6.6.504    DEFINITIONS

For purposes of this subchapter, the terms defined in 33-22-903, MCA, will have the same meaning in this subchapter unless clearly designated otherwise. The following definitions are in addition to those in 33-22-903, MCA.

(1) "Bankruptcy" means when a Medicare advantage organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in the state.

(2) "Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than 63 days. The 63-day period shall be counted as described in 33-22-141 and 33-22-142, MCA.

(3) "Creditable coverage":

(a) means, with respect to an individual, coverage of the individual provided under any of the following:

(i) a group health plan;

(ii) health insurance coverage;

(iii) Part A or Part B of Title XVIII of the Social Security Act (Medicare);

(iv) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;

(v) chapter 55 of Title 10 USC (CHAMPUS);

(vi) a medical care program of the Indian health service or of a tribal organization;

(vii) a state health benefits risk pool;

(viii) a health plan offered under chapter 89 of Title 5 USC (Federal Employees Health Benefits Program);

(ix) a public health plan as defined in federal regulation; and

(x) a health benefit plan under section 5(e) of the Peace Corps Act (22 USC 2504(e)).

(b) does not include:

(i) one or more, or any combination of, the following:

(A) coverage only for accident or disability income insurance, or any combination;

(B) coverage issued as a supplement to liability insurance;

(C) liability insurance, including general liability insurance and automobile liability insurance;

(D) workers' compensation or similar insurance;

(E) automobile medical payment insurance;

(F) credit-only insurance;

(G) coverage for on-site medical clinics; and

(H) other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

(ii) the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

(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 of; and

(C) such other similar, limited benefits as are specified in federal regulations.

(iii) the following benefits if offered as independent, noncoordinated benefits:

(A) coverage only for a specified disease or illness; and

(B) hospital indemnity or other fixed indemnity insurance.

(iv) the following if it is offered as a separate policy, certificate, or contract of insurance:

(A) Medicare supplement health insurance 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; and

(C) similar supplemental coverage provided to coverage under a group health plan.

(4) "Employee welfare benefit plan" means a plan, fund, or program of employee benefits as defined in 29 USC section 1002 (Employee Retirement Income Security Act).

(5) "Insolvency" means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile.

(6) "MACRA" means the Medicare Access and CHIP Reauthorization Act of 2015.

(7) "Medicare advantage plan" means a plan of coverage for health benefits under Medicare Part C as defined in 42 USC 1395w-28(b)(1), and includes:

(a) coordinated care plans which provide health care services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;

(b) medical savings account plans coupled with a contribution into a Medicare advantage plan medical savings account; and

(c) Medicare advantage private fee-for-service plans.

(8) "Medicare supplement policy" has the meaning provided for in 33-22-903, MCA, except that "Medicare supplement policy" does not include Medicare advantage plans established under Medicare Part C, outpatient prescription drug plans established under Medicare Part D, or any health care prepayment plan (HCPP) that provides benefits pursuant to an agreement under section 1833(a)(1)(A) of the Social Security Act.

(9) ″MMA″ means the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

(10) "Pre-standardized Medicare supplement benefit plan," "pre-standardized benefit plan," or "pre-standardized plan" means a group or individual policy of Medicare supplement insurance issued prior to July 16, 1993.

(11) "Secretary" means the secretary of the United States Department of Health and Human Services.

(12) "1990 standardized Medicare supplement benefit plan," "1990 standardized benefit plan," or "1990 plan" means a group or individual policy of Medicare supplement insurance issued on or after July 16, 1993, and with an effective date for coverage prior to June 1, 2010, and includes Medicare supplement insurance policies and certificates renewed on or after that date which are not replaced by the issuer at the request of the insured.

(13) "2010 standardized Medicare supplement benefit plan," "2010 standardized benefit plan," or "2010 plan" means a group or individual policy of Medicare supplement insurance issued with an effective date for coverage on or after June 1, 2010.


History: 33-1-313, 33-22-904, MCA; IMP, 33-22-902, 33-22-903, 33-22-923, MCA; NEW, 1981 MAR p. 1474, Eff. 2/1/82; AMD, 1998 MAR p. 3269, Eff. 12/18/98; AMD, 2004 MAR p. 313, Eff. 2/13/04; AMD, 2005 MAR p. 1672, Eff. 9/9/05; AMD, 2009 MAR p. 1107, Eff. 7/17/09; AMD, 2018 MAR p. 969, Eff. 3/17/18.