Health Insurance Benefit Coverage Law Summaries

Health Insurance Benefit Coverage Law Summaries

Montana, Health Insurance Benefit Coverage Law Summaries

Montana's mandated health care law is located in the Montana Code Annotated at Title 33. Coordination of benefits provisions are located in the Administrative Rules of Montana at Title 6, Subchapter 24.

DEFINITIONS

“Small employer” means a person, firm, corporation, partnership or bona fide association that is actively engaged in business and that, with respect to a calendar year and a plan year, employed at least two but not more than 50 eligible employees during the preceding calendar year and employed at least two employees on the first day of the plan year (Sec. 33-22-1803, as amended by Ch. 416 (S. 378), L. 1997, effective July 1, 1997; and by Ch. 531 (H. 131), L. 1997, effective October 1, 1997).

“Preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on presence of a condition before the enrollment date coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before the enrollment date (Sec. 34, Ch. 416 (S. 378), L. 1997, effective July 1, 1997).

WHAT THE EMPLOYER MUST DO

Montana does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, there are specific requirements for coverage in health insurance policies and contracts in Montana. This coverage is summarized below.

Mental health coverage.- A group health plan or a health insurance issuer that provides group health insurance coverage must provide for Montana residents covered by the plan at least the following level of benefits for the necessary care and treatment of mental illness (Sec. 33-22-703, as amended by H. 512, L. 1999):

1. under basic inpatient expense policies or contracts, inpatient hospital benefits and outpatient benefits consisting of durational limits, dollar limits, deductibles and coinsurance factors that are not less favorable than for physical illness generally, except that (a) inpatient treatment for mental illness is subject to a maximum yearly benefit of 21 days; and (b) inpatient treatment for mental illness may be traded on a two-for-one basis for a benefit for partial hospitalization through a program that complies with the standards for a partial hospitalization program that are published by the American Association for Partial Hospitalization if the program is operated by a hospital.

2. under major medical policies or contracts, inpatient benefits and outpatient benefits consisting of durational limits, dollar limits, deductibles and coinsurance factors that are not less favorable than for physical illness generally, except that (a) inpatient treatment for mental illness is subject to a maximum yearly benefit of 21 days; (b) inpatient treatment for mental illness may be traded on a two-for-one basis for a benefit for partial hospitalization through a program that complies with the standards for a partial hospitalization program that are published by the American Association for Partial Hospitalization if the program is operated by a hospital; and (c) outpatient treatment for mental illness may be subject to a maximum yearly benefit of no less than $2,000 (item (c) does not apply to benefits for services furnished before September 30, 2001.

Dependent care coverage.- Each policy of disability insurance or certificate issued thereunder must contain a provision granting immediate accident and sickness coverage, from and after the moment of birth, to each newborn infant of any insured. The coverage for newborn infants must be the same as provided by the policy for the other covered persons; provided, however, that for newborn infants, there are no waiting or elimination periods. A deductible or reduction in benefits applicable to the coverage for newborn infants is not permissible unless it conforms and is consistent with the deductible or reduction in benefits applicable to all other covered persons (Sec. 33-22-301).

Adoption.- Each group and individual disability policy, certificate of insurance or membership contract that is delivered, issued for delivery, renewed, extended or modified in Montana must provide coverage for an adopted child of the insured or subscriber to the same extent as for natural children of the insured or subscriber. Coverage must be effective from the date of placement for the purpose of adoption and must continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. Coverage at the time of placement must include the necessary care and treatment of medical conditions existing prior to the date of placement and may not impose a preexisting condition exclusion (Sec. 33-22-130, as amended by Ch. 416 (S. 378), L. 1997, effective July 1, 1997).

Disabilities.- An individual hospital or medical expense insurance policy or hospital or medical service plan contract delivered or issued for delivery in Montana which provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children specified in the policy or contract must also provide in substance that attainment of the limiting age may not operate to terminate the coverage of the child while the child is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical disability and chiefly dependent upon the policyholder or subscriber for support and maintenance (Sec. 33-22-304, as amended by Ch. 472 (H. 53), L. 1997).

Well-child care.- Each policy of disability insurance or certificate issued under the policy that is delivered, issued for delivery, renewed, extended, or modified in Montana by a disability insurer and that provides coverage for a family member of the insured or subscriber, other than disability income, specified disease, Medicare supplement, or hospital indemnity policies, must provide coverage for well-child care for children from the moment of birth through two years of age. Benefits provided under this coverage are exempt from deductibles (Sec. 33-22-303).

Coverage for well-child care must include (Sec. 33-22-303):

1. a history, physical examination, developmental assessment, anticipatory guidance, and laboratory tests, according to the schedule of visits adopted under the state's early and periodic screening, diagnosis, and treatment services program; and

2. routine immunizations according to the schedule for immunizations recommended by the Immunization Practices Advisory Committee of the U.S. Department of Health and Human Services.

Continuation of coverage.- Effective January 1, 2008, a health insurance issuer that issues or renews a group health insurance policy, certificate, or membership contract under which an individual's or employee's dependents are eligible for coverage may not terminate coverage on the basis of the age of an unmarried dependent prior to the dependent reaching 25 years of age. Except as otherwise provided by law, the continuation of the coverage of the dependent is at the option of the covered employee (Sec. 33-22-140, as amended by Sec. 1, S. 419, L. 2007, effective January 1, 2008).

Substance abuse coverage.- A group health plan or a health insurance issuer that provides group health insurance coverage must provide for Montana residents covered by the plan at least the following level of benefits for the necessary care and treatment of alcoholism and drug addiction (Sec. 33-22-703, as amended by H. 512, L. 1999):

1. under basic inpatient expense policies or contracts, inpatient hospital benefits and outpatient benefits, consisting of durational limits, dollar limits, deductibles and coinsurance factors that are not less favorable than for physical illness generally, except that (a) inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $4,000 in any 24-month period and a maximum lifetime benefit of $6,000 for a 12-month period until a lifetime maximum inpatient benefit of $12,000 is met, after which the annual benefit may be reduced to $2,000; and (b) costs for medical detoxification treatment must be paid the same as any other illness under the terms of the contract and are not subject to the annual and lifetime limits under (a) above.

2. under major medical policies or contracts, inpatient benefits and outpatient benefits consisting of durational limits, dollar limits, deductibles and coinsurance factors that are not less favorable than for physical illness generally, except that (a) inpatient treatment for alcoholism and drug addiction is subject to a maximum yearly benefit of 21 days; (b) inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, may be subject to a maximum benefit of $6,000 for a 12-month period until a lifetime maximum inpatient benefit of $12,000 is met, after which the annual benefit may be reduced to $2,000; (c) costs for medical detoxification treatment must be paid the same as any other illness under the terms of the contract and are not subject to the annual and lifetime benefits in (b) immediately above.

Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.

Group or group-type contracts providing health care benefits must specify how benefits will be coordinated (Administrative Rules of Montana Title 6, Subch. 24, Secs. 6.6.2401-6.6.2405, as authorized by Montana Code Annotated Sec. 33-1-313).

Order of benefits.- The following priority applies when coordinating health benefit payments (Administrative Rules of Montana Title 6, Subch. 24, Secs. 6.6.2404 and 6.6.2405):

1. Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;

2. Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time;

3. Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent;

4. Active/Inactive Employee: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;

5. Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time; and

6. Excess Benefits: A complying plan may coordinate its benefits with a plan that is “excess” or “always secondary” or that uses an order of benefit determination provision that is inconsistent with that contained in this rule (called a noncomplying plan), on the following basis: if the complying plan is the primary plan, it must pay or provide its benefits on a primary basis. If the complying plan is the secondary plan, it must still pay or provide its benefits first, as the secondary plan. In such a situation, such payment is the limit of the complying plan's liability, except if the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan may assume that the benefits of the noncomplying plan are identical to its own and pay its benefits accordingly. The complying plan must adjust any payments it makes based on such assumption when information becomes available about the actual benefits of the noncomplying plan. If the noncomplying plan pays less in benefits than it would have if the noncomplying plan paid or provided its benefits as the primary plan, the complying plan must advance an amount equal to such difference.

Maintenance of benefits.- A plan that pays benefits on a secondary basis may reduce benefits payable so long as total benefits paid do not exceed allowable expenses (Administrative Rules of Montana Title 6, Subch. 24, Sec. 6.6.2404).

Medicare coordination.- A group contract may not reduce benefits if a person is or could be covered under another plan, except for Part B of Medicare (Administrative Rules of Montana Title 6, Subch. 24, Sec. 6.6.2404).

Providers.- All policies or certificates of disability insurance, including group policies or certificates, must provide that the insured has full freedom of choice in the selection of any licensed physician, physician assistant (certified), dentist, osteopath, chiropractor, optometrist, podiatrist, psychologist, licensed social worker, licensed professional counselor, acupuncturist, naturopathic physician, physical therapist, or advanced practice registered nurse for treatment of any illness or injury within the scope and limitations of the person's practice (Sec. 33-22-111, as amended by S. 321, L. 2001, effective January 1, 2002).

Physician assistants.- An insurer, a health service corporation, or any employee health and welfare fund that provides accident or health insurance benefits to Montana residents must provide, in group and individual insurance contracts, coverage for health services provided by a physician assistant (certified) as normally covered by contracts for services supplied by a physician if health care services that the physician assistant is approved to perform are covered by the contract (Sec. 33-22-114).

Preexisting conditions.- A group health plan or a health insurance issuer offering group health insurance coverage may not exclude coverage for a preexisting condition unless (Sec. 40, Ch. 416 (S. 378), L. 1997, effective July 1, 1997):

1. medical advice, diagnosis, care or treatment was recommended or received by the participant or beneficiary within the six-month period ending on the enrollment date;

2. exclusion of coverage extends for a period of not more than 12 months; and

3. the period of the preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.

Genetic information may not be excluded as a preexisting condition in the absence of a diagnosis of the condition related to the genetic information. Pregnancy may not be excluded as a preexisting condition (Sec. 40, Ch. 416 (S. 378), L. 1997, effective July 1, 1997).

Small employers.- A health benefit plan covering small employers may not (Sec. 33-22-1811, as amended by Ch. 416 (S. 378), L. 1997, effective July 1, 1997):

1. because of a preexisting condition, deny, exclude or limit benefits for a covered individual for losses incurred more than 12 months following the effective date of the individual's coverage.

2. use a preexisting condition exclusion more restrictive than those described above.

A health benefit plan must waive any time period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the period of time that an individual was previously covered by creditable coverage that provided benefits with respect to those services if the creditable coverage was continuous to a date not more than 63 days prior to the submission of an application for new coverage. This does not preclude application of any waiting period applicable to all new enrollees under the plan (Sec. 33-22-1811, as amended by Ch. 416 (S. 378), L. 1997, effective July 1, 1997).

A health benefit plan may exclude coverage for late enrollees for 18 months or for an 18-month preexisting condition exclusion, provided that if both a period of exclusion from coverage and a preexisting condition exclusion are applicable to a late enrollee, the combined period may not exceed 18 months from the date the individual enrolls for coverage under the plan (Sec. 33-22-1811, as amended by Ch. 416 (S. 378), L. 1997, effective July 1, 1997).

Health maintenance organizations.- An HMO that offers health insurance coverage in connection with a group health plan and that does not impose a preexisting condition exclusion allowed by Sec. 40, Ch. 416 (S. 378), L. 1997 (above) with respect to any particular coverage option may impose an affiliation period for that coverage option if (Sec. 44, Ch. 416 (S. 378), L. 1997, effective July 1, 1997):

1. the affiliation period is applied uniformly without regard to any health status-related factors; and

2. the affiliation period does not exceed two months, or three months in the case of a late enrollee.

An HMO is not required to provide health care services or benefits during the affiliation period, and a premium may not be charged to the participant or beneficiary for any coverage during the affiliation period. An affiliation period begins on the enrollment date and runs concurrently with any waiting period under the plan (Sec. 44, Ch. 416 (S. 378), L. 1997, effective July 1, 1997).

Pharmaceutical services: Open choice.- Whenever policies or certificates of disability insurance, including group policies or certificates, insure against the expense of drugs, the insured has full freedom of choice in the selection of any licensed and registered pharmacist (Sec. 33-22-111, as amended by S. 321, L. 2001, effective January 1, 2002).

Metabolic disorders.- Each group medical expense disability policy, certificate of insurance, and membership contract that is delivered, issued for delivery, renewed, extended, or modified in Montana must provide coverage for the treatment of inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and monitoring exist (Sec. 33-22-131, as amended by H. 266, L. 1999, effective January 1, 2000).

Mammograms.- Each group or individual disability policy, certificate of insurance, and membership contract that is delivered, issued for delivery, renewed, extended, or modified in Montana must provide minimum mammography examination coverage as follows (Sec. 33-22-132):

1. one baseline mammogram for a woman who is 35 years of age or older and under 40 years of age;

2. a mammogram every two years for any woman who is 40 years of age or older and under 50 years of age or more frequently if recommended by the woman's physician; and

3. a mammogram each year for a woman who is 50 years of age or older.

A minimum $70 payment or the actual charge if the charge is less than $70 must be made for each mammography examination performed before the application of the terms of the applicable group or individual disability policy, certificate of insurance, or membership contract that establish durational limits, deductibles, and copayment provisions as long as the terms are not less favorable than for physical illness generally (Sec. 33-22-132).

Mastectomies.- Each group disability policy, certificate of insurance or membership contract that is delivered, issued for delivery, renewed, extended or modified in Montana must provide coverage for hospital inpatient care for a period of time as is determined by the attending physician and, in the case of an HMO, also the primary care physician, in consultation with the patient, to be medically necessary following a mastectomy, a lumpectomy, or a lymph node dissection for the treatment of breast cancer (Sec. 1, Ch. 410 (S. 324), L. 1997, effective January 1, 1998).

Reconstructive breast surgery.- Each group disability policy, certificate of insurance or membership contract that is delivered, issued for delivery, renewed, extended or modified in Montana must provide coverage for: (1) all stages of reconstruction of the breast on which a mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prosthetics and physical complications of a mastectomy including lymphedemas. Coverage may be subject to annual deductibles and coinsurance consistent with other benefits under the policy, certificate or contract. Insurers must provide written notice in compliance with the Women's Health and Cancer Rights Act of 1998 upon enrollment and subsequently on an annual basis (Sec. 33-22-135, as amended by Ch. 67 (H. 151), L. 2009, effective July 1, 2009).

Maternity benefits.- Each group policy, subscriber contract, membership contract or health care services agreement that provides coverage for maternity services, including benefits for childbirth, must provide coverage for at least 48 hours of inpatient hospital care following a vaginal delivery and at least 96 hours of inpatient hospital care following delivery by cesarean section for a mother and newborn infant in a health care facility. A decision to shorten the length of inpatient stay to less than that provided above must be made by the attending health care provider and the mother (Sec. 1, Ch. 183 (S. 34), L. 1997; and Sec. 62, Ch. 416 (S. 378), L. 1997, both effective January 1, 1998).

Domestic abuse victims.- An insurer, health maintenance organization, or health service corporation may not unfairly discriminate against a victim of abuse (Sec. 1, S. 234, L. 1997, effective October 1, 1997).

Diabetes.- Each group disability policy, certificate of insurance, and membership contract that is delivered, issued for delivery, renewed, extended, or modified in Montana must provide coverage for (1) outpatient self-management training and education for the treatment of diabetes; and (2) diabetic equipment and supplies that is limited to insulin, syringes, injection aids, devises for self-monitoring of glucose levels (including those for the visually impaired), test strips, visual reading and urine test strips, one insulin pump for each warranty period, accessories to insulin pumps, one prescriptive oral agent for controlling blood sugar levels for each class of drug approved by the FDA, and glucagon emergency kits. HMOs must also provide this coverage (Sec. 1, H. 406, L. 2001, effective January 1, 2002; and Sec. 33-31-111, as amended by H. 406, L. 2001, effective January 1, 2002).

Genetic testing.- An insurer, health service corporation, HMO, fraternal benefit society, or other issuer of a group policy or certificate of insurance may not require an individual to obtain a genetic test unless the test is otherwise required by law for reasons including but not limited to the following (Sec. 4, H. 111, L. 1999, effective October 1, 1999):

1. to establish parentage;

2. to determine the presence of metabolic disorders in a newborn by testing conducted pursuant to newborn screening and protocols;

3. in connection with a criminal investigation or prosecution; or

4. for remains identification.

Unless otherwise required by law, an insurer, health service corporation, HMO, fraternal benefit society, or other issuer of a group policy or certificate of insurance may not, on the basis of a person's genetic traits (Sec. 5, H. 111, L. 1999, effective October 1, 1999):

1. fail or refuse to accept an application for a policy or certificate of insurance;

2. fail or refuse to issue a policy or certificate of insurance to an applicant;

3. cancel a policy or certificate of insurance;

4. refuse to renew a policy or certificate of insurance;

5. charge a higher rate or premium for a policy or certificate of insurance; or

6. offer or provide different terms, conditions or benefits or place a limitation on coverage under a policy or certificate of insurance.

An insurer, health service corporation, HMO, fraternal benefit society or other issuer of a group policy or certificate of insurance may not underwrite or condition coverage on the basis of (Sec. 5, H. 111, L. 1999, effective October 1, 1999):

1. a requirement or agreement that the individual undergo genetic testing; or

2. genetic information about a member of the individual's family.

An insurer, health service corporation, HMO, fraternal benefit society or other issuer of a group policy or certificate of insurance may not seek genetic information about an individual for a purpose that is (Sec. 6, H. 111, L. 1999, effective October 1, 1999):

1. unrelated to assessing or managing the individual's current health;

2. inappropriate in an asymptomatic individual; or

3. unrelated to research in which a subject is not personally identifiable.

Medical use of marijuana.- Health insurers are not required to reimburse a person for costs associated with the medical use of marijuana (Sec. 6, Initiative No. 148, approved by voters November 2, 2004).

Note: The U.S. Supreme Court, in Gonzales v. Raich, Dkt. No. 03-1454, June 6, 2005, ruled that federal authorities legally may prosecute persons using marijuana under state medical marijuana laws that allow such use.

Home health care benefits.- Insurers and health services corporations transacting health insurance business in Montana must make available, under group insurance policies and under group hospital and medical service plan contracts, benefits for home health care. Such coverage is not required of blanket, short-term travel, accident only, limited or specified disease, or individual conversion policies or contracts, or to policies or contracts designed for coverage under Medicare or any other similar coverage under federal governmental plans (Secs. 33-22-1002 and 33-22-1003).

State institutions.- It is unlawful for any insurance company issuing disability insurance policies in Montana to exclude from coverage in a disability insurance policy services rendered the insured while a resident in a Montana state institution, provided the services to the insured would be covered by the disability insurance policy if rendered to him or her outside a Montana state institution (Sec. 33-22-112).

Confidentiality of personal information.- A business that provides group health insurance for its employees, other than a business with between two and 50 employees, may request underwriting information pertaining to its coverage, but such information may not include any personal information pertaining to an individual covered by a group plan that has been obtained or administered by the business (Sec. 1, S. 274, L. 2001, effective October 1, 2001).

<p>Confidentiality of personal information.— A business that provides group health insurance for its employees, other than a business with between two and 50 emplo</p>

Montana, Health Insurance Benefit Coverage Law Summaries

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