Montana Code 33-22-1705. Incentives in health benefit plans
33-22-1705. Incentives in health benefit plans. (1) A health care insurer may issue a policy or a health benefit plan that provides for incentives for covered persons to use the health care services of preferred providers. The policy or health benefit plan must contain at least:
Terms Used In Montana Code 33-22-1705
- Health benefit plan: means the health insurance policy or subscriber arrangement between the insured or subscriber and the health care insurer that defines the covered services and benefit levels available. See Montana Code 33-22-1703
- Health care insurer: means :
(a)an insurer that provides disability insurance as defined in 33-1-207;
(b)a health service corporation as defined in 33-30-101;
(c)a fraternal benefit society as described in 33-7-105; or
(d)any other entity regulated by the commissioner that provides health coverage except a health maintenance organization. See Montana Code 33-22-1703
- Health care services: means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization or services provided under Title 33, chapter 22, part 7. See Montana Code 33-22-1703
- Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
- Preferred provider: means a provider or group of providers who have contracted to provide specified health care services. See Montana Code 33-22-1703
- Preferred provider agreement: means a contract between or on behalf of a health care insurer and a preferred provider. See Montana Code 33-22-1703
- Provider: means an individual or entity licensed or legally authorized to provide health care services or services covered within Title 33, chapter 22, part 7. See Montana Code 33-22-1703
(a)a provision that if a covered person receives emergency care for services specified in the preferred provider agreement and cannot reasonably reach a preferred provider, the care rendered during the course of the emergency will be reimbursed as though the covered person had been treated by a preferred provider; and
(b)a provision that clearly identifies the difference in benefit levels for health care services of a preferred provider and benefit levels for the same health care services of a nonpreferred provider.
(2)A health care insurer may not require hospital staff privileges as criteria for designation as a preferred provider in a preferred provider agreement.