Montana Code 33-22-115. Provider agreement limited to covered services — dental network constraints — penalty — definitions
33-22-115. Provider agreement limited to covered services — dental network constraints — penalty — definitions. (1) A provider agreement entered into or renewed on or after July 1, 2013, between dentists licensed under Title 37, chapter 4, and an issuer that offers an excepted benefits plan for limited-scope dental benefits or a health benefit plan that includes covered services may not:
Terms Used In Montana Code 33-22-115
- 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.
- Excepted benefits: means :
(a)coverage only for accident or disability income insurance, or both;
(b)coverage issued as a supplement to liability insurance;
(c)liability insurance, including general liability insurance and automobile liability insurance;
(d)workers' compensation or similar insurance;
(e)automobile medical payment insurance;
(f)credit-only insurance;
(g)coverage for onsite medical clinics;
(h)other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits, as approved by the commissioner;
(i)if offered separately, any of the following:
(i)limited-scope dental or vision benefits;
(ii)benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these types of care; or
(iii)other similar, limited benefits as approved by the commissioner;
(j)if offered as independent, noncoordinated benefits, any of the following:
(i)coverage only for a specified disease or illness; or
(ii)hospital indemnity or other fixed indemnity insurance;
(k)if offered as a separate insurance policy:
(i)medicare supplement coverage;
(ii)coverage supplemental to the coverage provided under Title 10, chapter 55, of the United States Code; and
(iii)similar supplemental coverage provided under a group health plan. See Montana Code 33-22-140
(a)require the dentist to provide dental services to an individual covered under the excepted benefits plan or health benefit plan at a fee set by or subject to the approval of the issuer unless the dental services are covered services; or
(b)prohibit the dentist from offering or providing to an individual covered under the excepted benefits plan or health benefit plan any dental services that are not covered services. The fee for the noncovered services may be determined only under terms or conditions set by the dentist or negotiated by the dentist with the individual covered under the excepted benefits plan or health benefit plan.
(c)provide minimal coverage for covered services under the provider agreement for the sole purpose of avoiding the requirements of this section.
(2)A business entity that owns a network of health care providers and markets access to that network may not circumvent the terms of this section by making available to an issuer of an excepted benefits plan for limited-scope dental benefits or a health benefit plan that includes covered services any dentists in that network if the business entity sets dental services fees in its network for any services except covered services.
(3)An issuer of an excepted benefits plan for limited-scope dental benefits or a health benefit plan that includes covered services is subject to a fine as provided in 33-1-317 for a violation of this section.
(4)For the purposes of this section, the following definitions apply:
(a)”Covered services” means dental care services provided under a plan for limited-scope dental benefits or a health benefit plan for which a payment is available subject to the application of contractual terms, including but not limited to annual or lifetime maximums, deductibles, copayments, coinsurance, waiting periods, frequency limitations, or alternative benefit reimbursement.
(b)”Issuer” includes an insurer, a health service corporation, or a third-party administrator that offers or administers an excepted benefits plan for limited-scope dental benefits or a health benefit plan that includes covered services.