33-31-202. Issuance of certificate of authority. (1) The commissioner shall issue or deny a certificate of authority to any person filing an application pursuant to 33-31-201 within 180 days after receipt of the application. The commissioner shall grant a certificate of authority upon payment of the application fee prescribed in 33-31-212 if the commissioner is satisfied that each of the following conditions is met:

Terms Used In Montana Code 33-31-202

  • 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;

    (ii)well-child care from birth;

    (iii)periodic health evaluations for adults;

    (iv)voluntary family planning services;

    (v)infertility services; and

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

    (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. See Montana Code 33-31-102

  • Commissioner: means the commissioner of insurance of the state of Montana. See Montana Code 33-31-102
  • 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.
  • Health care services: means :

    (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. See Montana Code 33-31-102

  • 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. See Montana Code 33-31-102
  • Person: means :

    (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. See Montana Code 33-31-102

  • 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

(a)The persons responsible for the conduct of the applicant’s affairs are competent and trustworthy.

(b)The health maintenance organization will effectively provide or arrange for the provision of basic health care services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments. This requirement does not apply to the physical or mental health care services provided by a health maintenance organization to a person receiving medicaid services under the Montana medicaid program as established in Title 53, chapter 6.

(c)The health maintenance organization is financially responsible and can reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the commissioner may consider:

(i)the financial soundness of the arrangements for health care services and the schedule of charges used in connection with the services;

(ii)the adequacy of working capital;

(iii)any agreement with an insurer, a health service corporation, a government, or any other organization for ensuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage in the event of discontinuance of the health maintenance organization;

(iv)any agreement with providers for the provision of health care services;

(v)any deposit of cash or securities submitted in accordance with 33-31-216; and

(vi)any additional information that the commissioner may reasonably require.

(d)The enrollees must be afforded an opportunity to participate in matters of policy and operation pursuant to 33-31-222.

(e)Nothing in the proposed method of operation, as shown by the information submitted pursuant to 33-31-201 or by independent investigation, violates any provision of this chapter or rules adopted by the commissioner.

(2)The commissioner may deny a certificate of authority only if the requirements of 33-31-404 are complied with.

(3)The commissioner shall examine each health maintenance organization applying for an initial certificate of authority to do business in this state. In lieu of making an examination under this part of any health maintenance organization domiciled in another state, the commissioner may accept an examination report on the organization prepared by the insurance department of the organization’s state of domicile.

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