Small employer health insurance availability act--definitions.
379.930. 1. Sections 379.930 to 379.952 shall be known and may becited as the "Small Employer Health Insurance Availability Act".
2. For the purposes of sections 379.930 to 379.952, the followingterms shall mean:
(1) "Actuarial certification", a written statement by a member of theAmerican Academy of Actuaries or other individual acceptable to thedirector that a small employer carrier is in compliance with the provisionsof section 379.936, based upon the person's examination, including a reviewof the appropriate records and of the actuarial assumptions and methodsused by the small employer carrier in establishing premium rates forapplicable health benefit plans;
(2) "Affiliate" or "affiliated", any entity or person who directly orindirectly through one or more intermediaries, controls or is controlledby, or is under common control with, a specified entity or person;
(3) "Base premium rate", for each class of business as to a ratingperiod, the lowest premium rate charged or that could have been chargedunder the rating system for that class of business, by the small employercarrier to small employers with similar case characteristics for healthbenefit plans with the same or similar coverage;
(4) "Board" means the board of directors of the program establishedpursuant 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 otherthan obtaining insurance;
(c) Does not condition membership in the association on any healthstatus-related factor relating to an individual (including an employee ofan employer or a dependent of an employee);
(d) Makes health insurance coverage offered through the associationavailable to all members regardless of any health status-related factorrelating to such members (or individuals eligible for coverage through amember);
(e) Does not make health insurance coverage offered through theassociation available other than in connection with a member of theassociation; and
(f) Meets all other requirements for an association set forth insubdivision (5) of subsection 1 of section 376.421, RSMo, that are notinconsistent with this subdivision;
(6) "Carrier" or "health insurance issuer", any entity that provideshealth insurance or health benefits in this state. For the purposes ofsections 379.930 to 379.952, carrier includes an insurance company, healthservices corporation, fraternal benefit society, health maintenanceorganization, multiple employer welfare arrangement specifically authorizedto operate in the state of Missouri, or any other entity providing a planof health insurance or health benefits subject to state insuranceregulation;
(7) "Case characteristics", demographic or other objectivecharacteristics of a small employer that are considered by the smallemployer carrier in the determination of premium rates for the smallemployer, provided that claim experience, health status and duration ofcoverage since issue shall not be case characteristics for the purposes ofsections 379.930 to 379.952;
(8) "Church plan", the meaning given such term in Section 3(33) ofthe Employee Retirement Income Security Act of 1974;
(9) "Class of business", all or a separate grouping of smallemployers established pursuant to section 379.934;
(10) "Committee", the health benefit plan committee created pursuantto section 379.944;
(11) "Control" shall be defined in manner consistent with chapter382, RSMo;
(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 coverageconsisting 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 tribalorganization;
g. A state health benefits risk pool;
h. A health plan offered under Chapter 89 of Title 5, United StatesCode;
i. A public health plan, as defined in federal regulations authorizedby Section 2701(c)(1)(I) of the Public Health Services Act, as amended byPublic 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 solelyof excepted benefits;
(13) "Dependent", a spouse or an unmarried child under the age ofnineteen years; an unmarried child who is a full-time student under the ageof twenty-three years and who is financially dependent upon the parent; oran unmarried child of any age who is medically certified as disabled anddependent 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 basisand has a normal work week of thirty or more hours. The term includes asole proprietor, a partner of a partnership, and an independent contractor,if the sole proprietor, partner or independent contractor is included as anemployee under a health benefit plan of a small employer, but does notinclude an employee who works on a part-time, temporary or substitutebasis. For purposes of sections 379.930 to 379.952, a person, his spouseand his minor children shall constitute only one eligible employee whenthey are employed by the same small employer;
(16) "Established geographic service area", a geographical area, asapproved by the director and based on the carrier's certificate ofauthority to transact insurance in this state, within which the carrier isauthorized to provide coverage;
(17) "Excepted benefits":
(a) Coverage only for accident (including accidental death anddismemberment) insurance;
(b) Coverage only for disability income insurance;
(c) Coverage issued as a supplement to liability insurance;
(d) Liability insurance, including general liability insurance andautomobile 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 otherinsurance benefits;
(j) If provided under a separate policy, certificate or contract ofinsurance, 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 ofinsurance, 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 ofinsurance, any of the following:
a. Medicare supplemental coverage (as defined under Section1882(g)(1) of the Social Security Act);
b. Coverage supplemental to the coverage provided under Chapter 55 ofTitle 10, United States Code;
c. Similar supplemental coverage provided to coverage under a grouphealth plan;
(18) "Governmental plan", the meaning given such term under Section3(32) of the Employee Retirement Income Security Act of 1974 or any federalgovernment plan;
(19) "Group health plan", an employee welfare benefit plan as definedin Section 3(1) of the Employee Retirement Income Security Act of 1974 andPublic Law 104-191 to the extent that the plan provides medical care, asdefined in this section, and including any item or service paid for asmedical care to an employee or the employee's dependent, as defined underthe terms of the plan, directly or through insurance, reimbursement orotherwise, but not including excepted benefits;
(20) "Health benefit plan" or "health insurance coverage", benefitsconsisting of medical care, including items and services paid for asmedical care, that are provided directly, through insurance, reimbursement,or otherwise, under a policy, certificate, membership contract, or healthservices agreement offered by a health insurance issuer, but not includingexcepted 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 anact of domestic violence;
(h) Disability;
(22) "Index rate", for each class of business as to a rating periodfor small employers with similar case characteristics, the arithmetic meanof the applicable base premium rate and the corresponding highest premiumrate;
(23) "Late enrollee", an eligible employee or dependent who requestsenrollment in a health benefit plan of a small employer following theinitial enrollment period for which such individual is entitled to enrollunder the terms of the health benefit plan, provided that such initialenrollment period is a period of at least thirty days. However, aneligible 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 timeof the initial enrollment;
b. The individual lost coverage under creditable coverage as a resultof cessation of employer contribution, termination of employment oreligibility, reduction in the number of hours of employment, theinvoluntary termination of the creditable coverage, death of a spouse,dissolution or legal separation;
c. The individual requests enrollment within thirty days aftertermination of the creditable coverage;
(b) The individual is employed by an employer that offers multiplehealth benefit plans and the individual elects a different plan during anopen enrollment period; or
(c) A court has ordered coverage be provided for a spouse or minor ordependent child under a covered employee's health benefit plan and requestfor enrollment is made within thirty days after issuance of the courtorder;
(24) "Medical care", an amount paid for:
(a) The diagnosis, care, mitigation, treatment or prevention ofdisease, or for the purpose of affecting any structure or function of thebody;
(b) Transportation primarily for and essential to medical carereferred 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 healthinsurance issuer under which the financing and delivery of medical care,including items and services paid for as medical care, are provided, inwhole or in part, through a defined set of providers under contract withthe issuer;
(26) "New business premium rate", for each class of business as to arating period, the lowest premium rate charged or offered, or which couldhave been charged or offered, by the small employer carrier to smallemployers with similar case characteristics for newly issued health benefitplans with the same or similar coverage;
(27) "Plan of operation", the plan of operation of the programestablished pursuant to sections 379.942 and 379.943;
(28) "Plan sponsor", the meaning given such term under Section3(16)(B) of the Employee Retirement Income Security Act of 1974;
(29) "Premium", all moneys paid by a small employer and eligibleemployees as a condition of receiving coverage from a small employercarrier, including any fees or other contributions associated with thehealth benefit plan;
(30) "Producer", the meaning given such term in section 375.012,RSMo, and includes an insurance agent or broker;
(31) "Program", the Missouri small employer health reinsuranceprogram created pursuant to sections 379.942 and 379.943;
(32) "Rating period", the calendar period for which premium ratesestablished by a small employer carrier are assumed to be in effect;
(33) "Restricted network provision", any provision of a healthbenefit plan that conditions the payment of benefits, in whole or in part,on the use of health care providers that have entered into a contractualarrangement with the carrier pursuant to section 354.400, RSMo, et seq. toprovide health care services to covered individuals;
(34) "Small employer", in connection with a group health plan withrespect to a calendar year and a plan year, any person, firm, corporation,partnership, association, or political subdivision that is actively engagedin business that employed an average of at least two but no more than fiftyeligible employees on business days during the preceding calendar year andthat employs at least two employees on the first day of the plan year. Allpersons 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 oneemployer. Subsequent to the issuance of a health plan to a small employerand for the purpose of determining continued eligibility, the size of asmall employer shall be determined annually. Except as otherwisespecifically provided, the provisions of sections 379.930 to 379.952 thatapply to a small employer shall continue to apply at least until the plananniversary following the date the small employer no longer meets therequirements of this definition. In the case of an employer which was notin existence throughout the preceding calendar year, the determination ofwhether the employer is a small or large employer shall be based on theaverage number of employees that it is reasonably expected that theemployer will employ on business days in the current calendar year. Anyreference in sections 379.930 to 379.952 to an employer shall include areference to any predecessor of such employer;
(35) "Small employer carrier", a carrier that offers health benefitplans covering eligible employees of one or more small employers in thisstate.
3. Other terms used in sections 379.930 to 379.952 not set forth insubsection 2 of this section shall have the same meaning as defined insection 376.450, RSMo.
Small employer health insurance availability act--definitions.
379.930. 1. Sections 379.930 to 379.952 shall be known and may becited as the "Small Employer Health Insurance Availability Act".
2. For the purposes of sections 379.930 to 379.952, the followingterms shall mean:
(1) "Actuarial certification", a written statement by a member of theAmerican Academy of Actuaries or other individual acceptable to thedirector that a small employer carrier is in compliance with the provisionsof section 379.936, based upon the person's examination, including a reviewof the appropriate records and of the actuarial assumptions and methodsused by the small employer carrier in establishing premium rates forapplicable health benefit plans;
(2) "Affiliate" or "affiliated", any entity or person who directly orindirectly through one or more intermediaries, controls or is controlledby, or is under common control with, a specified entity or person;
(3) "Base premium rate", for each class of business as to a ratingperiod, the lowest premium rate charged or that could have been chargedunder the rating system for that class of business, by the small employercarrier to small employers with similar case characteristics for healthbenefit plans with the same or similar coverage;
(4) "Board" means the board of directors of the program establishedpursuant 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 otherthan obtaining insurance;
(c) Does not condition membership in the association on any healthstatus-related factor relating to an individual (including an employee ofan employer or a dependent of an employee);
(d) Makes health insurance coverage offered through the associationavailable to all members regardless of any health status-related factorrelating to such members (or individuals eligible for coverage through amember);
(e) Does not make health insurance coverage offered through theassociation available other than in connection with a member of theassociation; and
(f) Meets all other requirements for an association set forth insubdivision (5) of subsection 1 of section 376.421, RSMo, that are notinconsistent with this subdivision;
(6) "Carrier" or "health insurance issuer", any entity that provideshealth insurance or health benefits in this state. For the purposes ofsections 379.930 to 379.952, carrier includes an insurance company, healthservices corporation, fraternal benefit society, health maintenanceorganization, multiple employer welfare arrangement specifically authorizedto operate in the state of Missouri, or any other entity providing a planof health insurance or health benefits subject to state insuranceregulation;
(7) "Case characteristics", demographic or other objectivecharacteristics of a small employer that are considered by the smallemployer carrier in the determination of premium rates for the smallemployer, provided that claim experience, health status and duration ofcoverage since issue shall not be case characteristics for the purposes ofsections 379.930 to 379.952;
(8) "Church plan", the meaning given such term in Section 3(33) ofthe Employee Retirement Income Security Act of 1974;
(9) "Class of business", all or a separate grouping of smallemployers established pursuant to section 379.934;
(10) "Committee", the health benefit plan committee created pursuantto section 379.944;
(11) "Control" shall be defined in manner consistent with chapter382, RSMo;
(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 coverageconsisting 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 tribalorganization;
g. A state health benefits risk pool;
h. A health plan offered under Chapter 89 of Title 5, United StatesCode;
i. A public health plan, as defined in federal regulations authorizedby Section 2701(c)(1)(I) of the Public Health Services Act, as amended byPublic 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 solelyof excepted benefits;
(13) "Dependent", a spouse or an unmarried child under the age ofnineteen years; an unmarried child who is a full-time student under the ageof twenty-three years and who is financially dependent upon the parent; oran unmarried child of any age who is medically certified as disabled anddependent 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 basisand has a normal work week of thirty or more hours. The term includes asole proprietor, a partner of a partnership, and an independent contractor,if the sole proprietor, partner or independent contractor is included as anemployee under a health benefit plan of a small employer, but does notinclude an employee who works on a part-time, temporary or substitutebasis. For purposes of sections 379.930 to 379.952, a person, his spouseand his minor children shall constitute only one eligible employee whenthey are employed by the same small employer;
(16) "Established geographic service area", a geographical area, asapproved by the director and based on the carrier's certificate ofauthority to transact insurance in this state, within which the carrier isauthorized to provide coverage;
(17) "Excepted benefits":
(a) Coverage only for accident (including accidental death anddismemberment) insurance;
(b) Coverage only for disability income insurance;
(c) Coverage issued as a supplement to liability insurance;
(d) Liability insurance, including general liability insurance andautomobile 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 otherinsurance benefits;
(j) If provided under a separate policy, certificate or contract ofinsurance, 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 ofinsurance, 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 ofinsurance, any of the following:
a. Medicare supplemental coverage (as defined under Section1882(g)(1) of the Social Security Act);
b. Coverage supplemental to the coverage provided under Chapter 55 ofTitle 10, United States Code;
c. Similar supplemental coverage provided to coverage under a grouphealth plan;
(18) "Governmental plan", the meaning given such term under Section3(32) of the Employee Retirement Income Security Act of 1974 or any federalgovernment plan;
(19) "Group health plan", an employee welfare benefit plan as definedin Section 3(1) of the Employee Retirement Income Security Act of 1974 andPublic Law 104-191 to the extent that the plan provides medical care, asdefined in this section, and including any item or service paid for asmedical care to an employee or the employee's dependent, as defined underthe terms of the plan, directly or through insurance, reimbursement orotherwise, but not including excepted benefits;
(20) "Health benefit plan" or "health insurance coverage", benefitsconsisting of medical care, including items and services paid for asmedical care, that are provided directly, through insurance, reimbursement,or otherwise, under a policy, certificate, membership contract, or healthservices agreement offered by a health insurance issuer, but not includingexcepted 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 anact of domestic violence;
(h) Disability;
(22) "Index rate", for each class of business as to a rating periodfor small employers with similar case characteristics, the arithmetic meanof the applicable base premium rate and the corresponding highest premiumrate;
(23) "Late enrollee", an eligible employee or dependent who requestsenrollment in a health benefit plan of a small employer following theinitial enrollment period for which such individual is entitled to enrollunder the terms of the health benefit plan, provided that such initialenrollment period is a period of at least thirty days. However, aneligible 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 timeof the initial enrollment;
b. The individual lost coverage under creditable coverage as a resultof cessation of employer contribution, termination of employment oreligibility, reduction in the number of hours of employment, theinvoluntary termination of the creditable coverage, death of a spouse,dissolution or legal separation;
c. The individual requests enrollment within thirty days aftertermination of the creditable coverage;
(b) The individual is employed by an employer that offers multiplehealth benefit plans and the individual elects a different plan during anopen enrollment period; or
(c) A court has ordered coverage be provided for a spouse or minor ordependent child under a covered employee's health benefit plan and requestfor enrollment is made within thirty days after issuance of the courtorder;
(24) "Medical care", an amount paid for:
(a) The diagnosis, care, mitigation, treatment or prevention ofdisease, or for the purpose of affecting any structure or function of thebody;
(b) Transportation primarily for and essential to medical carereferred 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 healthinsurance issuer under which the financing and delivery of medical care,including items and services paid for as medical care, are provided, inwhole or in part, through a defined set of providers under contract withthe issuer;
(26) "New business premium rate", for each class of business as to arating period, the lowest premium rate charged or offered, or which couldhave been charged or offered, by the small employer carrier to smallemployers with similar case characteristics for newly issued health benefitplans with the same or similar coverage;
(27) "Plan of operation", the plan of operation of the programestablished pursuant to sections 379.942 and 379.943;
(28) "Plan sponsor", the meaning given such term under Section3(16)(B) of the Employee Retirement Income Security Act of 1974;
(29) "Premium", all moneys paid by a small employer and eligibleemployees as a condition of receiving coverage from a small employercarrier, including any fees or other contributions associated with thehealth benefit plan;
(30) "Producer", the meaning given such term in section 375.012,RSMo, and includes an insurance agent or broker;
(31) "Program", the Missouri small employer health reinsuranceprogram created pursuant to sections 379.942 and 379.943;
(32) "Rating period", the calendar period for which premium ratesestablished by a small employer carrier are assumed to be in effect;
(33) "Restricted network provision", any provision of a healthbenefit plan that conditions the payment of benefits, in whole or in part,on the use of health care providers that have entered into a contractualarrangement with the carrier pursuant to section 354.400, RSMo, et seq. toprovide health care services to covered individuals;
(34) "Small employer", in connection with a group health plan withrespect to a calendar year and a plan year, any person, firm, corporation,partnership, association, or political subdivision that is actively engagedin business that employed an average of at least two but no more than fiftyeligible employees on business days during the preceding calendar year andthat employs at least two employees on the first day of the plan year. Allpersons 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 oneemployer. Subsequent to the issuance of a health plan to a small employerand for the purpose of determining continued eligibility, the size of asmall employer shall be determined annually. Except as otherwisespecifically provided, the provisions of sections 379.930 to 379.952 thatapply to a small employer shall continue to apply at least until the plananniversary following the date the small employer no longer meets therequirements of this definition. In the case of an employer which was notin existence throughout the preceding calendar year, the determination ofwhether the employer is a small or large employer shall be based on theaverage number of employees that it is reasonably expected that theemployer will employ on business days in the current calendar year. Anyreference in sections 379.930 to 379.952 to an employer shall include areference to any predecessor of such employer;
(35) "Small employer carrier", a carrier that offers health benefitplans covering eligible employees of one or more small employers in thisstate.
3. Other terms used in sections 379.930 to 379.952 not set forth insubsection 2 of this section shall have the same meaning as defined insection 376.450, RSMo.
Small employer health insurance availability act--definitions.
379.930. 1. Sections 379.930 to 379.952 shall be known and may becited as the "Small Employer Health Insurance Availability Act".
2. For the purposes of sections 379.930 to 379.952, the followingterms shall mean:
(1) "Actuarial certification", a written statement by a member of theAmerican Academy of Actuaries or other individual acceptable to thedirector that a small employer carrier is in compliance with the provisionsof section 379.936, based upon the person's examination, including a reviewof the appropriate records and of the actuarial assumptions and methodsused by the small employer carrier in establishing premium rates forapplicable health benefit plans;
(2) "Affiliate" or "affiliated", any entity or person who directly orindirectly through one or more intermediaries, controls or is controlledby, or is under common control with, a specified entity or person;
(3) "Base premium rate", for each class of business as to a ratingperiod, the lowest premium rate charged or that could have been chargedunder the rating system for that class of business, by the small employercarrier to small employers with similar case characteristics for healthbenefit plans with the same or similar coverage;
(4) "Board" means the board of directors of the program establishedpursuant 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 otherthan obtaining insurance;
(c) Does not condition membership in the association on any healthstatus-related factor relating to an individual (including an employee ofan employer or a dependent of an employee);
(d) Makes health insurance coverage offered through the associationavailable to all members regardless of any health status-related factorrelating to such members (or individuals eligible for coverage through amember);
(e) Does not make health insurance coverage offered through theassociation available other than in connection with a member of theassociation; and
(f) Meets all other requirements for an association set forth insubdivision (5) of subsection 1 of section 376.421, RSMo, that are notinconsistent with this subdivision;
(6) "Carrier" or "health insurance issuer", any entity that provideshealth insurance or health benefits in this state. For the purposes ofsections 379.930 to 379.952, carrier includes an insurance company, healthservices corporation, fraternal benefit society, health maintenanceorganization, multiple employer welfare arrangement specifically authorizedto operate in the state of Missouri, or any other entity providing a planof health insurance or health benefits subject to state insuranceregulation;
(7) "Case characteristics", demographic or other objectivecharacteristics of a small employer that are considered by the smallemployer carrier in the determination of premium rates for the smallemployer, provided that claim experience, health status and duration ofcoverage since issue shall not be case characteristics for the purposes ofsections 379.930 to 379.952;
(8) "Church plan", the meaning given such term in Section 3(33) ofthe Employee Retirement Income Security Act of 1974;
(9) "Class of business", all or a separate grouping of smallemployers established pursuant to section 379.934;
(10) "Committee", the health benefit plan committee created pursuantto section 379.944;
(11) "Control" shall be defined in manner consistent with chapter382, RSMo;
(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 coverageconsisting 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 tribalorganization;
g. A state health benefits risk pool;
h. A health plan offered under Chapter 89 of Title 5, United StatesCode;
i. A public health plan, as defined in federal regulations authorizedby Section 2701(c)(1)(I) of the Public Health Services Act, as amended byPublic 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 solelyof excepted benefits;
(13) "Dependent", a spouse or an unmarried child under the age ofnineteen years; an unmarried child who is a full-time student under the ageof twenty-three years and who is financially dependent upon the parent; oran unmarried child of any age who is medically certified as disabled anddependent 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 basisand has a normal work week of thirty or more hours. The term includes asole proprietor, a partner of a partnership, and an independent contractor,if the sole proprietor, partner or independent contractor is included as anemployee under a health benefit plan of a small employer, but does notinclude an employee who works on a part-time, temporary or substitutebasis. For purposes of sections 379.930 to 379.952, a person, his spouseand his minor children shall constitute only one eligible employee whenthey are employed by the same small employer;
(16) "Established geographic service area", a geographical area, asapproved by the director and based on the carrier's certificate ofauthority to transact insurance in this state, within which the carrier isauthorized to provide coverage;
(17) "Excepted benefits":
(a) Coverage only for accident (including accidental death anddismemberment) insurance;
(b) Coverage only for disability income insurance;
(c) Coverage issued as a supplement to liability insurance;
(d) Liability insurance, including general liability insurance andautomobile 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 otherinsurance benefits;
(j) If provided under a separate policy, certificate or contract ofinsurance, 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 ofinsurance, 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 ofinsurance, any of the following:
a. Medicare supplemental coverage (as defined under Section1882(g)(1) of the Social Security Act);
b. Coverage supplemental to the coverage provided under Chapter 55 ofTitle 10, United States Code;
c. Similar supplemental coverage provided to coverage under a grouphealth plan;
(18) "Governmental plan", the meaning given such term under Section3(32) of the Employee Retirement Income Security Act of 1974 or any federalgovernment plan;
(19) "Group health plan", an employee welfare benefit plan as definedin Section 3(1) of the Employee Retirement Income Security Act of 1974 andPublic Law 104-191 to the extent that the plan provides medical care, asdefined in this section, and including any item or service paid for asmedical care to an employee or the employee's dependent, as defined underthe terms of the plan, directly or through insurance, reimbursement orotherwise, but not including excepted benefits;
(20) "Health benefit plan" or "health insurance coverage", benefitsconsisting of medical care, including items and services paid for asmedical care, that are provided directly, through insurance, reimbursement,or otherwise, under a policy, certificate, membership contract, or healthservices agreement offered by a health insurance issuer, but not includingexcepted 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 anact of domestic violence;
(h) Disability;
(22) "Index rate", for each class of business as to a rating periodfor small employers with similar case characteristics, the arithmetic meanof the applicable base premium rate and the corresponding highest premiumrate;
(23) "Late enrollee", an eligible employee or dependent who requestsenrollment in a health benefit plan of a small employer following theinitial enrollment period for which such individual is entitled to enrollunder the terms of the health benefit plan, provided that such initialenrollment period is a period of at least thirty days. However, aneligible 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 timeof the initial enrollment;
b. The individual lost coverage under creditable coverage as a resultof cessation of employer contribution, termination of employment oreligibility, reduction in the number of hours of employment, theinvoluntary termination of the creditable coverage, death of a spouse,dissolution or legal separation;
c. The individual requests enrollment within thirty days aftertermination of the creditable coverage;
(b) The individual is employed by an employer that offers multiplehealth benefit plans and the individual elects a different plan during anopen enrollment period; or
(c) A court has ordered coverage be provided for a spouse or minor ordependent child under a covered employee's health benefit plan and requestfor enrollment is made within thirty days after issuance of the courtorder;
(24) "Medical care", an amount paid for:
(a) The diagnosis, care, mitigation, treatment or prevention ofdisease, or for the purpose of affecting any structure or function of thebody;
(b) Transportation primarily for and essential to medical carereferred 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 healthinsurance issuer under which the financing and delivery of medical care,including items and services paid for as medical care, are provided, inwhole or in part, through a defined set of providers under contract withthe issuer;
(26) "New business premium rate", for each class of business as to arating period, the lowest premium rate charged or offered, or which couldhave been charged or offered, by the small employer carrier to smallemployers with similar case characteristics for newly issued health benefitplans with the same or similar coverage;
(27) "Plan of operation", the plan of operation of the programestablished pursuant to sections 379.942 and 379.943;
(28) "Plan sponsor", the meaning given such term under Section3(16)(B) of the Employee Retirement Income Security Act of 1974;
(29) "Premium", all moneys paid by a small employer and eligibleemployees as a condition of receiving coverage from a small employercarrier, including any fees or other contributions associated with thehealth benefit plan;
(30) "Producer", the meaning given such term in section 375.012,RSMo, and includes an insurance agent or broker;
(31) "Program", the Missouri small employer health reinsuranceprogram created pursuant to sections 379.942 and 379.943;
(32) "Rating period", the calendar period for which premium ratesestablished by a small employer carrier are assumed to be in effect;
(33) "Restricted network provision", any provision of a healthbenefit plan that conditions the payment of benefits, in whole or in part,on the use of health care providers that have entered into a contractualarrangement with the carrier pursuant to section 354.400, RSMo, et seq. toprovide health care services to covered individuals;
(34) "Small employer", in connection with a group health plan withrespect to a calendar year and a plan year, any person, firm, corporation,partnership, association, or political subdivision that is actively engagedin business that employed an average of at least two but no more than fiftyeligible employees on business days during the preceding calendar year andthat employs at least two employees on the first day of the plan year. Allpersons 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 oneemployer. Subsequent to the issuance of a health plan to a small employerand for the purpose of determining continued eligibility, the size of asmall employer shall be determined annually. Except as otherwisespecifically provided, the provisions of sections 379.930 to 379.952 thatapply to a small employer shall continue to apply at least until the plananniversary following the date the small employer no longer meets therequirements of this definition. In the case of an employer which was notin existence throughout the preceding calendar year, the determination ofwhether the employer is a small or large employer shall be based on theaverage number of employees that it is reasonably expected that theemployer will employ on business days in the current calendar year. Anyreference in sections 379.930 to 379.952 to an employer shall include areference to any predecessor of such employer;
(35) "Small employer carrier", a carrier that offers health benefitplans covering eligible employees of one or more small employers in thisstate.
3. Other terms used in sections 379.930 to 379.952 not set forth insubsection 2 of this section shall have the same meaning as defined insection 376.450, RSMo.
