6.6.5001    DEFINITIONS

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 maintained; 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 Code.

(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

guarantees 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 employer group.

(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.