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Montana Statutes, Title 33

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Montana/Statutes

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Title 33, Title 33

37 chapters · 1,713 sections in this title.

All chapters in Title 331,713 Ch 2, REGULATION OF INSURANCE COMPANIES311 Ch 22, DISABILITY INSURANCE227 Ch 20, LIFE INSURANCE154 Ch 1, ADMINISTRATION AND GENERAL PROVISIONS106 Ch 17, INSURANCE PRODUCERS, ADJUSTERS, CONS…80 Ch 15, THE INSURANCE CONTRACT72 Ch 18, UNFAIR TRADE PRACTICES67 Ch 3, DOMESTIC STOCK AND MUTUAL INSURERS65 Ch 16, RATES -- RATING AND ADVISORY ORGANIZ…62 Ch 4, FARM MUTUAL INSURERS51 Ch 32, HEALTH UTILIZATION REVIEW47 Ch 30, HEALTH SERVICE CORPORATIONS44 Ch 10, INSURANCE GUARANTY ASSOCIATIONS41 Ch 7, FRATERNAL BENEFIT SOCIETIES39

1,713 sections·Filtered byTitle 33✕

Mont. Code Ann. § 33-31-304 Dual Choice
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An employer in this state that offers its employees the option to enroll in a health maintenance organization and an employee benefit fund in this state that offers its members the option to enroll in a health maintenance organization may not be required to pay more for health be…
Mont. Code Ann. § 33-31-305 Dentist Participation As Provider
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A contract for dental care services through a health maintenance organization that is offered, delivered, or renewed under this chapter must allow a dentist to request participation as a provider on the same terms and conditions as those by which other dentists participate. This …
Mont. Code Ann. § 33-31-306 Point-Of-Service Option
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(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 s…
Mont. Code Ann. § 33-31-307 Affiliation Periods
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(1) A health maintenance organization that offers health insurance coverage in connection with a group health plan and that does not impose a preexisting condition exclusion allowed by 33-22-246 or 33-22-514 with respect to any particular coverage option may impose an affiliation…

Showing 1,601–1,650 of 1,713

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Mont. Code Ann. § 33-31-311 Insurance Producer License Required

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An individual or business entity may not act as or represent to the public that the individual or business entity is an insurance producer for a health maintenance organization unless the individual or business entity is: (1) licensed as a disability insurance producer by the com…

Mont. Code Ann. § 33-31-312 Prohibited Practices

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(1) A health maintenance organization or representative of a health maintenance organization may not cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or any form of evidence of coverage that is deceptive. Fo…

Mont. Code Ann. § 33-31-313 Premium Increase Restriction -- Exception

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(1) A health maintenance organization may not increase a premium for an individual's or an individual's group health care services agreement more frequently than once during a 12-month period unless failure to increase the premium more frequently than once during the 12-month per…

Mont. Code Ann. § 33-31-321 Disclosure Standards -- Health Maintenance Organizations

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(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 ap…

Mont. Code Ann. § 33-31-401 Examination

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(1) The commissioner may examine the affairs of a health maintenance organization as often as is reasonably necessary to protect the interests of the people of this state. The commissioner shall make an examination at least once every 5 years. Similarly, the commissioner shall ex…

Mont. Code Ann. § 33-31-402 Suspension Or Revocation Of Certificate Of Authority

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(1) The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if the commissioner finds that any of the following conditions exist: (a) The health maintenance organization is operating in contravention of it…

Mont. Code Ann. § 33-31-403 Supervision, Rehabilitation, Or Liquidation Of Health Maintenance Organization

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(1) The supervision, rehabilitation, or liquidation of a health maintenance organization is considered to be the supervision, rehabilitation, or liquidation of an insurer and must be conducted under the supervision of the commissioner pursuant to chapter 2, part 13. The commissio…

Mont. Code Ann. § 33-31-404 Administrative Procedures

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(1) When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist or that grounds for the suspension or revocation of a certificate of authority exist, the commissioner shall give written notice to the health mainten…

Mont. Code Ann. § 33-31-405 Penalties And Enforcement

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(1) The commissioner may, in addition to suspension or revocation of a certificate of authority under 33-31-402, after notice and hearing, impose an administrative penalty in an amount not less than $500 or more than $10,000 if the commissioner gives reasonable notice in writing …

Mont. Code Ann. § 33-32-101 Purpose

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The legislature finds and declares that it is the purpose of this chapter to: (1) promote the delivery of quality health care in a cost-effective manner; (2) foster greater coordination between health care providers, third-party payors, and others who conduct utilization review a…

Mont. Code Ann. § 33-32-102 Definitions

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As used in this chapter, the following definitions apply: (1) "Adverse determination", except as provided in 33-32-402, means: (a) a determination by a health insurance issuer or its designated utilization review organization that, based on the provided information and after appl…

Mont. Code Ann. § 33-32-103 Utilization Review Plan

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An entity covered under the provisions of this chapter may not conduct a utilization review of health care services provided or to be provided to a patient covered under a contract or plan for health care services issued in this state unless that entity, at all times, maintains a…

Mont. Code Ann. § 33-32-104 Preemption By Federal Law

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If any provision of this chapter is preempted by federal law or regulations as applied to any specific health care service, then the provision of this chapter that is preempted by federal law or regulations does not apply to that health care service but only to the extent of the …

Mont. Code Ann. § 33-32-105 Application -- Exemptions

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(1) Except as provided in subsections (2) and (3), the provisions of this chapter apply to: (a) a health insurance issuer that offers a health plan and provides or performs utilization review services; (b) any designee of the health insurance issuer or utilization review organiza…

Mont. Code Ann. § 33-32-106 Disclosure Of Utilization Review Requirements -- Drug Benefit Information

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(1) A utilization review organization shall make its current utilization review plan prepared pursuant to 33-32-103, including clinical review criteria, standards, procedures, requirements, and restrictions, readily accessible on its website to covered persons, prospective covere…

Mont. Code Ann. § 33-32-107 Length Of Prior Authorization

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(1) A certification by a utilization review organization approving health care services is valid for at least 6 months from the date the health care provider receives the certification unless the covered person loses coverage under the applicable health plan or health insurance c…

Mont. Code Ann. § 33-32-108 Retroactive Denials Prohibited

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When prior approval for a covered service is required and obtained by or on behalf of a covered person and the covered person undergoes the covered service, the approval is final and the health insurance issuer may not rescind approval after the covered service has been provided.…

Mont. Code Ann. § 33-32-109 Biologic Prescriptions For Minors

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(1) Biologic therapies may be prescribed by a treating provider for individuals under 18 years of age as provided in this section. The biologic therapies must meet the following requirements: (a) the biologic therapies must be approved by the U.S. food and drug administration for…

Mont. Code Ann. § 33-32-202 Commissioner Not To Approve Or Disapprove Plans

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Nothing in this chapter may be construed as authorizing the commissioner to approve or disapprove a utilization review plan required in 33-32-103.

Mont. Code Ann. § 33-32-205 Corporate Oversight Of Utilization Review Program

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A health insurance issuer is responsible for: (1) monitoring all utilization review activities carried out by or on behalf of the health insurance issuer; (2) ensuring that all requirements of this part and rules adopted pursuant to this part are met; and (3) ensuring that approp…

Mont. Code Ann. § 33-32-206 Responsibility For Contracted Services

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Whenever a health insurance issuer contracts with a utilization review organization or other entity to perform the utilization review functions required by this part or rules adopted pursuant to this part, the commissioner shall hold the health insurance issuer responsible for mo…

Mont. Code Ann. § 33-32-207 Health Insurance Issuer Duties For Utilization Review

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(1) A health insurance issuer that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a utilization review program with written documentation describing all review activities and procedures, both delegated …

Mont. Code Ann. § 33-32-208 Operational Requirements

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(1) A utilization review program must use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to ensure ongoing efficacy. A health insurance issuer may develop its own clinical review criteria or may purchase or license cli…

Mont. Code Ann. § 33-32-209 Exemption For Continuity Of Care On Change In Health Plans

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(1) When a covered person changes health plans, a health insurance issuer or its utilization review organization shall honor a certification for health care services granted by a previous health insurance issuer or its utilization review organization for at least the first 3 mont…

Mont. Code Ann. § 33-32-210 Qualifications Of Individuals Making Or Reviewing Adverse Determinations

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(1) A health insurance issuer or its utilization review organization shall ensure that all adverse determinations pursuant to 33-32-211 or 33-32-212 are made by: (a) a physician when the request is by or on behalf of a physician; or (b) a health care professional licensed in the …

Mont. Code Ann. § 33-32-211 Procedures For Standard Utilization Review And Benefit Determinations -- Notices

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(1) A health insurance issuer shall establish written procedures and clinical review criteria for conducting standard utilization reviews and making benefit determinations on requests for benefits submitted to the health insurance issuer by covered persons or their authorized rep…

Mont. Code Ann. § 33-32-212 Procedures For Expedited Utilization Review And Benefit Determinations

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(1) With respect to urgent care requests and concurrent review urgent care requests, a health insurance issuer shall establish written procedures and clinical review criteria for receiving benefit requests from covered persons or, if applicable, their authorized representatives, …

Mont. Code Ann. § 33-32-215 Emergency Services

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(1) When conducting a utilization review or making a benefit determination for emergency services, a health insurance issuer that provides benefits for services in an emergency department of a hospital shall follow the provisions of this section. (2) A health insurance issuer sha…

Mont. Code Ann. § 33-32-216 Confidentiality

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A health insurance issuer and its designee shall comply with all applicable state and federal laws establishing confidentiality and reporting requirements with regard to its utilization review program, including the provisions of Title 33, chapter 19, and 45 CFR, parts 160 and 16…

Mont. Code Ann. § 33-32-217 Disclosure

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(1) In the certificate of coverage and member handbook provided to covered persons, a health insurance issuer shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a s…

Mont. Code Ann. § 33-32-221 Prior Authorization Requirements

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(1) A health insurance issuer or an entity that it contracts with to perform prior authorization on its behalf may not perform prior authorization on benefits for: (a) any generic prescription drug that is not included in subsections (1)(d) through (1)(g) and that is not listed w…

Mont. Code Ann. § 33-32-222 Prohibition On Prior Authorization Requirements For Prescriptions Written At Discharge From Inpatient Care

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(1) A prescription written for an inpatient and patient under observation at the time of discharge requiring a prior authorization may not be subject to prior authorization requirements and must be immediately approved for not less than 3 days, provided that: (a) the cost of the …

Mont. Code Ann. § 33-32-223 Required Method Of Accepting Prior Authorization Requests

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(1) A health insurance issuer or utilization review organization shall accept and respond electronically to prior authorization requests from a health care provider submitted through a secure electronic transmission as determined by the health insurance issuer or utilization revi…

Mont. Code Ann. § 33-32-301 Short Title

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The provisions of Title 33, chapter 32, parts 3 and 4, may be cited as the "Health Insurance Issuer Grievance Procedures and External Review Act".

Mont. Code Ann. § 33-32-302 Applicability And Scope

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(1) Except as provided in subsection (2), the provisions of Title 33, chapter 32, parts 3 and 4, apply to all health insurance issuers. (2) The provisions of Title 33, chapter 32, parts 3 and 4, do not apply to: (a) a policy or certificate that provides coverage only for a specif…

Mont. Code Ann. § 33-32-303 Purpose

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The purpose of this part is to provide standards for the establishment and maintenance of procedures by health insurance issuers to ensure that covered persons have the opportunity for the appropriate resolution of grievances.

Mont. Code Ann. § 33-32-306 Grievance Reporting And Recordkeeping Requirements -- Definition

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(1) (a) A health insurance issuer shall maintain within a register all written records that document grievances received during a calendar year, including the notices and claims associated with the grievances. (b) For the purposes of this section, "register" means the written rec…

Mont. Code Ann. § 33-32-307 Grievance Review Procedures

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(1) Except as specified in 33-32-309, a health insurance issuer shall use written procedures for receiving and resolving grievances from covered persons as provided in 33-32-308. (2) (a) Whenever a health insurance issuer fails to adhere to the requirements of 33-32-308 or 33-32-…

Mont. Code Ann. § 33-32-308 Grievances Involving Adverse Determination

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(1) Within 180 days after the date of receipt of a notice of an adverse determination sent pursuant to Title 33, chapter 32, part 2, a covered person or, if applicable, the covered person's authorized representative may file a grievance with the health insurance issuer requesting…

Mont. Code Ann. § 33-32-309 Expedited Review Of Grievance Involving Adverse Determination

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(1) A health insurance issuer shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. (2) A health insurance issuer shall provide an expedited review of a grievance involving an adverse determination wi…

Mont. Code Ann. § 33-32-401 Purpose

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The purpose of this part is to provide uniform standards for the establishment and maintenance of external review procedures to ensure that covered persons have the opportunity for an independent review of an adverse determination or a final adverse determination.

Mont. Code Ann. § 33-32-402 Definitions For External Review

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For the purposes of this part, the following definitions apply: (1) "Adverse determination" means a determination by a health insurance issuer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service t…

Mont. Code Ann. § 33-32-403 Notice Of Right To External Review

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(1) A health insurance issuer shall: (a) notify the covered person or, if applicable, the covered person's authorized representative in writing of the covered person's right to request an external review pursuant to 33-32-410, 33-32-411, or 33-32-412; and (b) include the appropri…

Mont. Code Ann. § 33-32-404 Request For External Review

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(1) Except for a request for an expedited external review provided for in 33-32-411, all requests for an external review must be made in writing to the health insurance issuer. (2) A request for expedited external review may be made by telephone or in another expeditious manner. …

Mont. Code Ann. § 33-32-405 Exhaustion Of Internal Grievance Process

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(1) Except as provided in subsections (2), (4), (5), and (6), a request for an external review pursuant to 33-32-410, 33-32-411, or 33-32-412 may not be made until the covered person has exhausted the health insurance issuer's internal grievance process provided for in Title 33, …

Mont. Code Ann. § 33-32-410 Standard External Review

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(1) Within 120 days after the date of receipt of a notice of an adverse determination or a final adverse determination pursuant to 33-32-403, a covered person or, if applicable, the covered person's authorized representative may file a request for an external review with the heal…