reglab/statecodes huggingface dataset:
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1102. Purpose

33-22-1102. Purpose.
The purpose of this part is to:
(1) promote the public interest;
(2) promote the availability of long-term care insurance;
(3) protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices;
(4) establish standards for long-term care insurance;
(5) facilitate public understanding and comparison of long-term care insurance policies; and
(6) facilitate flexibility and innovation in the development of long-term care insurance coverage.
History: En. Sec. 2, Ch. 355, L. 1989.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1103. Compliance required

33-22-1103. Compliance required.
A policy may not be advertised, marketed, or offered in this state as long-term care insurance or nursing home insurance unless it complies with this part.
History: En. Sec. 13, Ch. 355, L. 1989.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1104. Scope

33-22-1104. Scope.
This part is not intended to supersede the obligations of entities subject to this part to comply with the substance of other applicable insurance laws insofar as they do not conflict with this part. However, laws and regulations designed and intended to apply to medicare supplement insurance policies may not be applied to long-term care insurance.
History: En. Sec. 3, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1108. Preexisting condition -- definition

33-22-1108. Preexisting condition -- definition.
(1) A long-term care insurance policy or certificate other than a policy or certificate issued to a group, as specified in 33-22-1107(5)(a)(ii), (5)(a)(iii), or (5)(a)(iv), may not use a definition of preexisting condition that is more restrictive than the definition in 33-22-1107.
(2) A long-term care insurance policy or certificate may not exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within 6 months following the effective date of coverage of an insured person.
(3) If a long-term care insurance policy or certificate replaces, with similar benefits, another long-term care insurance policy or certificate, the insurer issuing the replacing long-term care insurance policy or certificate shall waive any time periods applicable to preexisting conditions or probationary periods in the replacing long-term care insurance policy or certificate to the extent that similar time periods have been satisfied under the original policy.
(4) The commissioner may extend the limitation periods in subsections (1) and (2) as to specific age group categories in specific policy forms if extending the limitation periods is in the best interests of the public.
(5) An insurer may use an application form designed to elicit the complete health history of an applicant and on the basis of the answers on that application perform underwriting in accordance with the insurer's established underwriting standards. Unless otherwise provided in the long-term care insurance policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in subsection (2) expires. A long-term care insurance policy or certificate may not exclude or use a waiver or rider of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subsection (2).
History: En. Sec. 7, Ch. 355, L. 1989; amd. Sec. 151, Ch. 42, L. 1997; amd. Sec. 11, Ch. 416, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1111. Outline of coverage

33-22-1111. Outline of coverage.
(1) (a) An insurer shall deliver an outline of coverage as approved by the commissioner to a prospective applicant for long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose.
(b) The commissioner shall prescribe a standard format, including style, arrangement, and overall appearance, and the content of the outline of coverage.
(c) In the case of insurance producer solicitations, an insurance producer shall deliver the outline of coverage prior to the presentation of an application or enrollment form.
(d) In the case of direct response solicitations, the insurer shall deliver the outline of coverage upon the earlier of the applicant's request or the delivery of the policy.
(2) The outline of coverage must include:
(a) a description of the principal benefits and coverage provided in the policy;
(b) a statement of the principal exclusions, reductions, and limitations contained in the policy;
(c) a statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premiums. Continuation or conversion provisions of a group policy must be specifically described.
(d) a statement that the outline of coverage is only a summary of the policy issued or applied for, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;
(e) a description of the terms under which the policy or certificate may be returned and the premium refunded;
(f) a brief description of the relationship of cost of care and benefits; and
(g) a statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract.
(3) The outline of coverage:
(a) must prominently display the name of the insurer;
(b) must be a freestanding document not dependent for purposes of reader comprehension upon any other document;
(c) must use no smaller than 12-point type; and
(d) may not contain material of an advertising nature.
History: En. Sec. 11, Ch. 355, L. 1989; amd. Sec. 1, Ch. 713, L. 1989; amd. Sec. 12, Ch. 416, L. 1997; amd. Sec. 5, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1112. Required content for certificate

33-22-1112. Required content for certificate.
A certificate issued pursuant to a group long-term care insurance policy that is delivered or issued for delivery in this state must include:
(1) a description of the principal benefits and coverage provided in the policy;
(2) a statement of the principal exclusions, reductions, and limitations contained in the policy; and
(3) a statement that the group master policy determines governing contractual provisions.
History: En. Sec. 12, Ch. 355, L. 1989.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1113. Disclosure and performance standards for long-term care insurance

33-22-1113. Disclosure and performance standards for long-term care insurance.
(1) The commissioner may by rule adopt standards for full and fair disclosure, setting forth the manner, content, and disclosures required to be made in a long-term care insurance policy, including but not limited to:
(a) terms of renewability;
(b) initial and subsequent conditions of eligibility;
(c) nonduplication of coverage provisions;
(d) coverage of dependents;
(e) preexisting conditions;
(f) termination of insurance;
(g) continuation or conversion;
(h) probationary periods;
(i) limitations;
(j) exceptions;
(k) reductions;
(l) elimination periods;
(m) requirements for replacement;
(n) recurrent conditions;
(o) definition of terms;
(p) prohibitions on limitations and exclusions;
(q) extension of benefits;
(r) discontinuance and replacement of policies;
(s) unintentional lapse;
(t) prohibitions against postclaim underwriting;
(u) minimum standards for home health and community care benefits;
(v) inflation protection;
(w) incontestability period; and
(x) tax consequences.
(2) A group long-term care insurance policy must include a provision relating to conversion on termination of eligibility as described in 33-22-508 or include a provision for continuation of coverage that maintains coverage under the existing group policy if the coverage would otherwise terminate.
History: En. Sec. 5, Ch. 355, L. 1989; amd. Sec. 13, Ch. 416, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1114. Prohibited practices and policy provisions

33-22-1114. Prohibited practices and policy provisions.
(1) An insurance company may not issue a refund to a person other than the owner of the policy or certificate.
(2) A long-term care insurance policy may not:
(a) be canceled, nonrenewed, or otherwise terminated on any grounds other than the insured's or certificate holder's failure to pay the premium;
(b) contain a provision establishing a new waiting period if existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or
(c) provide coverage for only skilled nursing care or provide substantially more coverage for skilled nursing care in a facility than coverage for lower levels of care.
History: En. Sec. 6, Ch. 355, L. 1989; amd. Sec. 2, Ch. 240, L. 1995; amd. Sec. 14, Ch. 416, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1115. Prior hospitalization or institutionalization

33-22-1115. Prior hospitalization or institutionalization.
(1) A long-term care insurance policy may not be delivered or issued for delivery in Montana if the policy conditions eligibility for a benefit:
(a) on a prior hospitalization requirement;
(b) provided in an institutional care setting on the receipt of a higher level of institutional care; or
(c) other than waiver of premium, postconfinement benefits, postacute care benefits, or recuperative benefits, on a prior institutionalization requirement.
(2) A long-term care insurance policy containing a limitation or condition for eligibility other than those prohibited in subsection (1) must clearly label, in a separate paragraph of the policy or certificate entitled "Limitations or Conditions on Eligibility for Benefits", the limitations or conditions, including any required number of days of confinement.
(3) A long-term care insurance policy that contains a benefit advertised, marketed, or offered as a home health care benefit may not condition receipt of a benefit on a prior institutionalization requirement.
(4) A long-term care insurance policy that conditions eligibility of noninstitutional benefits on the prior receipt of institutional care may not require a prior institutional stay of more than 30 days.
(5) A long-term care insurance policy that provides benefits only following institutionalization may not condition the benefits upon admission to a facility for the same or a related condition within a period of less than 30 days after discharge from the institution.
History: En. Sec. 8, Ch. 355, L. 1989; amd. Sec. 15, Ch. 416, L. 1997; amd. Sec. 6, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1116. Nonforfeiture benefits -- offer requirement

33-22-1116. Nonforfeiture benefits -- offer requirement.
(1) Except as provided in subsection (3), a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy that includes a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy.
(2) If a policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that must be available for a specified period of time following a substantial increase in premium rates.
(3) When a group long-term care insurance policy is issued, the offer required in subsection (1) must be made to the group policyholder. However, if the policy is issued as group long-term care insurance as defined in 33-22-1107(5)(d), other than to a continuing care retirement community or other similar entity, the offer must be made to each proposed certificate holder.
History: En. Sec. 4, Ch. 240, L. 1995; amd. Sec. 7, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1117. Appropriate sale criteria

33-22-1117. Appropriate sale criteria.
(1) Appropriate sale criteria must be established and communicated to the consumer prior to the insurance company's acceptance of a person's application for long-term care insurance.
(2) This section may not preclude the purchase of a long-term care insurance policy by a consumer.
History: En. Sec. 5, Ch. 240, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1119. Right to return policy -- free look -- refunds upon denial of application

33-22-1119. Right to return policy -- free look -- refunds upon denial of application.
(1) A long-term care insurance applicant and insured has the right to return the policy within 30 days of the policy's delivery and to have the premium refunded if, after examination of the policy, the applicant or insured is not satisfied for any reason. A long-term care insurance policy must have a notice prominently printed on the first page of the policy or attached to the policy stating that the applicant or insured has the right to return the policy within 30 days of the policy's delivery and to have the premium refunded if, after examination of the policy, other than a certificate issued to a group defined in 33-22-1107(5)(a), the applicant or insured is not satisfied for any reason.
(2) An applicant or a person insured under a long-term care insurance policy issued pursuant to a direct response solicitation has the right to return the policy within 30 days of its delivery and to have the premium refunded if, after examination of the policy, the applicant or the insured is not satisfied for any reason. A long-term care insurance policy issued pursuant to a direct response solicitation must have a notice prominently printed on the first page or attached to it stating that the applicant or the insured has the right to return the policy within 30 days of its delivery and to have the premium refunded if, after examination of the policy, the applicant or the insured is not satisfied for any reason.
(3) If the application of a person for long-term care insurance is denied, any refund due the person must be refunded within 30 days of the denial or return of the application.
History: En. Sec. 10, Ch. 355, L. 1989; amd. Sec. 3, Ch. 240, L. 1995; amd. Sec. 8, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1120. Extraterritorial jurisdiction

33-22-1120. Extraterritorial jurisdiction.
A group long-term care insurance policy or certificate may not be delivered or issued for delivery to a resident of Montana under a group policy issued in another state unless it is approved by:
(1) the commissioner; and
(2) the insurance regulatory official of a state that has statutory and regulatory long-term care insurance requirements substantially similar to those adopted in Montana.
History: En. Sec. 4, Ch. 355, L. 1989; amd. Sec. 64, Ch. 379, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1121. Rules

33-22-1121. Rules.
The commissioner may adopt rules necessary to implement this part, including but not limited to rules that:
(1) establish loss ratio standards for long-term care insurance policies;
(2) promote premium adequacy and protect the policyholder in the event of substantial rate increases;
(3) establish minimum standards for insurance producer training, marketing practices, compensation, and testing;
(4) establish penalties and reporting practices for long-term care insurance;
(5) specify, with respect to nonforfeiture benefits and contingent benefits:
(a) the type or types of nonforfeiture benefits to be offered as part of long-term care insurance policies;
(b) the standards for nonforfeiture benefits;
(c) the rules regarding contingent benefits upon lapse, including:
(i) a determination of the specified period of time during which a contingent benefit upon lapse will be available;
(ii) the substantial premium rate increase that triggers a contingent benefit upon lapse as described in 33-22-1116; and
(d) the types of appropriate sale criteria to be communicated at the time of application;
(6) establish a requirement for the mandatory triggering of policy benefits based upon the number of activities of daily living that an individual is capable or incapable of performing; and
(7) are necessary to implement a determination made by the secretary of health and human services pursuant to 45 CFR, parts 160 and 164, as to who is a licensed health care practitioner.
History: (1)En. Sec. 14, Ch. 355, L. 1989; (2)En. Sec. 9, Ch. 355, L. 1989; amd. Sec. 6, Ch. 240, L. 1995; amd. Sec. 16, Ch. 416, L. 1997; amd. Sec. 9, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1122. Policy waiting periods not cumulative

33-22-1122. Policy waiting periods not cumulative.
A waiting or elimination period contained in a long-term care insurance policy under which an insured is required to wait a specified period of time before receiving policy benefits must be concurrent with any 90-day period used to determine whether an individual is a chronically ill individual.
History: En. Sec. 46, Ch. 416, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1123. Delivery of policy -- policy summary -- monthly reports

33-22-1123. Delivery of policy -- policy summary -- monthly reports.
(1) If an application for a long-term care insurance policy is approved, the issuer shall deliver the policy to the applicant or policyholder not later than 30 days after the date of approval.
(2) (a) At the time of delivery of an individual life insurance policy that provides long-term care benefits within the policy or by rider, a policy summary must be provided to the insured.
(b) In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, and whether or not a request is made, a policy summary must be delivered not later than at the time the policy is delivered.
(c) In addition to complying with any other applicable requirements, the summary must include:
(i) an explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;
(ii) an illustration of the amount of benefit, the length of benefit, and the guaranteed lifetime benefit, if any, for each covered person;
(iii) any exclusions, reductions, and limitations on benefits of long-term care;
(iv) a statement that any long-term care inflation protection option required by the Administrative Rules of Montana is or is not available under this policy;
(d) If applicable to the policy type, the summary must also include:
(i) a disclosure of the effects of other exercising rights under the policy;
(ii) a disclosure of guarantees related to long-term care costs of insurance charges; and
(iii) current and projected maximum lifetime benefits.
(3) The required provisions of the policy summary may be incorporated into a basic illustration required to be delivered in accordance with administrative rules or into the life insurance policy summary.
(4) Any time a long-term care benefit funded through a life insurance vehicle by the acceleration of the death benefits is in benefit payment status, a monthly report must be provided to the policyholder. The report must include:
(a) any long-term care benefits paid out during the month;
(b) an explanation of any changes in the policy, such as to death benefits or cash values, due to long-term care benefits being paid out; and
(c) the amount of long-term care benefits existing or remaining.
History: En. Sec. 47, Ch. 416, L. 1997; amd. Sec. 10, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1124. Denial of claims

33-22-1124. Denial of claims.
If a claim under a long-term care insurance policy is denied, the issuer shall, not later than 60 days after the date of a written request by the policyholder, certificate holder, or the representative of either of them:
(1) provide a written explanation of the reasons for the denial; and
(2) provide all information possessed by the issuer relating to the denial.
History: En. Sec. 48, Ch. 416, L. 1997; amd. Sec. 11, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1125. Benefit triggers

33-22-1125. Benefit triggers.
(1) A long-term care insurance policy may not be delivered or issued for delivery in this state unless it complies with the requirements of this section and applicable rules for the triggering of mandatory provision of benefits.
(2) (a) A long-term care insurance policy must condition the payment of benefits on a determination of the insured's inability to perform activities of daily living or on cognitive impairment.
(b) Eligibility for the payment of benefits may not be more restrictive than requiring a deficiency in the ability to perform not more than three of the activities of daily living or requiring the presence of cognitive impairment.
(c) Insurers may use activities of daily living to trigger covered benefits that are in addition to those contained in the definition under 33-22-1107 or rules as long as they are defined in the policy.
(3) An insurer may use additional provisions for the determination of when benefits are payable under a policy. However, the provisions may not restrict or be in lieu of the requirements contained in subsections (1) and (2).
(4) For purposes of this section, the determination of a deficiency may not be more restrictive than:
(a) requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or
(b) if the deficiency is due to the presence of a cognitive impairment, the need for supervision or verbal cueing by another person in order to protect the insured or others.
(5) Assessments of activities of daily living and cognitive impairment must be performed by licensed or certified professionals, such as physicians, nurses, or social workers.
(6) Long-term care insurance policies must include a clear description of the process of appealing and resolving benefit determinations.
History: En. Sec. 49, Ch. 416, L. 1997; amd. Sec. 12, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1127. Incontestability period

33-22-1127. Incontestability period.
(1) Upon a showing of misrepresentation that is material to the acceptance for coverage, a policy that has been in force for less than 6 months may be rescinded by the insurer or the insurer may deny an otherwise valid long-term care insurance claim.
(2) Upon a showing of misrepresentation that is both material to the acceptance for coverage and that pertains to the condition for which benefits are sought, a policy that has been in force for at least 6 months but less than 2 years may be rescinded by the insurer or the insurer may deny an otherwise valid long-term care insurance claim.
(3) After a policy has been in force for 2 years, it is not contestable upon the grounds of misrepresentation alone. The policy may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.
(4) (a) A long-term care insurance policy may be field-issued if the compensation to the field issuer is not based on the number of policies sold.
(b) For purposes of subsection (4)(a), "field-issued" means a policy issued by a producer or a third-party administrator pursuant to the underwriting authority granted to the producer or third-party administrator by an insurer and using the insurer's underwriting guidelines.
(5) If an insurer has paid benefits under the long-term care insurance policy, the benefit payments may not be recovered by the insurer if the policy is rescinded.
(6) In the event of the death of the insured, this section may not be applied to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In that situation, the remaining death benefits under the policy must be governed by Title 33, chapter 20. In all other situations, this section applies to life insurance policies that accelerate benefits for long-term care.
History: En. Sec. 14, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 11. Long-Term Care Insurance Act › 33-22-1129. Penalties

33-22-1129. Penalties.
In addition to any other penalty provided for in Title 33, an insurer or an insurance producer found to have violated any requirement of this state relating to the regulation of long-term care insurance or the marketing of long-term care insurance is subject to a fine of up to three times the amount of any commissions paid for each policy involved in the violation or up to $10,000, whichever is greater.
History: En. Sec. 16, Ch. 32, L. 2007.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 12. Limited Benefit Disability Insurance (Repealed) › 33-22-1201. Repealed

33-22-1201. Repealed.
Sec. 44, Ch. 531, L. 1997.
History: En. Sec. 1, Ch. 606, L. 1991.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 12. Limited Benefit Disability Insurance (Repealed) › 33-22-1202. Repealed

33-22-1202. Repealed.
Sec. 44, Ch. 531, L. 1997.
History: En. Sec. 2, Ch. 606, L. 1991; amd. Sec. 26, Ch. 504, L. 1995; amd. Sec. 85, Ch. 546, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 12. Limited Benefit Disability Insurance (Repealed) › 33-22-1203. Repealed

33-22-1203. Repealed.
Sec. 44, Ch. 531, L. 1997.
History: En. Sec. 3, Ch. 606, L. 1991.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 12. Limited Benefit Disability Insurance (Repealed) › 33-22-1204. Repealed

33-22-1204. Repealed.
Sec. 44, Ch. 531, L. 1997.
History: En. Sec. 4, Ch. 606, L. 1991.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 12. Limited Benefit Disability Insurance (Repealed) › 33-22-1205. Repealed

33-22-1205. Repealed.
Sec. 44, Ch. 531, L. 1997.
History: En. Sec. 5, Ch. 606, L. 1991.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1301. Short title -- purpose

33-22-1301. Short title -- purpose.
This part may be cited as the "Montana Reinsurance Association Act". The purpose of this act is to establish a Montana-based public reinsurance program in order to stabilize the individual health insurance market, maintain competition, and reduce premiums.
History: En. Sec. 1, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1302. Reinsurance association -- mandatory membership -- exceptions

33-22-1302. Reinsurance association -- mandatory membership -- exceptions.
(1) The Montana reinsurance association is established as a nonprofit legal entity. As a condition of doing business, an insurer that has issued or renewed disability insurance, as defined in 33-1-207, regardless of license type, in this state in the past 12 months must be a member of the association.
(2) Disability insurers are exempt from the requirement to be association members and are not subject to the assessment in 33-22-1313 if the insurers solely issue or administer one or more of the following coverage types under the Montana Insurance Code:
(a) self-funded multiple employer welfare arrangements licensed under chapter 35;
(b) disability insurance sold through a fraternal benefit society as described in chapter 7;
(c) excepted benefits as defined in 33-22-140;
(d) long-term care insurance as described in chapter 22, part 11; or
(e) disability income insurance as defined in 33-1-235.
History: En. Sec. 2, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1303. Definitions

33-22-1303. Definitions.
As used in this part, the following definitions apply:
(1) "Association" means the Montana reinsurance association provided for in this part.
(2) "Attachment point" means the threshold amount for claims costs incurred by an eligible health insurer for an enrolled individual's covered benefits in a benefit year, beyond which the claims costs for benefits are eligible for reinsurance payments.
(3) "Benefit year" means the calendar year for which an eligible health insurer provides coverage through an individual health insurance policy.
(4) "Board" means the association's board of directors provided for in 33-22-1306.
(5) "Coinsurance rate" means the rate at which the association will reimburse an eligible health insurer for claims incurred for an enrolled individual's covered benefits in a benefit year above the attachment point and below the reinsurance cap.
(6) "Eligible health insurer" means a health insurer, health service corporation, or health maintenance organization that:
(a) offers individual health insurance coverage in the individual market, as defined in 33-22-140;
(b) offers a qualified health plan as defined in 42 U.S.C. 18021(a) that does not discriminate on the basis of health status in rating or issuance, covers all essential health benefits, and does not impose lifetime or annual limits or exclude preexisting conditions; and
(c) incurs claims costs for an individual enrollee's covered benefits in the applicable benefit year.
(7) "Major medical" health insurance includes individual market and employer group health insurance that:
(a) is guaranteed available;
(b) is guaranteed renewable;
(c) does not impose preexisting condition exclusions;
(d) (i) offers essential health benefits as defined in 42 U.S.C. 18022; or
(ii) for large employer group coverage, meets the federal requirements for minimum value;
(e) pays medical claims, with no lifetime or annual limits; and
(f) complies with the federal limits for maximum out-of-pocket.
(8) "Payment parameters" means the attachment point, reinsurance cap, and coinsurance rate for the Montana reinsurance program.
(9) "Program" means the Montana reinsurance program operated by the Montana reinsurance association.
(10) "Reinsurance cap" means the maximum amount of each claim incurred by an eligible health insurer for an enrolled individual's covered benefits in a benefit year, after which the claims costs for benefits are no longer eligible for reinsurance payments.
(11) "Reinsurance payments" means an amount paid by the association to an eligible health insurer under the program.
History: En. Sec. 3, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1306. Association board of directors

33-22-1306. Association board of directors.
(1) The association is governed by a board of directors consisting of five directors who have experience in health care, health insurance, or finance as follows:
(a) three directors, one each from the eligible health insurers with the largest enrollment in the individual market. If there are fewer than three, the board shall select another director from a health insurance issuer that markets primarily major medical insurance.
(b) one insurer director appointed by the commissioner who is a participating member of the association; and
(c) one director appointed by the governor to represent the public interest.
(2) The board of directors may be reimbursed by the association for travel expenses but may not otherwise be compensated for their services.
(3) Each director has one vote.
(4) Initial appointments must be finalized no later than May 1, 2019, and the board shall meet for the first time no later than May 8, 2019.
History: En. Sec. 4, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1307. Duties of commissioner -- rulemaking

33-22-1307. Duties of commissioner -- rulemaking.
(1) The commissioner shall:
(a) oversee the activities of the association and the board;
(b) examine the affairs of the board and program;
(c) approve the plan of operation set by the board as needed within 30 days of receiving the plan or amendments to the plan from the board;
(d) with the assistance of the association, collect the assessment and the federal funding designated for this program;
(e) designate staff to attend meetings of the board and the association as an ex officio member; and
(f) require all eligible health insurers to calculate the premium amount the eligible health insurer would have charged for the benefit year if the Montana reinsurance program had not been established. The eligible health insurer shall submit this information as part of its rate filing. The commissioner shall consider this information as part of the rate review.
(2) The commissioner may adopt rules necessary to implement this part. Any proposed administrative rules must be submitted to the board for review and comment before the proposed rules are submitted to the secretary of state.
History: En. Sec. 5, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1308. Board duties -- powers

33-22-1308. Board duties -- powers.
(1) The board shall:
(a) adopt a plan of operation and the reinsurance parameters for the following year, no later than June 15, 2019, in accordance with the requirements of this part, and update the plan of operation and reinsurance parameters, if needed, no later than May 1 of each succeeding year. The board shall submit its plan of operation to the commissioner for approval.
(b) establish administrative and accounting procedures for the association and the program;
(c) select an association administrator in accordance with 33-22-1309 who will pay reinsurance claims in accordance with the plan of operation; and
(d) set the budget for the reinsurance program for each policy year, including the assessment levels as provided in 33-22-1313 for the various members of the association.
(2) The board may:
(a) enter into contracts as necessary to carry out the purposes of this part;
(b) appoint appropriate actuarial or other committees as necessary to provide technical assistance and any other functions within the authority of the association; and
(c) apply for funds or grants from public or private sources.
(3) The board may be audited by the legislative auditor.
(4) An annual review of the association and the program for solvency and compliance must be performed by an independent certified public accountant using generally accepted accounting principles and submitted to the commissioner and the economic affairs committee of the legislature provided for in 5-5-223 as provided in 5-11-210 for review by June 30 of each year, beginning in 2020.
(5) The board shall prepare an annual report on operations and finance and send that report to the economic affairs interim committee as provided in 5-11-210 and the commissioner by June 30 of each year, beginning in 2020.
History: En. Sec. 6, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1309. Association administrator

33-22-1309. Association administrator.
(1) The board shall select an administrator, who is either an employee of the nonprofit association or an independent contractor, to administer the reinsurance program pursuant to the parameters decided by the board of directors. The board shall establish qualifications and compensation in the plan of operation for the administrator and the length of the contract of an independent contractor.
(2) The administrator shall:
(a) perform all administrative functions relating to the association;
(b) submit regular reports to the board regarding the operation of the association. The frequency, content, and form of the reports must be set forth in the plan of operation.
(c) pay reinsurance claims as provided for in the plan of operation.
History: En. Sec. 7, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1313. Association member assessments

33-22-1313. Association member assessments.
(1) (a) (i) For 2020 and each year thereafter, the commissioner shall assess each member insurer 1.2% of its total premium volume covering Montana residents, from the prior calendar year, regardless of type of license.
(ii) For purposes of subsection (1)(a)(i), total premium volume may not include premiums that member insurers collect on any coverage issued for excepted benefits as defined in 33-22-140.
(b) The board shall determine the timing of the assessment.
(c) The commissioner shall consider the board's recommendation when determining the assessment amounts.
(d) The commissioner shall verify the amount of each insurer's assessment based on annual financial statements and other reports determined to be necessary.
(2) The association shall determine and report to the commissioner the association's reinsurance payments and other expenses for the previous calendar year, including administrative expenses and any incurred but not reported claims for the previous calendar year.
(a) The report must consider investment income and other appropriate gains.
(b) The report must include an estimate of the assessments needed to cover the expected reinsurance claims for the following calendar year.
(3) If assessments and other funds collected by the association exceed the actual losses and administrative expenses of the association, the board shall use the excess funds to offset future claims or to reduce future assessments.
(4) The commissioner may, after notice and hearing:
(a) suspend or revoke the certificate of authority to transact insurance in this state of any member insurer that fails to pay an assessment;
(b) impose a penalty on any insurer that fails to pay an assessment when due; or
(c) use any power granted to the commissioner to collect any unpaid assessment.
(5) An eligible health insurer may not submit claims for reinsurance payments unless the insurer has a medical loss ratio of 80% or greater, as defined in 45 CFR 158.232(f).
History: En. Sec. 8, Ch. 210, L. 2019; amd. Sec. 6, Ch. 471, L. 2021.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1314. Payment parameters

33-22-1314. Payment parameters.
(1) The board shall design and adjust the payment parameters to ensure that the payment parameters will:
(a) stabilize or reduce premium rates in the individual market;
(b) increase or maintain participation in the individual market;
(c) mitigate the impact high-cost individuals have on premium rates in the individual market;
(d) consider any federal funding available for the plan; and
(e) consider the total amount available to fund the plan.
(2) The attachment point must be set by the board at $40,000 or more but may not exceed the reinsurance cap.
(3) The coinsurance rate must be set by the board between 50% and 80%.
(4) The reinsurance cap must be set by the board at $1 million or less.
(5) The board may adjust the payment parameters annually to the extent necessary to secure federal approval of the state innovation waiver.
History: En. Sec. 9, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1315. Calculation of reinsurance payments

33-22-1315. Calculation of reinsurance payments.
(1) Each reinsurance payment must be calculated with respect to an eligible health insurer's incurred claims costs for an individual enrollee's covered benefits in the applicable benefit year. If the claims costs do not exceed the attachment point, the reinsurance payment is $0. If the claims costs exceed the attachment point, the reinsurance payment must be calculated as the product of the coinsurance rate and the less of:
(a) the claims costs minus the attachment point; or
(b) the reinsurance cap minus the attachment point.
(2) The board shall ensure that the reinsurance payments made to the eligible health insurer do not exceed the total amount paid by the eligible health insurer for any eligible claim.
(3) For purposes of this section, "total amount paid" means the amount paid by the eligible health insurer based on the allowed amount less any deductible, coinsurance, or copayment.
History: En. Sec. 10, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1316. Administration of reinsurance payments

33-22-1316. Administration of reinsurance payments.
(1) Claims that are incurred during a benefit year and are submitted for reimbursement in the following benefit year by the date established by the board in the plan of operation will be allocated to the benefit year in which they are incurred. Any claims from the preceding benefit year not submitted for reimbursement by the date established in the plan of operation may not be reimbursed.
(2) If funds accumulated in the reinsurance program account in the state special revenue fund with respect to a benefit year are expected to be insufficient to pay all program expenses, claims for reimbursement, and other disbursements allocable to that benefit year, all claims for reimbursement allocable to that benefit year must be reduced proportionately to the extent necessary to prevent a deficiency in the funds for that benefit year. Any reduction in claims for reimbursement with respect to a benefit year must apply to all claims that are allocated to that benefit year without regard to when those claims were submitted for reimbursement, and any reduction must be applied to each claim in the same proportion.
(3) If funds accumulated in the reinsurance program account in the state special revenue fund exceed the actual claims for reimbursement and program expenses of the association in a given benefit year, the board shall use the excess funds to pay reinsurance claims in successive benefit years and may recommend to the commissioner a reduction in the assessment amount for the following year.
(4) For each applicable benefit year, the board shall notify eligible health insurers of reinsurance payments to be made for the applicable benefit year by the date established in the plan of operation in the year following the applicable benefit year.
(5) By December 31 of the year following the applicable benefit year, the board shall disburse all applicable reinsurance payments payable to an eligible health insurer.
History: En. Sec. 11, Ch. 210, L. 2019; amd. Sec. 7, Ch. 471, L. 2021; amd. Sec. 28, Ch. 157, L. 2023.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1317. Eligible health insurer requests for reinsurance payments

33-22-1317. Eligible health insurer requests for reinsurance payments.
(1) An eligible health insurer shall:
(a) make requests for reinsurance payment in accordance with any requirements established by the board;
(b) provide the association with access to data according to the rules and timeline established by the board in the plan of operation or by the commissioner in the administrative rules. The data environment utilized must be compatible with the federal risk adjustment program.
(c) maintain documents and records sufficient to substantiate the requests for reinsurance payments made pursuant to this part for a period of at least 6 years;
(d) apply all managed care, utilization review, case management, preferred provider arrangements, claims processing, and other methods of operation as appropriate to each claim without regard to whether that claim is eligible for or may be paid by reinsurance;
(e) make records available upon request from the commissioner or the board for purposes of verification, investigation, audit, or other review of reinsurance payment requests; and
(f) repay to the reinsurance program account in the state special revenue fund any reinsurance overpayments as determined by the commissioner as a result of an investigation, audit, or other review.
(2) Data collected from eligible health insurers under this section is confidential and not subject to public inspection.
History: En. Sec. 12, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1320. Liability of association members

33-22-1320. Liability of association members.
An association member may not be held liable for the acts or omissions of the association board or the association membership.
History: En. Sec. 13, Ch. 210, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 22. Disability Insurance › Part 13. Montana Reinsurance Association Act › 33-22-1321. State and federal special revenue accounts -- reinsurance program

33-22-1321. State and federal special revenue accounts -- reinsurance program.
(1) (a) There is a reinsurance program account in the state special revenue fund established by 17-2-102. The account must be administered by the commissioner for the benefit of the program.
(b) There must be deposited in the account:
(i) all assessments collected under 33-22-1313;
(ii) any interest and income earned on the account; and
(iii) any other money from any other source accepted for the benefit of the account.
(c) The account may be used only to provide funding for the administration, operation, and claims expenses incurred by the program created in 33-22-1302.
(2) There is an account in the federal special revenue fund to the credit of the board and administered by the commissioner for the benefit of the program. There must be deposited in the account:
(a) federal funding allocated as a result of a section 1332 waiver application;
(b) any federal or grant funding; and
(c) any interest and income earned on the account.
History: En. Sec. 14, Ch. 210, L. 2019.