19 Miss. Code. R. 3-18.05 - Filing Requirements and State Administration

A. Beginning June 1, 2025, managed care entities shall file with the Commissioner sample contract forms proposed for use with its participating providers and intermediaries.

B. By June 1 of each calendar year, managed care entities shall submit to the Commissioner, in an electronic format (such as Excel) that is readily useable by the Department, a complete list, effective January 1 of that calendar year, of:

(1) the names of its Participating Providers;

(2) each Participating Provider's most closely-affiliated type as provided for in Rule 14.05;

(3) the complete practice location address for each Participating Provider; and

(4) contact information for each Participating Provider.

C. By June 1 of each calendar year, managed care entities shall submit to the Commissioner, a geoaccess report sufficient for the Commissioner to confirm the adequacy of the managed care entity's network under Title 19, Part 3, Rule 14.05. If the Commissioner deems it necessary to determine the managed care entity's network's compliance with Title 19, Part 3, Rule 14.05, the Commissioner may require the managed care entity provide, in electronic format (such as Microsoft Excel), a complete list, effective as of a date determined by the Commissioner, of the names of its covered persons and those covered persons' residential addresses, subject to any confidentiality restrictions of Miss. Code Ann. § 83-5-209(7)(a)(i)(Rev. 2022).

D. By June 1 of each calendar year, managed care entities shall submit to the Commissioner a certification attestation in the following format: "I attest that [managed care entity] has complied with the Managed Care Plan Network Adequacy Regulation and the Managed Care Plan Certification Regulation promulgated by the Mississippi Department of Insurance." If a managed care entity is unable to meet compliance with any rules in those Regulations, including, but not limited to, Rule 14.05(B), Rule 14.05(C) and Rule 14.05(D), such attestation shall include reasons why the carrier contends it was unable to meet such standards and why the Commissioner should give special consideration to the reasons asserted for lack of compliance.

E. By June 1 of each calendar year, managed care entities shall submit to the Commissioner a complete, detailed description of their measures to provide covered persons, in easily understandable language, written information on the terms and conditions of coverage, including:

(1) coverage provisions;

(2) benefits;

(3) limitations;

(4) exclusions and restrictions on the use of any providers of care;

(5) a summary of utilization review and quality assurance policies;

(6) enrollee financial responsibility for copayments, deductions, and payment for out-of-plan services and supplies;

(7) the managed care entity's policies, in circumstances where the managed care entity has an insufficient number or type of participating providers/facilities to provide a covered benefit consistent with the geographic access standards set forth in the Managed Care Network Adequacy Regulation, Section 14.05(B), or fails to provide a covered benefit consistent with the geographic access standards set forth in Section 14.05(B), to ensure covered persons obtain the covered benefit at no greater cost to the covered person than if the benefit were obtained from participating providers, and to ensure in such situations, the provision of covered persons with reasonable reimbursement for the covered persons travel, lodging, and food expenses as set forth in the Managed Care Network Adequacy Regulation, Rule 14.05(C);

(8) a summary of the managed care entity's credentialing criteria and process and policies relating to the credentialing criteria;

(9) the managed care entity's procedures for ensuring a provider may request a copy of the provider's individual profile if economic or practice profiles, or both, are used in the credentialing process;

(10) the managed care entity's procedures for ensuring a provider is aware that the provider may request to review the reasons for denial or termination with regard to a provider's application that has been denied or where the provider's contract is terminated;

(11) the managed care entity's procedure/policy to ensure adherence with all applicable state and federal laws designed to protect the confidentiality of medical records; and

(12) the managed care entity's procedures to ensure interested healthcare providers within the geographic area of the managed care entity's network are given an opportunity to apply for participation.

Notes

19 Miss. Code. R. 3-18.05

Miss. Code Ann. § 83-41-405; § 83-41-413 (Rev. 2022)

Adopted 8/12/2024