37.86.5020    HEALTH MAINTENANCE ORGANIZATIONS: ACCESS TO SERVICES

(1) An enrollee must have the opportunity to choose a primary care provider to the extent possible and medically appropriate from any of the participating primary care providers in the enrollee's HMO. The HMO may assign an enrollee to a primary care provider when an enrollee fails to chose one after being notified to do so. The assignment must be appropriate to the enrollee's age, sex and residence. The HMO may limit an enrollee's ability to change primary care providers without cause.

(2) An HMO must have in effect the following arrangements which provide for adequate after hours call-in coverage by participating providers:

(a) An after hours call-in must include 24-hour-a-day phone coverage;

(b) If a medical provider is unavailable to answer the initial telephone call, there must be a written protocol specifying when the answering party must consult a medical provider;

(c) Calls requiring a medical decision must be forwarded to the on-call medical provider;

(d) A response to each call which requires a medical decision must be provided by the medical provider within 60 minutes.

History: 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; NEW, 1995 MAR p. 1974, Eff. 9/29/95; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 866, Eff. 3/31/00.