Montana Code 33-31-306. Point-of-service option
33-31-306. Point-of-service option. (1) (a) A health maintenance organization that has at least 10,000 enrollees shall offer a point-of-service option benefit plan to each purchaser of a health care services agreement. The purchaser may accept or reject the addition of a point-of-service option to the health care services agreement.
Terms Used In Montana Code 33-31-306
- Contract: A legal written agreement that becomes binding when signed.
- 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. See Montana Code 33-31-102
- 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 care services agreement: means an agreement for health care services between a health maintenance organization and an enrollee. 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
- 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. See Montana Code 33-31-102
- 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. See Montana Code 33-31-102
- 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. See Montana Code 33-31-102
(b)For the purposes of subsection (1)(a), an enrollee does not include an individual receiving medicaid services under the Montana medicaid program provided for in Title 53, chapter 6, or an individual participating in an approved medicare risk contract administered by a licensed health maintenance organization.
(2)Any difference in premium charged for the point-of-service option benefit plan compared to the premium for a standard health care services agreement may not exceed the expected cost to the insurer of benefits and expenses based on sound actuarial principles.
(3)This section may not be construed to permit a health maintenance organization to offer stand-alone indemnity insurance coverage.