Montana Code 33-31-402. Suspension or revocation of certificate of authority
33-31-402. Suspension or revocation of certificate of authority. (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:
Terms Used In Montana Code 33-31-402
- 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
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- 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
(a)The health maintenance organization is operating in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under 33-31-201 and the operation adversely affects the health maintenance organization’s ability to provide benefits and operate under the application approved by the commissioner, unless amendments to the submissions have been filed with and approved by the commissioner.
(b)The health maintenance organization issues evidences of coverage or uses a schedule of charges for health care services that do not comply with the requirements of 33-31-301.
(c)The health maintenance organization does not provide or arrange for basic health care services.
(d)The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees.
(e)The health maintenance organization has failed to implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation under 33-31-222.
(f)The health maintenance organization has failed to implement the complaint system required by 33-31-303 to resolve valid complaints in a reasonable manner.
(g)The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner.
(h)The continued operation of the health maintenance organization would be hazardous to its enrollees.
(i)The health maintenance organization has otherwise failed to substantially comply with this chapter.
(2)The commissioner may suspend or revoke a certificate of authority only if the commissioner complies with the requirements of 33-31-404.
(3)When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization may not, during the period of suspension, enroll any additional enrollees except newborn infants or other newly acquired dependents of existing enrollees and may not engage in any advertising or solicitation.
(4)If the commissioner revokes the certificate of authority of a health maintenance organization, the health maintenance organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and may not transact further business except as may be essential to the orderly conclusion of its affairs. It may not engage in further advertising or solicitation following the effective date of the order of revocation. The commissioner may by written order permit further operation of the health maintenance organization if the commissioner finds further operation to be in the best interest of enrollees to the extent that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.