Mont. Code Ann. § 33-31-102

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

(1) "Affiliation period" "Accountable care organization" means a period that, under the terms group of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage care providers that are willing and capable of accepting accountability for the total cost and becomes effective.

(10) "Person" means:

(10) (a) an individual; "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) a group of individuals; 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.

(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.

(11) "Plan" "Insurance producer" means a an individual health or business entity appointed maintenance or authorized organization by operated by an insurer or a health service corporation as an integral part of the corporation and not

(12) "Point-of-service option" "PACE organization" means a delivery system that an permits an enrollee of a health maintenance organization to receive health care services from a organization, as defined in 42 CFR 460.6, that is authorized by provider who is, under the terms centers of for medicare and medicaid the services enrollee's contract for and health the care department of public services health with the health maintenance organization, not on the provider panel

(13) "Provider" means a physician, hospital, hospital-related facility, long-term care facility, dentist, osteopath, chiropractor, optometrist, podiatrist, "Person" means: psychologist, licensed social worker, registered pharmacist, or advanced practice registered nurse, as specifically listed in 37-8-202, 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.

(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) "Provider panel" "Plan" means those providers with whom a health maintenance organization contracts to provide operated by an insurer or health care services to service corporation as an integral part of the health maintenance organization's enrollees. corporation and not as

(15) "Purchaser" "Point-of-service option" means the individual, employer, or other entity, but not the individual certificate holder in the case of a group insurance, delivery system that enters into permits an enrollee of a health maintenance organization to receive health care services agreement. 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) "Uncovered expenditures" mean the costs of health "Provider" means care a services that are covered by a health maintenance organization and for which an enrollee is physician, hospital, hospital-related facility, long-term care facility, dentist, osteopath, chiropractor, optometrist, podiatrist, psychologist, licensed social liable if the health maintenance organization becomes insolvent. 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.

(2) "Basic health care services" means: "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.

(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;

(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.

(3) "Commissioner" means the commissioner of insurance of the state of Montana. "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;

(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) "Enrollee" "Commissioner" means a person: the commissioner of insurance of the state of Montana.

(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.

(5) "Evidence of coverage" means a certificate, agreement, policy, or contract issued to an enrollee setting "Dependent" has forth the coverage to which the enrollee is entitled. meaning provided in 33-22-140.

(6) "Health care services" means: "Enrollee" means a person:

(a) the services included who enrolls in furnishing medical or dental care to contracts with a person; health

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

(c) on whose behalf the services incident health maintenance organization contracts to furnishing medical or dental receive health care

(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.

(7) "Health care services agreement" "Evidence of coverage" means an a agreement for health care services between a health maintenance organization and certificate, agreement, policy, or contract issued to an enrollee. enrollee setting forth the coverage to which the enrollee is entitled.

(8) "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 services" means: or other arrangements with a provider or a group of providers. This subsection does not limit methods of provider payments made by health maintenance organizations.

(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) "Insurance producer" "Health care services agreement" means an individual, partnership, or corporation appointed or authorized by agreement a for health maintenance care organization services to solicit applications for between a health care services agreements on its behalf. maintenance organization and an enrollee.

Definitions

As used in this chapter, unless the context requires otherwise, the following definitions apply: