376.960. Definitions.
Definitions.
376.960. As used in sections 376.960 to 376.989, the following termsmean:
(1) "Benefit plan", the coverages to be offered by the pool toeligible persons pursuant to the provisions of section 376.986;
(2) "Board", the board of directors of the pool;
(3) "Church plan", a plan as defined in Section 3(33) of the EmployeeRetirement Income Security Act of 1974, as amended;
(4) "Creditable coverage", with respect to an individual:
(a) Coverage of the individual provided 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;
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; or
j. A health benefit plan under Section 5(e) of the Peace Corps Act,22 U.S.C. 2504(e);
(b) Creditable coverage does not include coverage consisting solelyof excepted benefits;
(5) "Department", the Missouri department of insurance, financialinstitutions and professional registration;
(6) "Dependent", a resident spouse or resident unmarried child underthe age of nineteen years, a child who is a student under the age oftwenty-five years and who is financially dependent upon the parent, or achild of any age who is disabled and dependent upon the parent;
(7) "Director", the director of the Missouri department of insurance,financial institutions and professional registration;
(8) "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;
(9) "Federally defined eligible individual", an individual:
(a) For whom, as of the date on which the individual seeks coveragethrough the pool, the aggregate of the periods of creditable coverage asdefined in this section is eighteen or more months and whose most recentprior creditable coverage was under a group health plan, governmental plan,church plan, or health insurance coverage offered in connection with anysuch plan;
(b) Who is not eligible for coverage under a group health plan, PartA or Part B of Title XVIII of the Social Security Act, or state plan underTitle XIX of such act or any successor program, and who does not have otherhealth insurance coverage;
(c) With respect to whom the most recent coverage within the periodof aggregate creditable coverage was not terminated because of nonpaymentof premiums or fraud;
(d) Who, if offered the option of continuation coverage under COBRAcontinuation provision or under a similar state program, both elected andexhausted the continuation coverage;
(10) "Governmental plan", a plan as defined in Section 3(32) of theEmployee Retirement Income Security Act of 1974 and any federalgovernmental plan;
(11) "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 andincluding items and services paid for as medical care to employees or theirdependents as defined under the terms of the plan directly or throughinsurance, reimbursement or otherwise, but not including excepted benefits;
(12) "Health insurance", any hospital and medical expense incurredpolicy, nonprofit health care service for benefits other than through aninsurer, nonprofit health care service plan contract, health maintenanceorganization subscriber contract, preferred provider arrangement orcontract, or any other similar contract or agreement for the provisions ofhealth care benefits. The term "health insurance" does not includeaccident, fixed indemnity, limited benefit or credit insurance, coverageissued as a supplement to liability insurance, insurance arising out of aworkers' compensation or similar law, automobile medical-payment insurance,or insurance under which benefits are payable with or without regard tofault and which is statutorily required to be contained in any liabilityinsurance policy or equivalent self-insurance;
(13) "Health maintenance organization", any person which undertakesto provide or arrange for basic and supplemental health care services toenrollees on a prepaid basis, or which meets the requirements of section1301 of the United States Public Health Service Act;
(14) "Hospital", a place devoted primarily to the maintenance andoperation of facilities for the diagnosis, treatment or care for not lessthan twenty-four hours in any week of three or more nonrelated individualssuffering from illness, disease, injury, deformity or other abnormalphysical condition; or a place devoted primarily to provide medical ornursing care for three or more nonrelated individuals for not less thantwenty-four hours in any week. The term "hospital" does not includeconvalescent, nursing, shelter or boarding homes, as defined in chapter198, RSMo;
(15) "Insurance arrangement", any plan, program, contract or otherarrangement under which one or more employers, unions or otherorganizations provide to their employees or members, either directly orindirectly through a trust or third party administration, health careservices or benefits other than through an insurer;
(16) "Insured", any individual resident of this state who is eligibleto receive benefits from any insurer or insurance arrangement, as definedin this section;
(17) "Insurer", any insurance company authorized to transact healthinsurance business in this state, any nonprofit health care service planact, or any health maintenance organization;
(18) "Medical care", amounts paid for:
(a) The diagnosis, care, mitigation, treatment, or prevention ofdisease, or amounts paid for the purpose of affecting any structure orfunction of the body;
(b) Transportation primarily for and essential to medical carereferred to in paragraph (a) of this subdivision; and
(c) Insurance covering medical care referred to in paragraphs (a) and(b) of this subdivision;
(19) "Medicare", coverage under both part A and part B of Title XVIIIof the Social Security Act, 42 U.S.C. 1395 et seq., as amended;
(20) "Member", all insurers and insurance arrangements participatingin the pool;
(21) "Physician", physicians and surgeons licensed under chapter 334,RSMo, or by state board of healing arts in the state of Missouri;
(22) "Plan of operation", the plan of operation of the pool,including articles, bylaws and operating rules, adopted by the boardpursuant to the provisions of sections 376.961, 376.962 and 376.964;
(23) "Pool", the state health insurance pool created in sections376.961, 376.962 and 376.964;
(24) "Resident", an individual who has been legally domiciled in thisstate for a period of at least thirty days, except that for a federallydefined eligible individual, there shall not be a thirty-day requirement;
(25) "Significant break in coverage", a period of sixty-threeconsecutive days during all of which the individual does not have anycreditable coverage, except that neither a waiting period nor anaffiliation period is taken into account in determining a significant breakin coverage;
(26) "Trade act eligible individual", an individual who is eligiblefor the federal health coverage tax credit under the Trade Act of 2002,Public Law 107-210.
(L. 1990 H.B. 998 § 1, A.L. 2007 H.B. 818)Effective 1-01-08