Terms Used In Montana Code > Title 33 > Chapter 22 > Part 18 - Small Employer Health Insurance Availability Act

• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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.
• 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

• 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 33-22-1803

• 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
• 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
• 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.
• 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

• 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.
• Group health plan: means an employee welfare benefit plan, as defined in 29 U. See Montana Code 33-22-140
• 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
• 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
• 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.
• 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
• 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
• 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
• 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.
• Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
• 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
• 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
• 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
• 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
• 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
• 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