Montana Code 33-31-221. Powers of health maintenance organizations
33-31-221. Powers of health maintenance organizations. (1) The powers of a health maintenance organization include but are not limited to the following:
Terms Used In Montana Code 33-31-221
- 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. See Montana Code 33-31-102
- Commissioner: means the commissioner of insurance of the state of Montana. See Montana Code 33-31-102
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- 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. See Montana Code 33-31-102
- 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. See Montana Code 33-31-102
- Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
- 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. See Montana Code 33-31-102
- Property: means real and personal property. See Montana Code 1-1-205
- 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. See Montana Code 33-31-102
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
(a)the purchase, lease, construction, renovation, operation, or maintenance of a hospital, a medical facility, or both, its ancillary equipment, and property that may reasonably be required for its principal office or for purposes that may be necessary in the transaction of the business of the organization;
(b)the making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation under its control for the purpose of acquiring or constructing a medical facility or hospital or in furtherance of a program providing health care services to enrollees;
(c)the furnishing of health care services through a provider who is under contract with or employed by the health maintenance organization;
(d)the contracting with a person for the performance on its behalf of certain functions, such as marketing, enrollment, and administration;
(e)the contracting with an insurer authorized to transact insurance in this state, or with a health service corporation authorized to do business in this state, for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization; and
(f)the offering of other health care services in addition to basic health care services.
(2)A health maintenance organization shall file notice, with adequate supporting information, with the commissioner before exercising a power granted in subsection (1)(a), (1)(b), or (1)(d). The commissioner may, after notice and hearing, within 60 days disapprove the exercise of a power under subsection (1)(a), (1)(b), or (1)(d) only if, in the commissioner’s opinion, it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. The commissioner may make reasonable rules exempting from the filing requirement of this subsection those activities having a de minimis effect. The commissioner may exempt certain contracts from the filing requirement whenever exercise of the authority granted in this section would have little or no effect on the health maintenance organization’s financial condition and ability to meet obligations.
(3)This section does not exempt the activities of a health maintenance organization from any applicable certificate of need requirements under Title 50, chapter 5, parts 1 and 3.