A contract or evidence of coverage delivered or issued for delivery to any person by a health maintenance organization required to obtain a certificate of authority in this state may not contain definitions respecting the words defined in the Montana Health Maintenance Organization Act or this rule unless the definitions comply with the definitions contained in the Montana Health Maintenance Organization Act and this rule. Definitions other than those set forth in the Montana Health Maintenance Organization Act or this rule may be used if they do not extend, modify, or conflict with the definitions contained in the Montana Health Maintenance Organization Act and this rule.

All definitions used in the contract and evidence of coverage must be in alphabetical order. As used in these rules, the Montana Health Maintenance Organization Act, and for the purpose of any terms used in the contract and evidence of coverage:

(1) "Basic health care services" means basic health care services as defined in 33-31-102(2) , MCA.

(2) "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.

(3) "Copayment" means the amount a subscriber must pay to receive a specific service that is not fully prepaid.

(4) "Dependent" means:

(a) a spouse of the subscriber:

(b) an unmarried dependent child of the subscriber who has not reached age 18 or a greater age agreed to between the health maintenance organization and the contract holder,

(c) an unmarried dependent child of the subscriber over the age of 18, or over a greater age agreed to between the health maintenance organization and the contract holder, who is both incapable of self-support because of mental retardation, mental illness, or physical incapacity and chiefly dependent upon the subscriber for support and maintenance; or

(d) an unmarried dependent child of the subscriber who is attending a recognized college, university, or trade or secondary school on a full-time basis. As used in this definition, "dependent child" means:

(i) related to the subscriber as either a natural child, a legally adopted child, or a stepchild; or

(ii) any other child residing in the subscriber's household who qualifies as a dependent of the subscriber or the subscriber's spouse under the United States Internal Revenue Code and the Federal Tax Regulations.

(5) "Enrollee" means an enrollee as defined in 33-31-102, MCA.

(6) "Evidence of coverage" means an evidence of coverage as defined in 33-31-102, MCA.

(7) "Group contract" means a contract for health care services that by its terms limits eligibility to members of a specified group.

(8) "Health care services" means health care services as defined in 33-31-102(8) , MCA.

(9) "Hospital" means hospital as defined in 50-5-101, MCA.

(l0) "Individual contract" means a contract for health care services issued to and covering an individual or a family.

(11) "Out-of-area services" means the health care services that a health maintenance organization covers when its enrollees are outside of the service area.

(12) "Physician" means physician as defined in 50-2-101, MCA.

(13) "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.

(14) "Provider" means a provider as defined in 33-31-102, MCA. "Person", as used in that definition, means a person as defined in 33-31-102, MCA.

(15) "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.

(16) "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.

(17) "Supplemental health care services" means health care services other than basic health care services.