33-22-1803. Definitions. As used in this part, the following definitions apply:
     (1) "Actuarial certification" means a written statement by a member of the American academy of actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with the provisions of 33-22-1809, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer carrier in establishing premium rates for applicable health benefit plans.
     (2) "Affiliate" or "affiliated" means any entity or person who directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with a specified entity or person.
     (3) "Assessable carrier" means all carriers of disability insurance, including excess of loss and stop loss disability insurance.
     (4) "Base premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under the rating system for that class of business by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage.
     (5) "Basic health benefit plan" means a health benefit plan, except a uniform health benefit plan, developed by a small employer carrier, that has a lower benefit value than the small employer carrier's standard benefit plan and that provides the benefits required by 33-22-1827.
     (6) "Benefit equivalency" means a method developed by the small employer carrier for comparing the types of health care services and articles covered under a health benefit plan with the types of health care services required to be covered under a uniform, basic, or standard health benefit plan.
     (7) "Benefit value" means an actuarially based method developed by the small employer carrier for comparing the value of determinable contingencies covered under a health benefit plan with the value of determinable contingencies required under a uniform, basic, or standard health benefit plan.
     (8) "Board" means the board of directors of the program established pursuant to 33-22-1818.
     (9) "Carrier" means any person who provides a health benefit plan in this state subject to state insurance regulation. The term includes but is not limited to an insurance company, a fraternal benefit society, a health service corporation, and a health maintenance organization. For purposes of this part, companies that are affiliated companies or that are eligible to file a consolidated tax return must be treated as one carrier, except that the following may be considered as separate carriers:
     (a) an insurance company or health service corporation that is an affiliate of a health maintenance organization located in this state;
     (b) a health maintenance organization located in this state that is an affiliate of an insurance company or health service corporation; or
     (c) a health maintenance organization that operates only one health maintenance organization in an established geographic service area of this state.
     (10) "Case characteristics" means demographic or other objective characteristics of a small employer that are considered by the small employer carrier in the determination of premium rates for the small employer, provided that gender, claims experience, health status, and duration of coverage are not case characteristics for purposes of this part.
     (11) "Class of business" means all or a separate grouping of small employers established pursuant to 33-22-1808.
     (12) "Dependent" means:
     (a) a spouse or an unmarried child under 19 years of age;
     (b) an unmarried child, under 23 years of age, who is a full-time student and who is financially dependent on the insured;
     (c) a child of any age who is disabled and dependent upon the parent as provided in 33-22-506 and 33-30-1003; or
     (d) any other individual defined as a dependent in the health benefit plan covering the employee.
     (13) "Eligible employee" means an employee who works on a full-time basis with a normal workweek of 30 hours or more, except that at the sole discretion of the employer, the term may include an employee who works on a full-time basis with a normal workweek of between 20 and 40 hours as long as this eligibility criteria is applied uniformly among all of the employer's employees. The term includes a sole proprietor, a partner of a partnership, and an independent contractor if the sole proprietor, partner, or independent contractor is included as an employee under a health benefit plan of a small employer. The term does not include an employee who works on a part-time, temporary, or substitute basis.
     (14) "Established geographic service area" means a geographic area, as approved by the commissioner and based on the carrier's certificate of authority to transact insurance in this state, within which the carrier is authorized to provide coverage.
     (15) "Health benefit plan" means any hospital or medical policy or certificate providing for physical and mental health care issued by an insurance company, a fraternal benefit society, or a health service corporation or issued under a health maintenance organization subscriber contract. Health benefit plan does not include:
     (a) accident-only, credit, dental, vision, specified disease, medicare supplement, long-term care, or disability income insurance;
     (b) coverage issued as a supplement to liability insurance, workers' compensation insurance, or similar insurance; or
     (c) automobile medical payment insurance.
     (16) "Index rate" means, for each class of business for a rating period for small employers with similar case characteristics, the average of the applicable base premium rate and the corresponding highest premium rate.
     (17) "Late enrollee" means an eligible employee or dependent who requests enrollment in a health benefit plan of a small employer following the initial enrollment period during which the individual was entitled to enroll under the terms of the health benefit plan, provided that the initial enrollment period was a period of at least 30 days. However, an eligible employee or dependent may not be considered a late enrollee if:
     (a) the individual requests enrollment within 30 days after termination of the qualifying previous coverage and:
     (i) the individual was covered under qualifying previous coverage at the time of the initial enrollment; or
     (ii) the individual lost coverage under qualifying previous coverage as a result of termination of employment or eligibility, the involuntary termination of the qualifying previous coverage, the death of a spouse, or divorce;
     (b) the individual is employed by an employer that offers multiple health benefit plans and the individual elects a different plan during an open enrollment period; or
     (c) a court has ordered that coverage be provided for a spouse, minor, or dependent child under a covered employee's health benefit plan and a request for enrollment is made within 30 days after issuance of the court order.
     (18) "New business premium rate" means, for each class of business for a rating period, the lowest premium rate charged or offered or that could have been charged or offered by the small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage.
     (19) "Plan of operation" means the operation of the program established pursuant to 33-22-1818.
     (20) "Premium" means all money paid by a small employer and eligible employees as a condition of receiving coverage from a small employer carrier, including any fees or other contributions associated with the health benefit plan.
     (21) "Program" means the Montana small employer health reinsurance program created by 33-22-1818.
     (22) "Qualifying previous coverage" means benefits or coverage provided under:
     (a) medicare or medicaid;
     (b) an employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under the minimum basic health benefit plan; or
     (c) an individual health insurance policy, including coverage issued by an insurance company, a fraternal benefit society, a health service corporation, or a health maintenance organization that provides benefits similar to or exceeding the benefits provided under the minimum basic health benefit plan, provided that the policy has been in effect for a period of at least 1 year.
     (23) "Rating period" means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect.
     (24) "Reinsuring carrier" means a small employer carrier participating in the reinsurance program pursuant to 33-22-1819.
     (25) "Restricted network provision" means a provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of health care providers that have entered into a contractual arrangement with the carrier pursuant to Title 33, chapter 22, part 17, or Title 33, chapter 31, to provide health care services to covered individuals.
     (26) "Small employer" means a person, firm, corporation, partnership, or association that is actively engaged in business and that, on at least 50% of its working days during the preceding calendar quarter, employed at least 3 but not more than 25 eligible employees, the majority of whom were employed within this state or were residents of this state. In determining the number of eligible employees, companies are considered one employer if they:
     (a) are affiliated companies;
     (b) are eligible to file a combined tax return for purposes of state taxation; or
     (c) are members of an association that:
     (i) has been in existence for 1 year prior to January 1, 1994;
     (ii) provides a health benefit plan to employees of its members as a group; and
     (iii) does not deny coverage to any small employer member of its association or any employee of its small employer members who applies for coverage as part of a group.
     (27) "Small employer carrier" means a carrier that offers health benefit plans that cover eligible employees of one or more small employers in this state.
     (28) "Standard health benefit plan" means a health benefit plan that is developed by a small employer carrier and that contains the provisions required pursuant to 33-22-1828.

     History: En. Sec. 24, Ch. 606, L. 1993; amd. Sec. 1, Ch. 377, L. 1995; amd. Sec. 65, Ch. 379, L. 1995.