For the purposes of this sub-chapter, the following terms
have the following definitions:
(1) "Act" means the Montana Small
Employer Health Insurance Availability Act.
(2) "Adjusted gross income" means
gross income minus deductions recognized by the Internal Revenue Code.
(3) "Associate member of an employee
organization" means any individual who participates in an employee benefit
plan, as defined in 29 U.S.C. 1002(1) , that is a multiemployer plan, as defined
in 29 U.S.C. 1002(37A) , other than the following:
(a) An individual (or the eligible dependent of
such individual) who is employed by a participating employer within a
bargaining unit covered by at least one of the collective bargaining agreements
under or pursuant to which the employee benefit plan is established or
(b) An individual who is a present or former
employee (or an eligible dependent of such employee) of the sponsoring employee
organization, of an employer who is, or was a party to at least one of the
collective bargaining agreements under or pursuant to which the employee
benefit plan is established or maintained, or of the employee benefit plan, or
of a related plan.
(4) "Coinsurance" means the percentage
of eligible charges which the insurer must pay, after the deductible is met.
(5) "Copayment" means a fixed dollar
amount or percentage of eligible charges which the insured must pay for each
service after a deductible, if any, is met.
(6) "Deductible" means the dollar
amount of eligible charges which the insured must pay in an annual benefit
period before any benefits are payable by the insurer.
(7) "Eligible dependent" means any
dependent defined in 33-22-1803(12) , MCA, including a common law
spouse, or any child who qualifies as a dependent under the Internal Revenue
(8) "Eligible employee" means any
employee defined in 33-22-1803(13) , MCA. All employees who work an
average of 30 hours a week or more shall be considered an eligible employee
unless, at the sole discretion of the employer, the insurance contract has
specified in an endorsement a different hourly requirement of between 20 and 40
hours a week as contemplated in ARM 6.6.5058(3) . An eligible employee does not
include an employee who works on a part-time or temporary basis.
(a) "Temporary employee" means an
employee who is designated as temporary by an employer for a definite period of
time, not to exceed twelve months, and who has no
of becoming a permanent employee. A temporary employee may not be an eligible
employee. At the employer's discretion, a seasonal employee may be an eligible
employee provided they are not designated as temporary and that they work the
requisite number of hours per week.
(b) Officers must be subject to the same
eligibility criteria as other employees including working the required number
of hours per week.
(c) "Part-time employees" means anyone
who works less than the hourly requirement of an eligible employee.
(9) "Lifetime maximum benefit" means
maximum total benefits paid by the insurer throughout the life of the policy.
(10) "Maximum annual out-of-pocket"
means the total amount of eligible charges paid by the insured as copayments
and deductible in an annual benefit period.
(11) "Risk characteristic" means the
health status, claims experience, duration of coverage, or any similar
characteristic related to the health status or experience of a small employer
group or of any member of a small employer group.
(12) "Renewal date" means the first day
of a group health plan year, or the first day of a shorter period if a plan is
issued for a period shorter than one year.
(13) "Risk load" means the percentage
above the applicable base premium rate that is charged by a small employer
carrier to a small employer to reflect the risk characteristics of the small
(14) "This subchapter" means ARM Title
6, chapter 6, subchapter 50.
History: Sec. 33-1-313 and 33-22-1822, MCA; IMP, Sec. 33-22-1802, 33-22-1803, and 33-22-1813, MCA; NEW, 1994 MAR p. 1990, Eff. 6/10/94; AMD, 1994 MAR p. 2926, Eff. 11/11/94; AMD, 1995 MAR p. 2127, Eff. 10/13/95; AMD, 1998 MAR p. 1698, Eff. 6/26/98.