Montana Code 33-31-321. Disclosure standards — health maintenance organizations
33-31-321. Disclosure standards — health maintenance organizations. (1) In order to provide for full and fair disclosure in the sale of disability insurance, an enrollment form or evidence of coverage may not be delivered or issued for delivery in this state by a health maintenance organization unless an outline of coverage is delivered to the applicant at the time the application is made. The outline of coverage must be filed with the commissioner as required by 33-1-501.
Terms Used In Montana Code 33-31-321
- Commissioner: means the commissioner of insurance of the state of Montana. See Montana Code 33-31-102
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- 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
- 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
(2)The outline of coverage must include:
(a)a general description of the principal benefits and coverages provided by the policy;
(b)a general description of the insureds financial responsibility under the policy, including, if applicable, the amount of the deductible, the amount or percentage of copayment, and the maximum annual out-of-pocket expenses to be paid by the insured;
(c)a statement of the maximum lifetime benefit available under the policy;
(d)a statement of the estimated periodic premium to be paid by the insured;
(e)a general description of the factors or case characteristics that the insurer may consider in establishing or changing the premiums and, if applicable, in determining the insurability of the applicant; and
(f)a general description of the trend of premium increases or decreases for comparable policies issued by the insurer during the preceding 5 years, if the trend data is available.
(3)The outline of coverage may include any other information that the insurer considers relevant to the applicant’s selection of an appropriate health benefit plan.
(4)An insurer or producer shall provide to an individual, upon request, an outline of coverage for any health benefit product marketed to the general public. The outline of coverage provided under this subsection may exclude the statement of the estimated periodic premium to be paid by the insured.