Missouri Revised Statutes
Chapter 379
Insurance Other Than Life
←379.901
Section 379.930.1
379.932→
August 28, 2015
Small employer health insurance availability act--definitions.
379.930. 1. Sections 379.930 to 379.952 shall be known and may be cited
as the "Small Employer Health Insurance Availability Act".
2. For the purposes of sections 379.930 to 379.952, the following terms
shall mean:
(1) "Actuarial certification", a written statement by a member of the
American Academy of Actuaries or other individual acceptable to the director
that a small employer carrier is in compliance with the provisions of section
379.936, 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;
(2) "Affiliate" or "affiliated", any entity or person who directly or
indirectly through one or more intermediaries, controls or is controlled by,
or is under common control with, a specified entity or person;
(3) "Base premium rate", 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;
(4) "Board" means the board of directors of the program established
pursuant to sections 379.942 and 379.943;
(5) "Bona fide association", an association which:
(a) Has been actively in existence for at least five years;
(b) Has been formed and maintained in good faith for purposes other than
obtaining insurance;
(c) Does not condition membership in the association on any 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 all members regardless of any health status-related factor
relating to such members (or individuals eligible for coverage through a
member);
(e) Does not make health insurance coverage offered through the
association available other than in connection with a member of the
association; and
(f) Meets all other requirements for an association set forth in
subdivision (5) of subsection 1 of section 376.421 that are not inconsistent
with this subdivision;
(6) "Carrier" or "health insurance issuer", any entity that provides
health insurance or health benefits in this state. For the purposes of
sections 379.930 to 379.952, carrier includes an insurance company, health
services corporation, fraternal benefit society, health maintenance
organization, multiple employer welfare arrangement specifically authorized to
operate in the state of Missouri, or any other entity providing a plan of
health insurance or health benefits subject to state insurance regulation;
(7) "Case characteristics", 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 claim experience, health status and duration of coverage since issue
shall not be case characteristics for the purposes of sections 379.930 to
379.952;
(8) "Church plan", the meaning given such term in Section 3(33) of the
Employee Retirement Income Security Act of 1974;
(9) "Class of business", all or a separate grouping of small employers
established pursuant to section 379.934;
(10) "Committee", the health benefit plan committee created pursuant to
section 379.944;
(11) "Control" shall be defined in manner consistent with chapter 382;
(12) "Creditable coverage", with respect to an individual:
(a) Coverage of the individual under any of the following:
a. A group health plan;
b. Health insurance coverage;
c. Part A or Part B of Title XVIII of the Social Security Act;
d. Title XIX of the Social Security Act, other than coverage consisting
solely of benefits under Section 1928 of such act;
e. Chapter 55 of Title 10, United States Code;
f. A medical care program of the Indian Health Service or of a tribal
organization;
g. A state health benefits risk pool;
h. A health plan offered under Chapter 89 of Title 5, United States
Code;
i. A public health plan, as defined in federal regulations authorized by
Section 2701(c)(1)(I) of the Public Health Services Act, as amended by Public
Law 104-191; and
j. A health benefit plan under Section 5(e) of the Peace Corps Act (22
U.S.C. 2504(e));
(b) Creditable coverage shall not include coverage consisting solely of
excepted benefits;
(13) "Dependent", a spouse or an unmarried child under the age of
nineteen years; an unmarried child who is a full-time student under the age of
twenty-three years and who is financially dependent upon the parent; or an
unmarried child of any age who is medically certified as disabled and
dependent upon the parent;
(14) "Director", the director of the department of insurance, financial
institutions and professional registration of this state;
(15) "Eligible employee", an employee who works on a full-time basis and
has a normal work week of thirty or more hours. The term includes a sole
proprietor, a partner of a partnership, and an independent contractor, if the
sole proprietor, partner or independent contractor is included as an employee
under a health benefit plan of a small employer, but does not include an
employee who works on a part-time, temporary or substitute basis. For
purposes of sections 379.930 to 379.952, a person, his spouse and his minor
children shall constitute only one eligible employee when they are employed by
the same small employer;
(16) "Established geographic service area", a geographical area, as
approved by the director and based on the carrier's certificate of authority
to transact insurance in this state, within which the carrier is authorized to
provide coverage;
(17) "Excepted benefits":
(a) Coverage only for accident (including accidental death and
dismemberment) insurance;
(b) Coverage only for disability income insurance;
(c) Coverage issued as a supplement to liability insurance;
(d) Liability insurance, including general liability insurance and
automobile liability insurance;
(e) Workers' compensation or similar insurance;
(f) Automobile medical payment insurance;
(g) Credit-only insurance;
(h) Coverage for on-site medical clinics;
(i) Other similar insurance coverage, as approved by the director, under
which benefits for medical care are secondary or incidental to other insurance
benefits;
(j) If provided under a separate policy, certificate or contract of
insurance, any of the following:
a. Limited scope dental or vision benefits;
b. Benefits for long-term care, nursing home care, home health care,
community-based care, or any combination thereof;
c. Other similar, limited benefits as specified by the director.
(k) If provided under a separate policy, certificate or contract of
insurance, any of the following:
a. Coverage only for a specified disease or illness;
b. Hospital indemnity or other fixed indemnity insurance.
(l) If offered as a separate policy, certificate or contract of
insurance, any of the following:
a. Medicare supplemental coverage (as defined under Section 1882(g)(1)
of the Social Security Act);
b. Coverage supplemental to the coverage provided under Chapter 55 of
Title 10, United States Code;
c. Similar supplemental coverage provided to coverage under a group
health plan;
(18) "Governmental plan", the meaning given such term under Section
3(32) of the Employee Retirement Income Security Act of 1974 or any federal
government plan;
(19) "Group health plan", an employee welfare benefit plan as defined in
Section 3(1) of the Employee Retirement Income Security Act of 1974 and Public
Law 104-191 to the extent that the plan provides medical care, as defined in
this section, and including any item or service paid for as medical care to an
employee or the employee's dependent, as defined under the terms of the plan,
directly or through insurance, reimbursement or otherwise, but not including
excepted benefits;
(20) "Health benefit plan" or "health insurance coverage", 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
services agreement offered by a health insurance issuer, but not including
excepted benefits or a policy that is individually underwritten;
(21) "Health status-related factor", any of the following:
(a) Health status;
(b) Medical condition, including both physical and mental illnesses;
(c) Claims experience;
(d) Receipt of health care;
(e) Medical history;
(f) Genetic information;
(g) Evidence of insurability, including a condition arising out of an
act of domestic violence;
(h) Disability;
(22) "Index rate", for each class of business as to a rating period for
small employers with similar case characteristics, the arithmetic mean of the
applicable base premium rate and the corresponding highest premium rate;
(23) "Late enrollee", an eligible employee or dependent who requests
enrollment in a health benefit plan of a small employer following the initial
enrollment period for which such individual is entitled to enroll under the
terms of the health benefit plan, provided that such initial enrollment period
is a period of at least thirty days. However, an eligible employee or
dependent shall not be considered a late enrollee if:
(a) The individual meets each of the following:
a. The individual was covered under creditable coverage at the time of
the initial enrollment;
b. The individual lost coverage under creditable coverage as a result of
cessation of employer contribution, termination of employment or eligibility,
reduction in the number of hours of employment, the involuntary termination of
the creditable coverage, death of a spouse, dissolution or legal separation;
c. The individual requests enrollment within thirty days after
termination of the creditable coverage;
(b) The individual is employed by an employer that offers multiple
health benefit plans and the individual elects a different plan during an open
enrollment period; or
(c) A court has ordered coverage be provided for a spouse or minor or
dependent child under a covered employee's health benefit plan and request for
enrollment is made within thirty days after issuance of the court order;
(24) "Medical care", an amount paid for:
(a) The diagnosis, care, mitigation, treatment or prevention of disease,
or for the purpose of affecting any structure or function of the body;
(b) Transportation primarily for and essential to medical care referred
to in paragraph (a) of this subdivision; or
(c) Insurance covering medical care referred to in paragraphs (a) and
(b) of this subdivision;
(25) "Network plan", 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;
(26) "New business premium rate", for each class of business as to a
rating period, the lowest premium rate charged or offered, or which 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;
(27) "Plan of operation", the plan of operation of the program
established pursuant to sections 379.942 and 379.943;
(28) "Plan sponsor", the meaning given such term under Section 3(16)(B)
of the Employee Retirement Income Security Act of 1974;
(29) "Premium", all moneys 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;
(30) "Producer", the meaning given such term in section 375.012 and
includes an insurance agent or broker;
(31) "Program", the Missouri small employer health reinsurance program
created pursuant to sections 379.942 and 379.943;
(32) "Rating period", the calendar period for which premium rates
established by a small employer carrier are assumed to be in effect;
(33) "Restricted network provision", any 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 section 354.400, et seq. to provide health care
services to covered individuals;
(34) "Small employer", in connection with a group health plan with
respect to a calendar year and a plan year, any person, firm, corporation,
partnership, association, or political subdivision that is actively engaged in
business that employed an average of at least two but no more than fifty
eligible employees on business days during the preceding calendar year and
that employs at least two employees on the first day of the plan year. All
persons treated as a single employer under subsection (b), (c), (m) or (o) of
Section 414 of the Internal Revenue Code of 1986 shall be treated as one
employer. Subsequent to the issuance of a health plan to a small employer and
for the purpose of determining continued eligibility, the size of a small
employer shall be determined annually. Except as otherwise specifically
provided, the provisions of sections 379.930 to 379.952 that apply to a small
employer shall continue to apply at least until the plan anniversary following
the date the small employer no longer meets the requirements of this
definition. In the case of an employer which was not in existence throughout
the preceding calendar year, the determination of whether the employer is a
small or large employer shall be based on the average number of employees that
it is reasonably expected that the employer will employ on business days in
the current calendar year. Any reference in sections 379.930 to 379.952 to an
employer shall include a reference to any predecessor of such employer;
(35) "Small employer carrier", a carrier that offers health benefit
plans covering eligible employees of one or more small employers in this
state.
3. Other terms used in sections 379.930 to 379.952 not set forth in
subsection 2 of this section shall have the same meaning as defined in section
376.450.
(L. 1992 S.B. 796 §1 , A.L. 2007 H.B. 818)
Effective 1-01-08
1993
1993
379.930. 1. Sections 379.930 to 379.952 shall be known and may be cited
as the "Small Employer Health Insurance Availability Act".
2. For the purposes of sections 379.930 to 379.952:
(1) "Actuarial certification" means a written statement by a member of
the American Academy of Actuaries or other individual acceptable to the
director that a small employer carrier is in compliance with the provisions of
section 379.936, 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;
(2) "Affiliate" or "affiliated" means any entity or person who directly
or indirectly through one or more intermediaries, controls or is controlled
by, or is under common control with, a specified entity or person;
(3) "Agent" means "insurance agent" as that term is defined in section
375.012, RSMo;
(4) "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;
(5) "Basic health benefit plan" means a lower cost health benefit plan
developed pursuant to section 379.944;
(6) "Board" means the board of directors of the program established
pursuant to sections 379.942 and 379.943;
(7) "Broker" means "broker" as that term is defined in section 375.012,
RSMo;
(8) "Carrier" means any entity that provides health insurance or health
benefits in this state. For the purposes of sections 379.930 to 379.952,
carrier includes an insurance company, health services corporation, fraternal
benefit society, health maintenance organization, multiple employer welfare
arrangement specifically authorized to operate in the state of Missouri, or
any other entity providing a plan of health insurance or health benefits
subject to state insurance regulation;
(9) "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 claim experience, health status and duration of coverage since issue
shall not be case characteristics for the purposes of sections 379.930 to
379.952;
(10) "Class of business" means all or a separate grouping of small
employers established pursuant to section 379.934;
(11) "Committee" means the health benefit plan committee created
pursuant to section 379.944;
(12) "Control" shall be defined in manner consistent with chapter 382,
RSMo;
(13) "Dependent" means a spouse or an unmarried child under the age of
nineteen years; an unmarried child who is a full-time student under the age of
twenty-three years and who is financially dependent upon the parent; or an
unmarried child of any age who is medically certified as disabled and
dependent upon the parent;
(14) "Director" means the director of the department of insurance of
this state;
(15) "Eligible employee" means an employee who works on a full-time
basis and has a normal work week of thirty or more hours. The term includes a
sole proprietor, a partner of a partnership, and an independent contractor, if
the sole proprietor, partner or independent contractor is included as an
employee under a health benefit plan of a small employer, but does not include
an employee who works on a part-time, temporary or substitute basis. For
purposes of sections 379.930 to 379.952, a person, his spouse and his minor
children shall constitute only one eligible employee when they are employed by
the same small employer;
(16) "Established geographic service area" means a geographical area, as
approved by the director and based on the carrier's certificate of authority
to transact insurance in this state, within which the carrier is authorized to
provide coverage;
(17) "Health benefit plan" means any hospital or medical policy or
certificate, health services corporation contract, or health maintenance
organization subscriber contract. Health benefit plan does not include a
policy of individual accident and sickness insurance or hospital supplemental
policies having a fixed daily benefit, or accident-only, specified
disease-only, credit, dental, vision, Medicare supplement, long-term care, or
disability income insurance, or coverage issued as a supplement to liability
insurance, worker's compensation or similar insurance, or automobile medical
payment insurance;
(18) "Index rate" means, for each class of business as to a rating
period for small employers with similar case characteristics, the arithmetic
mean of the applicable base premium rate and the corresponding highest premium
rate;
(19) "Late enrollee" means an eligible employee or dependent who
requests enrollment in a health benefit plan of a small employer following the
initial enrollment period for which such individual is entitled to enroll
under the terms of the health benefit plan, provided that such initial
enrollment period is a period of at least thirty days. However, an eligible
employee or dependent shall not be considered a late enrollee if:
(a) The individual meets each of the following:
a. The individual was covered under qualifying previous coverage at the
time of the initial enrollment;
b. The individual lost coverage under qualifying previous coverage as a
result of termination of employment or eligibility, the involuntary
termination of the qualifying previous coverage, death of a spouse or divorce;
c. The individual requests enrollment within thirty days after
termination of the qualifying previous coverage;
(b) The individual is employed by an employer that offers multiple
health benefit plans and the individual elects a different plan during an open
enrollment period; or
(c) A court has ordered coverage be provided for a spouse or minor or
dependent child under a covered employee's health benefit plan and request for
enrollment is made within thirty days after issuance of the court order;
(20) "New business premium rate" means, for each class of business as to
a rating period, the lowest premium rate charged or offered, or which 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;
(21) "Plan of operation" means the plan of operation of the program
established pursuant to sections 379.942 and 379.943;
(22) "Premium" means all moneys 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;
(23) "Producer" includes an insurance agent or broker;
(24) "Program" means the Missouri small employer health reinsurance
program created pursuant to sections 379.942 and 379.943;
(25) "Qualifying previous coverage" and "qualifying existing coverage"
mean benefits or coverage provided under:
(a) Medicare or Medicaid;
(b) An employer-based health insurance or health benefit arrangement
that provides benefits similar to or exceeding benefits provided under the
basic health benefit plan; or
(c) An individual health insurance policy (including coverage issued by
a health maintenance organization, health services corporation or a fraternal
benefit society) that provides benefits similar to or exceeding the benefits
provided under the basic health benefit plan, provided that such policy has
been in effect for a period of at least one year;
(26) "Rating period" means the calendar period for which premium rates
established by a small employer carrier are assumed to be in effect;
(27) "Restricted network provision" means any 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 section 354.400, RSMo, et seq. to
provide health care services to covered individuals;
(28) "Small employer" means any person, firm, corporation, partnership
or association that is actively engaged in business that, on at least fifty
percent of its working days during the preceding calendar quarter, employed
not less than three nor more than twenty-five eligible employees, the majority
of whom were employed within this state. In determining the number of
eligible employees, companies that are affiliated companies, or that are
eligible to file a combined tax return for purposes of state taxation, shall
be considered one employer;
(29) "Small employer carrier" means a carrier that offers health benefit
plans covering eligible employees of one or more small employers in this
state;
(30) "Standard health benefit plan" means a health benefit plan
developed pursuant to section 379.944.
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