Section: 379.0930 Small employer health insurance availability act--definitions. RSMO 379.930


Published: 2015

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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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