33-31-102. Definitions. As used in this chapter, unless the context requires otherwise, the following definitions apply:

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(1)”Accountable care organization” means a group of health care providers that are willing and capable of accepting accountability for the total cost and quality of care for a defined population.

(2)”Affiliation period” means a period that, under the terms of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective.

(3)”Basic health care services” means:

(a)consultative, diagnostic, therapeutic, and referral services by a provider;

(b)inpatient hospital and provider care;

(c)outpatient medical services;

(d)medical treatment and referral services;

(e)accident and sickness services by a provider to each newborn infant of an enrollee pursuant to 33-31-301(3)(e);

(f)care and treatment of mental illness, alcoholism, and drug addiction;

(g)diagnostic laboratory and diagnostic and therapeutic radiologic services;

(h)preventive health services, including:

(i)immunizations;

(ii)well-child care from birth;

(iii)periodic health evaluations for adults;

(iv)voluntary family planning services;

(v)infertility services; and

(vi)children’s eye and ear examinations conducted to determine the need for vision and hearing correction;

(i)minimum mammography examination, as defined in 33-22-132;

(j)outpatient self-management training and education for the treatment of diabetes along with certain diabetic equipment and supplies as provided in 33-22-129; and

(k)treatment and medical foods for inborn errors of metabolism. “Medical foods” and “treatment” have the meanings provided for in 33-22-131.

(4)”Commissioner” means the commissioner of insurance of the state of Montana.

(5)”Dependent” has the meaning provided in 33-22-140.

(6)”Enrollee” means a person:

(a)who enrolls in or contracts with a health maintenance organization;

(b)on whose behalf a contract is made with a health maintenance organization to receive health care services; or

(c)on whose behalf the health maintenance organization contracts to receive health care services.

(7)”Evidence of coverage” means a certificate, agreement, policy, or contract issued to an enrollee setting forth the coverage to which the enrollee is entitled.

(8)”Health care services” means:

(a)the services included in furnishing medical or dental care to a person;

(b)the services included in hospitalizing a person;

(c)the services incident to furnishing medical or dental care or hospitalization; or

(d)the services included in furnishing to a person other services for the purpose of preventing, alleviating, curing, or healing illness, injury, or physical disability.

(9)”Health care services agreement” means an agreement for health care services between a health maintenance organization and an enrollee.

(10)(a) “Health maintenance organization” means a person who provides or arranges for basic health care services to enrollees on a prepaid basis, either directly through provider employees or through contractual or other arrangements with a provider or a group of providers. This subsection (10) does not limit methods of provider payments made by health maintenance organizations.

(b)The term does not apply to:

(i)a PACE organization or an accountable care organization that has received a waiver pursuant to 33-31-201; or

(ii)a direct patient care agreement established pursuant to 50-4-107.

(11)”Insurance producer” means an individual or business entity appointed or authorized by a health maintenance organization to solicit applications for health care services agreements on its behalf.

(12)”PACE organization” means an organization, as defined in 42 C.F.R. § 460.6, that is authorized by the centers for medicare and medicaid services and the department of public health and human services to operate a program of all-inclusive care for the elderly.

(13)”Person” means:

(a)an individual;

(b)a group of individuals;

(c)an insurer, as defined in 33-1-201;

(d)a health service corporation, as defined in 33-30-101;

(e)a corporation, partnership, facility, association, or trust; or

(f)an institution of a governmental unit of any state licensed by that state to provide health care, including but not limited to a physician, hospital, hospital-related facility, or long-term care facility.

(14)”Plan” means a health maintenance organization operated by an insurer or health service corporation as an integral part of the corporation and not as a subsidiary.

(15)”Point-of-service option” means a delivery system that permits an enrollee of a health maintenance organization to receive health care services from a provider who is, under the terms of the enrollee’s contract for health care services with the health maintenance organization, not on the provider panel of the health maintenance organization.

(16)”Provider” means a physician, hospital, hospital-related facility, long-term care facility, dentist, osteopath, chiropractor, optometrist, podiatrist, psychologist, licensed social worker, registered pharmacist, or advanced practice registered nurse, as specifically listed in 37-8-202, or registered nurse first assistant as defined by the board of nursing under Title 37, chapter 8, who treats any illness or injury within the scope and limitations of the provider’s practice or any other person who is licensed or otherwise authorized in this state to furnish health care services.

(17)”Provider panel” means those providers with whom a health maintenance organization contracts to provide health care services to the health maintenance organization’s enrollees.

(18)”Purchaser” means the individual, employer, or other entity, but not the individual certificate holder in the case of group insurance, that enters into a health care services agreement.

(19)”Uncovered expenditures” mean the costs of health care services that are covered by a health maintenance organization and for which an enrollee is liable if the health maintenance organization becomes insolvent.