Montana Code 33-22-1813. Standards to ensure fair marketing
33-22-1813. Standards to ensure fair marketing. (1) Each small employer carrier shall actively market health benefit plan coverage, including the basic and standard health benefit plans, to eligible small employers in the state.
Terms Used In Montana Code 33-22-1813
- Carrier: means any person who provides a health benefit plan in this state subject to state insurance regulation. See Montana Code 33-22-1803
- Contract: A legal written agreement that becomes binding when signed.
- 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. See Montana Code 33-22-1803
- 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. See Montana Code 33-22-1803
- Health insurance coverage: means benefits consisting of medical care, including items and services paid for as medical care, that are provided directly, through insurance, reimbursement, or otherwise, under a policy, certificate, membership contract, or health care services agreement offered by a health insurance issuer. See Montana Code 33-22-140
- 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. See Montana Code 33-22-1803
- 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. See Montana Code 33-22-1803
- Small employer: means a person, firm, corporation, partnership, or bona fide association that is actively engaged in business and that, with respect to a calendar year and a plan year, employed at least two but not more than 50 eligible employees during the preceding calendar year and employed at least two employees on the first day of the plan year. See Montana Code 33-22-1803
- Small employer carrier: means a carrier that offers health benefit plans that cover eligible employees of one or more small employers in this state. See Montana Code 33-22-1803
- Standard health benefit plan: means a health benefit plan that is developed by a small employer carrier. See Montana Code 33-22-1803
- 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
- Writing: includes printing. See Montana Code 1-1-203
(2)(a) Except as provided in subsection (2)(b), a small employer carrier or producer may not directly or indirectly engage in the following activities:
(i)encouraging or directing small employers to refrain from filing an application for coverage with the small employer carrier because of the health status of the employer’s employees or the claims experience, industry, occupation, or geographic location of the small employer;
(ii)encouraging or directing small employers to seek coverage from another carrier because of the health status of the employer’s employees or the claims experience, industry, occupation, or geographic location of the small employer.
(b)The provisions of subsection (2)(a) do not apply with respect to information provided by a small employer carrier or producer to a small employer regarding the established geographic service area or a restricted network provision of a small employer carrier.
(3)(a) Except as provided in subsection (3)(b), a small employer carrier may not, directly or indirectly, enter into any contract, agreement, or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health benefit plan to be varied because of the health status of the employer’s employees or the claims experience, industry, occupation, or geographic location of the small employer.
(b)Subsection (3)(a) does not apply with respect to a compensation arrangement that provides compensation to a producer on the basis of the percentage of a premium, provided that the percentage may not vary because of the health status of the employer’s employees or the claims experience, industry, occupation, or geographic area of the small employer.
(4)A small employer carrier shall provide reasonable compensation, as provided under the plan of operation of the program, to a producer, if any, for the sale of a basic or standard health benefit plan.
(5)A small employer carrier may not terminate, fail to renew, or limit its contract or agreement of representation with a producer for any reason related to the health status of the employer’s employees or the claims experience, industry, occupation, or geographic location of the small employers placed by the producer with the small employer carrier.
(6)A small employer carrier or producer may not induce or otherwise encourage a small employer to separate or otherwise exclude an employee from health coverage or benefits provided in connection with the employee’s employment.
(7)Denial by a small employer carrier of health insurance coverage for a small employer must be in writing and must state the reason or reasons for the denial.
(8)The commissioner may adopt rules setting forth additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers in this state.
(9)(a) A violation of this section by a small employer carrier or a producer is an unfair trade practice under 33-18-102.
(b)If a small employer carrier enters into a contract, agreement, or other arrangement with an administrator who holds a certificate of registration pursuant to 33-17-603 to provide administrative, marketing, or other services related to the offering of health benefit plans to small employers in this state, the administrator is subject to this section as if the administrator were a small employer carrier.