6.6.8829    CONTINUITY OF CARE AND TRANSITIONAL CARE

(1) 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, referral process, quality-of-care standards and protocols, and reporting standards that apply to comparable participating providers:

(a) a new enrollee with a life-threatening, disabling or degenerative condition may obtain care from their previous provider for a period of 60 days, beginning the date of the enrollee's enrollment with the health carrier;

(b) a new enrollee who has received a diagnosis of terminal illness with life expectancy of less than 6 months, may continue to obtain care from their previous provider until death if it occurs prior to the end of the 6 month period, or, if it does not, for a period of 6 months from the date of the enrollee's enrollment with the health carrier, unless the period is extended after the enrollee's medical needs and the appropriateness of requiring a transition to a participating provider are reassessed. Such a reassessment must be conducted at or before the end of the 6 month period by the health carrier for such a terminally ill enrollee; and

(c) a new enrollee in the second or third trimester of pregnancy may obtain care from their previous provider through the completion of postpartum care.

(2) A health carrier must allow enrollees with the medical conditions described in (1) (a) through (1) (c) above to continue to receive services from their existing providers when their provider's contract is terminated by the carrier without cause or when the provider voluntarily terminates their contract with the carrier, so long as those providers agree to abide by the payment rates, credentialing, referral process, quality-of-care standards and protocols, and reporting standards which apply to comparable participating providers. The time periods during which such continued services are allowed are the same as those specified in (1) (a) through (1) (c) above, with the exception that, for the conditions described in (1) (a) and (1) (b) , the time period begins on the date the provider's contract is terminated, rather than the date of the enrollee's enrollment with the health carrier.

(3) A health carrier may not hold an enrollee covered by this rule responsible for any additional payments, copayments, co-insurance or deductibles beyond what would be required if the services were provided by a participating provider.

 

History: 33-36-105, MCA; IMP, 33-36-105, 33-36-201, MCA; NEW, 1999 MAR p. 2052, Eff. 9/24/99; AMD, 2000 MAR p. 2432, Eff. 9/8/00; TRANS, from 37.108.229, 2023 MAR p. 1401, Eff. 10/21/23.