Rule 6.6.2503 - DEFINITIONSAs used in this subchapter, the Montana Health Maintenance Organization Act, and for the purpose of any terms used in the contract and evidence of coverage:
(1) "Contract holder" means a person or entity consisting of employees or eligible persons that has entered into a group contract with a health maintenance organization for the provision of specified health care services to its eligible employees or eligible persons.(2) "Copayment" means the amount an enrollee must pay to receive a specific service that is not fully prepaid.(3) "Emergency care services" means the same as "emergency services," and incorporating "emergency medical condition," as defined in 33-36-103, MCA. (a) if within the service area: (i) covered health care services rendered by affiliated providers under unforeseen conditions that require immediate medical attention; and(ii) covered health care services from non-affiliated providers under unforeseen conditions that require immediate medical attention, but only when delay in receiving care from the health maintenance organization could reasonably be expected to cause severe jeopardy to the enrollee's condition; and(b) medically necessary health care services that are immediately required because of unforeseen illness or injury while the enrollee is outside the service area.(4) "Group contract" means a contract for health care services that by its terms limits eligibility to members of a specified group.(5) "Hospital" means hospital as defined in 50-5-101, MCA.(6) "Individual contract" means a contract for health care services issued to and covering an individual or a family. (7) "Out-of-area services" means the health care services that a health maintenance organization covers when its enrollees are outside of the service area.(8) "Physician" means physician as defined in 50-2-101, MCA.(9) "Primary care physician" means a physician who supervises, coordinates, and provides initial and basic care to enrollees; initiates their referral for specialist care; and maintains continuity of patient care.(10) "Service area" means the geographical area approved by the commissioner within which the health maintenance organization provides or arranges for health care services that are available and accessible to enrollees.(11) "Subscriber" means the individual whose employment or other status, except for family dependency, is the basis for eligibility for enrollment in the health maintenance organization.(12) "Supplemental health care services" means health care services other than basic health care services.NEW, 1987 MAR p. 1770, Eff. 10/16/87; AMD, 1998 MAR p. 1698, Eff. 6/26/98; AMD, 2018 MAR p. 1102, Eff. 6/9/2018AUTH: 33-31-103, MCA; IMP: 33-31-101 through 33-31-405, MCA