Plan design (indemnity, HMO, PPO and POS plans, deductibles, coinsurance, out-of-pocket maximums, HSAs and the ACA framework) is covered in the national Medical Plans guide. Montana calls health insurance disability insurance, and its exam is the Disability exam. This guide covers the Montana statutes and rules on medical expense coverage that the state portion tests, mostly from Title 33, chapters 22, 30 and 31 of the Montana Code Annotated.

Freedom of choice of provider (33-22-111)

• When a disability policy covers a service that's within a practitioner's scope of practice, the insured has full freedom to choose among licensed practitioners. The listed practitioners include physicians, chiropractors, optometrists, psychologists and advanced practice registered nurses, among others.
• When a policy covers drugs, the insured may use any licensed and registered pharmacist.

Coverage the insurer can't take away

• Public assistance. A hospital, medical or surgical policy may not deny or reduce benefits because the insured is eligible for or receiving public medical assistance (33-22-113).
• State institutions. An insurer may not exclude services received in a Montana state institution. It pays to the same extent and at the same rates as elsewhere (33-22-112).
• Mental health parity. Coverage for mental illness, severe mental illness and substance use disorders must be no less favorable than for physical illness generally (33-22-703).
• Home health care means services by a licensed home health agency in the insured's home under the attending physician's written plan of care (33-22-1001).

Managed care in Montana

• Preferred provider agreements (33-22-1703, 33-22-1704):
  • A preferred provider has contracted to provide specified health services.
  • Insurers may give insureds incentives to use preferred providers, but can't unfairly deny covered benefits.
• HMOs (Chapter 31) provide or arrange basic health care services on a prepaid basis (33-31-102). Every enrollee living in Montana is entitled to an evidence of coverage (33-31-301). Under the HMO rule (ARM 6.6.2506):
  • The contract or evidence of coverage is delivered within 15 days after the later of the coverage date or the HMO's notice of enrollment.
  • A subscriber may return the contract within 10 days for a premium refund. The contract is then void from the start.
  • The grace period is at least 10 days for every premium after the first.
• A health service corporation is a nonprofit corporation that operates nonprofit health care plans (33-30-101).

Premiums, renewals and claims

• Rate increases. An insurer may raise an individual policy's premium no more than once in any 12 months, with narrow exceptions. Advance notice of a rate or benefit change is 45 days for individual policyholders and 60 days for group policyholders (33-22-107).
• Cancellation (33-22-121):
  • For nonpayment: at least 30 days' written notice. Paying in full within that time stops the cancellation.
  • For any reason other than nonpayment or material misrepresentation: 90 days' notice.
• Postclaim underwriting. After issue, an insurer may rescind or add an elimination rider only for a material misrepresentation or fraudulent misstatement on the application, or for nonpayment (33-18-215).
• "Usual and customary" limits. A policy that limits payment to usual and customary (or reasonable and customary) charges must explain how the limit is derived. It must also warn that providers may charge more and the excess may not be covered (33-15-308).
• Prompt payment. The insurer pays or denies within 30 days of proof of loss, or 60 days if it reasonably asked for more information. Late claims carry 10% annual interest (33-18-232).
• Outline of coverage. An individual policy may not be delivered unless a commissioner-approved outline of coverage was given at the time of application (33-22-244).

For required policy provisions (grace periods, notice of claim, reinstatement, newborn and dependent coverage), see the Montana Individual Accident and Health Provisions guide. For group continuation, conversion and coordination of benefits, see the Montana Group Health Insurance guide.

Common exam traps

• Montana's health line is disability. "Disability insurance" in Montana statutes means accident and health coverage generally, not only income replacement.
• Insureds may choose chiropractors, optometrists and other listed practitioners for covered services within their scope of practice.
• HMO contracts: 10-day return right, 10-day grace period, evidence of coverage within 15 days.
• Individual rate changes need 45 days' notice, and group changes 60 days'. There's no more than one increase every 12 months.
• Health cancellation for nonpayment needs 30 days' notice. Any other reason except misrepresentation needs 90 days'.