, regulation or
licensure and certification requirement; or
(e) comply with the restrictions and
limitations placed on contractor activities under the contract and its
attachments.
(9) Prior
to termination of a contract or withholding of payments for cause, except as
provided in (9) (a), a notice to cure will be sent to the HMO, stating the
failures in performance and specifying the HMO has 30 days to correct the
failures. The department may proceed with the proposed termination or
withholding of payments, if the HMO fails to correct the failures in
performance in the specified time period for correction.
(a) A contract with an HMO may be terminated
immediately in whole or in part by the department when:
(i) the HMO becomes insolvent;
(ii) the HMO loses a certificate of
authority;
(iii) the department
determines that termination is necessary to protect the health of
enrollees;
(iv) the HMO applies for
or consents to the appointment of a receiver, trustee, or liquidation for
itself or any of its property;
(v)
the HMO admits in writing that it is unable to pay its debts as they
mature;
(vi) the HMO assigns for
the benefit of creditors;
(vii) the
HMO commences a proceeding in bankruptcy, reorganization, insolvency, or
readjustment under a provision of a federal or state law or files an answer
admitting the material allegations of a petition filed against the contract in
any such proceeding; or
(viii)
there is a commencement of an involuntary proceeding against the HMO under any
bankruptcy, reorganization, insolvency, or readjustment in a provision of
federal or state law that is not dismissed within 60 days.
(10) An HMO may not appeal a
contractual matter through the fair hearing process provided at ARM
37.5.304, et seq.
(11) An HMO may specify in a contract a limit
to the number of enrollees who can be enrolled with the HMO. If a limit is
specified, the HMO must accept the number of voluntarily and assigned enrollees
up to the limit specified in the contract.
(12) The department may contract with one or
more HMO or other managed health care providers to provide managed health care
in an enrollment area.
(13) The
contract may contain proprietary information. An HMO entering into a contract
with the department to provide HMO covered services does not constitute an
agreement to release information, including information concerning the
provider's information system, which is proprietary in nature.
Notes
Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-2-201, 53-6-101, 53-6-113 and 53-6-116, MCA;
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