Montana Code > Title 33 > Chapter 22 – Disability Insurance
Terms Used In Montana Code > Title 33 > Chapter 22 - Disability Insurance
- Activities of daily living: means :
(a)eating;
(b)toileting;
(c)transferring;
(d)bathing;
(e)dressing; and
(f)continence. See Montana Code 33-22-1107
- 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. See Montana Code 33-22-1803
- Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
- Affidavit: means a sworn written declaration made before an officer authorized to administer oaths or an unsworn written declaration made under penalty of perjury as provided in 1-6-105. See Montana Code 1-1-203
- 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. See Montana Code 33-22-1803
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- Annuity: A periodic (usually annual) payment of a fixed sum of money for either the life of the recipient or for a fixed number of years. A series of payments under a contract from an insurance company, a trust company, or an individual. Annuity payments are made at regular intervals over a period of more than one full year.
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Applicant: means :
(a)in the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits; and
(b)in the case of a group medicare supplement policy, the proposed certificate holder. See Montana Code 33-22-903
- Applicant: means :
(a)in the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; and
(b)in the case of a group long-term care insurance policy, the proposed certificate holder. See Montana Code 33-22-1107
- Appropriate sale criteria: means the set of conditions that an insurance company is required to address with an applicant that help to determine whether or not a particular insurance policy or contract offered for sale is appropriate to the applicant. See Montana Code 33-22-1107
- Arraignment: A proceeding in which an individual who is accused of committing a crime is brought into court, told of the charges, and asked to plead guilty or not guilty.
- Association: means the Montana reinsurance association provided for in this part. See Montana Code 33-22-1303
- Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
- Attachment point: means the threshold amount for claims costs incurred by an eligible health insurer for an enrolled individual's covered benefits in a benefit year, beyond which the claims costs for benefits are eligible for reinsurance payments. See Montana Code 33-22-1303
- 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. See Montana Code 33-22-1803
- Baseline: Projection of the receipts, outlays, and other budget amounts that would ensue in the future without any change in existing policy. Baseline projections are used to gauge the extent to which proposed legislation, if enacted into law, would alter current spending and revenue levels.
- 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. See Montana Code 33-22-1803
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Beneficiary: has the meaning given the term by 29 U. See Montana Code 33-22-140
- Benefit value: means a numerical value based on the expected dollar value of benefits payable to an insured under a health benefit plan. See Montana Code 33-22-1803
- Benefit year: means the calendar year for which an eligible health insurer provides coverage through an individual health insurance policy. See Montana Code 33-22-1303
- Board: means the association's board of directors provided for in 33-22-1306. See Montana Code 33-22-1303
- Bona fide association: means an association that:
(a)has been actively in existence for at least 5 years;
(b)was formed and has been maintained in good faith for purposes other than obtaining insurance;
(c)does not condition membership in the association on a health status-related factor relating to an individual, including an employee of an employer or a dependent of an employee;
(d)makes health insurance coverage offered through the association available to a member regardless of a health status-related factor relating to the member or an individual eligible for coverage through a member; and
(e)does not make health insurance coverage offered through the association available other than in connection with a member of the association. See Montana Code 33-22-1803
- Carrier: means any person who provides a health benefit plan in this state subject to state insurance regulation. See Montana Code 33-22-1803
- 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. See Montana Code 33-22-1803
- Certificate: means a certificate delivered or issued for delivery in this state under a group medicare supplement policy. See Montana Code 33-22-903
- Certificate: means a certificate issued under a group long-term care insurance policy that has been delivered or issued for delivery in this state. See Montana Code 33-22-1107
- Church plan: has the meaning given the term by 29 U. See Montana Code 33-22-140
- Class of business: means all or a separate grouping of small employers established pursuant to 33-22-1808. See Montana Code 33-22-1803
- Clerk of court: An officer appointed by the court to work with the chief judge in overseeing the court's administration, especially to assist in managing the flow of cases through the court and to maintain court records.
- COBRA continuation provision: means :
(a)section 4980B of the Internal Revenue Code, 26 U. See Montana Code 33-22-140
- Coinsurance rate: means the rate at which the association will reimburse an eligible health insurer for claims incurred for an enrolled individual's covered benefits in a benefit year above the attachment point and below the reinsurance cap. See Montana Code 33-22-1303
- Continuance: Putting off of a hearing ot trial until a later time.
- Contract: A legal written agreement that becomes binding when signed.
- 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.
- Covered person: means a policyholder, subscriber, certificate holder, enrollee, or other individual who is participating in a health benefit plan. See Montana Code 33-22-1902
- Creditable coverage: means coverage of the individual under any of the following:
(i)a group health plan;
(ii)health insurance coverage;
(iii)Title XVIII, part A or B, of the Social Security Act, 42 U. See Montana Code 33-22-140
- Customary: means according to usage. See Montana Code 1-1-206
- Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
- Dependent: A person dependent for support upon another.
- Dependent: means :
(a)a spouse;
(b)an unmarried child under 25 years of age:
(i)who is not an employee eligible for coverage under a group health plan offered by the child's employer for which the child's premium contribution amount is no greater than the premium amount for coverage as a dependent under a parent's individual or group health plan;
(ii)who is not a named subscriber, insured, enrollee, or covered individual under any other individual health insurance coverage, group health plan, government plan, church plan, or group health insurance;
(iii)who is not entitled to benefits under 42 U. See Montana Code 33-22-140
- Dependent: means :
(a)a spouse;
(b)an unmarried child under 25 years of age:
(i)who is not an employee eligible for coverage under a group health plan offered by the child's employer for which the child's premium contribution amount is no greater than the premium amount for coverage as a dependent under a parent's individual or group health plan;
(ii)who is not a named subscriber, insured, enrollee, or covered individual under any other individual health insurance coverage, group health plan, government plan, church plan, or group health insurance;
(iii)who is not entitled to benefits under 42 U. See Montana Code 33-22-1803
- Dismissal: The dropping of a case by the judge without further consideration or hearing. Source:
- 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. See Montana Code 33-22-1803
- Eligible health insurer: means a health insurer, health service corporation, or health maintenance organization that:
(a)offers individual health insurance coverage in the individual market, as defined in 33-22-140;
(b)offers a qualified health plan as defined in 42 U. See Montana Code 33-22-1303
- Elimination rider: means a provision attached to a policy that excludes coverage for a specific condition that would otherwise be covered under the policy. See Montana Code 33-22-140
- Emergency medical condition: means a condition manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in any of the following:
(a)the covered person's health would be in serious jeopardy;
(b)the covered person's bodily functions would be seriously impaired; or
(c)a bodily organ or part would be seriously damaged. See Montana Code 33-22-1703
- Enrollment date: means , with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for enrollment. See Montana Code 33-22-140
- Entitlement: A Federal program or provision of law that requires payments to any person or unit of government that meets the eligibility criteria established by law. Entitlements constitute a binding obligation on the part of the Federal Government, and eligible recipients have legal recourse if the obligation is not fulfilled. Social Security and veterans' compensation and pensions are examples of entitlement programs.
- Entity: means an insurer as defined in 33-1-201, a health service corporation as defined in 33-30-101, and a health maintenance organization as defined in 33-31-102. See Montana Code 33-22-903
- 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
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Ex officio: Literally, by virtue of one's office.
- Excepted benefits: means :
(a)coverage only for accident or disability income insurance, or both;
(b)coverage issued as a supplement to liability insurance;
(c)liability insurance, including general liability insurance and automobile liability insurance;
(d)workers' compensation or similar insurance;
(e)automobile medical payment insurance;
(f)credit-only insurance;
(g)coverage for onsite medical clinics;
(h)other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits, as approved by the commissioner;
(i)if offered separately, any of the following:
(i)limited-scope dental or vision benefits;
(ii)benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these types of care; or
(iii)other similar, limited benefits as approved by the commissioner;
(j)if offered as independent, noncoordinated benefits, any of the following:
(i)coverage only for a specified disease or illness; or
(ii)hospital indemnity or other fixed indemnity insurance;
(k)if offered as a separate insurance policy:
(i)medicare supplement coverage;
(ii)coverage supplemental to the coverage provided under Title 10, chapter 55, of the United States Code; and
(iii)similar supplemental coverage provided under a group health plan. See Montana Code 33-22-140
- Federally defined eligible individual: means an individual:
(a)for whom, as of the date on which the individual seeks coverage in the group market or individual market, the aggregate of the periods of creditable coverage is 18 months or more;
(b)whose most recent prior creditable coverage was under a group health plan, governmental plan, church plan, or health insurance coverage offered in connection with any of those plans;
(c)who is not eligible for coverage under:
(i)a group health plan;
(ii)Title XVIII, part A or B, of the Social Security Act, 42 U. See Montana Code 33-22-140
- federally tax-qualified long-term care insurance contract: means :
(a)an individual or group insurance contract that meets the requirement of section 7702B of the Internal Revenue Code, 26 U. See Montana Code 33-22-1107
- Fiduciary: A trustee, executor, or administrator.
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
- Fraud: Intentional deception resulting in injury to another.
- Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. Source: Federal Reserve
- Group health insurance coverage: means health insurance coverage offered in connection with a group health plan or health insurance coverage offered to an eligible group as described in 33-22-501. See Montana Code 33-22-140
- Group health plan: means an employee welfare benefit plan, as defined in 29 U. See Montana Code 33-22-140
- Group long-term care insurance: means a long-term care insurance policy that is delivered or issued for delivery in this state and issued to:
(a)(i) one or more employers;
(ii)a labor organization;
(iii)a trust established by an employer or labor organization; or
(iv)a trustee of a fund established by one or more employers or labor organizations or a combination of employers and labor organizations for:
(A)employees or former employees or a combination of employees and former employees; or
(B)members or former members of the labor organization or a combination of members and former members;
(b)any professional, trade, or occupational association for its current, former, or retired members or a combination of current, former, and retired members if the association:
(i)is composed of individuals all of whom are or were actively engaged in the same profession, trade, or occupation; and
(ii)has been maintained in good faith for purposes other than obtaining insurance; or
(c)an association, a trust, or the trustee of a fund established, created, or maintained for the benefit of members of one or more associations. See Montana Code 33-22-1107
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- Health benefit plan: means the health insurance policy or subscriber arrangement between the insured or subscriber and the health care insurer that defines the covered services and benefit levels available. See Montana Code 33-22-1703
- 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 benefit plan: means any individual or group plan, policy, certificate, subscriber contract, contract of insurance provided by a managed care plan, preferred provider agreement, or health maintenance organization subscriber contract that is issued, delivered, issued for delivery, or renewed in this state by a health carrier that pays for, purchases, or furnishes health care services to covered persons who receive health care services in this state. See Montana Code 33-22-1902
- Health care insurer: means :
(a)an insurer that provides disability insurance as defined in 33-1-207;
(b)a health service corporation as defined in 33-30-101;
(c)a fraternal benefit society as described in 33-7-105; or
(d)any other entity regulated by the commissioner that provides health coverage except a health maintenance organization. See Montana Code 33-22-1703
- Health care services: means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization or services provided under Title 33, chapter 22, part 7. See Montana Code 33-22-1703
- Health carrier: means a disability insurer, health care insurer, health maintenance organization, accident and sickness insurer, fraternal benefit society, nonprofit hospital service corporation, health service corporation, health care service plan, preferred provider organization or arrangement, multiple employer welfare arrangement, or any other person, firm, corporation, joint venture, or similar business entity. See Montana Code 33-22-1902
- 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
- Health insurance issuer: means an insurer, a health service corporation, or a health maintenance organization. See Montana Code 33-22-140
- Iatrogenic infertility: means an impairment of fertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment. See Montana Code 33-22-2102
- Impeachment: (1) The process of calling something into question, as in "impeaching the testimony of a witness." (2) The constitutional process whereby the House of Representatives may "impeach" (accuse of misconduct) high officers of the federal government for trial in the Senate.
- 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. See Montana Code 33-22-1803
- Individual health insurance coverage: means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance. See Montana Code 33-22-140
- Individual market: means the market for health insurance coverage offered to individuals other than in connection with group health insurance coverage. See Montana Code 33-22-140
- Insured: means an individual entitled to reimbursement for expenses of health care services under a policy or subscriber contract issued or administered by an insurer. See Montana Code 33-22-1703
- Issuer: includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any entity delivering or issuing for delivery in this state medicare supplement policies or certificates. See Montana Code 33-22-903
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Knowingly: means only a knowledge that the facts exist which bring the act or omission within the provisions of this code. See Montana Code 1-1-204
- Large employer: means , in connection with a group health plan, with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least two employees on the first day of the plan year. See Montana Code 33-22-140
- Large group market: means the health insurance market under which individuals obtain health insurance coverage directly or through any arrangement on behalf of themselves and their dependents through a group health plan or group health insurance coverage issued to a large employer. See Montana Code 33-22-140
- Late enrollee: means an eligible employee or dependent, other than a special enrollee under 33-22-523, who requests enrollment in a group health plan following the initial enrollment period during which the individual was entitled to enroll under the terms of the group health plan if the initial enrollment period was a period of at least 30 days. See Montana Code 33-22-140
- Lawsuit: A legal action started by a plaintiff against a defendant based on a complaint that the defendant failed to perform a legal duty, resulting in harm to the plaintiff.
- Legislative session: That part of a chamber's daily session in which it considers legislative business (bills, resolutions, and actions related thereto).
- Medical care: means :
(a)the diagnosis, cure, mitigation, treatment, or prevention of disease or amounts paid for the purpose of affecting any structure or function of the body;
(b)transportation primarily for and essential to medical care referred to in subsection (19)(a); or
(c)insurance covering medical care referred to in subsections (19)(a) and (19)(b). See Montana Code 33-22-140
- Medicare: means Health Insurance for the Aged, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended. See Montana Code 33-22-903
- Medicare supplement policy: means a group or individual policy of disability insurance or a subscriber contract of a health service corporation, other than a policy issued pursuant to a contract under 42 U. See Montana Code 33-22-903
- Network plan: means health insurance coverage offered by a health insurance issuer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the issuer. See Montana Code 33-22-140
- 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. See Montana Code 33-22-1803
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Obstetrician or gynecologist: means a physician who is board-eligible or board-certified by the American board of obstetrics and gynecology. See Montana Code 33-22-1902
- Participating obstetrician or gynecologist: means an obstetrician or gynecologist who is employed by or under contract with a health benefit plan. See Montana Code 33-22-1902
- Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
- Payment parameters: means the attachment point, reinsurance cap, and coinsurance rate for the Montana reinsurance program. See Montana Code 33-22-1303
- Peace officer: has the meaning as defined in 46-1-202. See Montana Code 1-1-207
- Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
- Plan sponsor: has the meaning provided under section 3(16)(B) of the Employee Retirement Income Security Act of 1974, 29 U. See Montana Code 33-22-140
- Policy: means any policy, certificate, contract, membership contract, subscriber agreement, health care services agreement, rider, or endorsement delivered or issued for delivery in this state by an insurer, fraternal benefit society, health service corporation, prepaid health plan, health maintenance organization, or similar organization. See Montana Code 33-22-1107
- Preexisting condition: means a condition for which medical advice or treatment was recommended by or received from a provider of health care services within 6 months preceding the effective date of coverage of an insured person. See Montana Code 33-22-1107
- Preexisting condition exclusion: means , with respect to coverage, a limitation or exclusion of benefits relating to a condition based on presence of a condition before the enrollment date coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before the enrollment date. See Montana Code 33-22-140
- Preferred provider: means a provider or group of providers who have contracted to provide specified health care services. See Montana Code 33-22-1703
- Preferred provider agreement: means a contract between or on behalf of a health care insurer and a preferred provider. See Montana Code 33-22-1703
- 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
- Primary care physician: means a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referrals for specialist care. See Montana Code 33-22-1902
- Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
- Program: means the Montana reinsurance program operated by the Montana reinsurance association. See Montana Code 33-22-1303
- Provider: means an individual or entity licensed or legally authorized to provide health care services or services covered within Title 33, chapter 22, part 7. See Montana Code 33-22-1703
- Public defender: Represent defendants who can't afford an attorney in criminal matters.
- Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
- Rating period: means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect. See Montana Code 33-22-1803
- Reinsurance cap: means the maximum amount of each claim incurred by an eligible health insurer for an enrolled individual's covered benefits in a benefit year, after which the claims costs for benefits are no longer eligible for reinsurance payments. See Montana Code 33-22-1303
- Reinsurance payments: means an amount paid by the association to an eligible health insurer under the program. See Montana Code 33-22-1303
- Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
- 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
- Several: means two or more. See Montana Code 1-1-201
- 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
- Small group market: means the health insurance market under which individuals obtain health insurance coverage directly or through an arrangement, on behalf of themselves and their dependents, through a group health plan or group health insurance coverage maintained by a small employer as defined in 33-22-1803. See Montana Code 33-22-140
- Standard fertility preservation services: means procedures consistent with established medical practices and professional guidelines published by a national association for practitioners of reproductive medicine or clinical oncology. See Montana Code 33-22-2102
- 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
- Statute: A law passed by a legislature.
- Subscriber: means a certificate holder or other person on whose behalf the health care insurer is providing or paying for health care coverage. See Montana Code 33-22-1703
- subscription: includes the mark of a person who cannot write if the person's name is written near the mark by another person who also signs that person's own name as a witness. See Montana Code 1-1-203
- Summons: Another word for subpoena used by the criminal justice system.
- Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
- Trustee: A person or institution holding and administering property in trust.
- United States: includes the District of Columbia and the territories. See Montana Code 1-1-201
- Waiting period: means , with respect to a group health plan and an individual who is a potential participant or beneficiary in the group health plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the group health plan. See Montana Code 33-22-140
- Writing: includes printing. See Montana Code 1-1-203