Terms Used In Montana Code > Title 33 > Chapter 36 > Part 1 - General Provisions

• Closed plan: means a managed care plan that requires covered persons to use only participating providers under the terms of the managed care plan. See Montana Code 33-36-103
• Combination plan: means an open plan with a closed component. See Montana Code 33-36-103
• 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.
• Covered person: means a policyholder, subscriber, or enrollee or other individual participating in a health benefit plan. See Montana Code 33-36-103
• Emergency medical condition: means a condition manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in any of the following:

  (a)the covered person's health would be in serious jeopardy;

  (b)the covered person's bodily functions would be seriously impaired; or

  (c)a bodily organ or part would be seriously damaged. See Montana Code 33-36-103

• Facility: means an institution providing health care services or a health care setting, including but not limited to a hospital, medical assistance facility, critical access hospital, or rural emergency hospital, as those terms are defined in 50-5-101, or other licensed inpatient center, an outpatient center for surgical services, a treatment center, a skilled nursing center, a residential treatment center, a diagnostic laboratory, a diagnostic imaging center, or a rehabilitation or other therapeutic health setting. See Montana Code 33-36-103
• Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Montana Code 33-36-103
• Health care professional: means a physician or other health care practitioner licensed, accredited, or certified pursuant to the laws of this state to perform specified health care services consistent with state law. See Montana Code 33-36-103
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Montana Code 33-36-103
• Health carrier: means an entity subject to the insurance laws and rules of this state that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a disability insurer, health maintenance organization, or health service corporation or another entity providing a health benefit plan. See Montana Code 33-36-103
• Intermediary: means a person authorized to negotiate, execute, and be a party to a contract between a health carrier and a provider or between a health carrier and a network. See Montana Code 33-36-103
• Managed care plan: means a health benefit plan that either requires or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by a health carrier, but not preferred provider organizations or other provider networks operated in a fee-for-service indemnity environment. See Montana Code 33-36-103
• Network: means the group of participating providers that provides health care services to a managed care plan. See Montana Code 33-36-103
• Open plan: means a managed care plan other than a closed plan that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan. See Montana Code 33-36-103
• Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
• Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
• provider: means a health care professional or a facility. See Montana Code 33-36-103
• Quality assessment: means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations. See Montana Code 33-36-103
• Quality assurance: means quality assessment and quality improvement. See Montana Code 33-36-103
• Quality improvement: means an effort to improve the processes and outcomes related to the provision of health care services within a health plan. See Montana Code 33-36-103
• 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