PURPOSE: This rule effectuates or aids in the interpretation of section 376.421, RSMo. The rule specifies how the Department of Insurance will determine whether group health coverage provided, solicited or issued in Missouri complies with the descriptions of groups in section 376.421, RSMo.

1. (1) As used in this rule, the following terms mean:

   1. (A) Discretionary group, any group not described in section 376.421.1, RSMo;
   2. (B) MDI, the Missouri Department of Insurance; and
   3. (C) True group, any group described in section 376.421.1, RSMo.

2. (2) Group health policies delivered in Missouri are subject to the following:

   1. (A) Any policy must be delivered to a true group or to a discretionary group;

3. (B) Any policy form issued to a discretionary group must be approved by the MDI under section 376.421.2(1), RSMo. This policy filed with the MDI must be accompanied by an affidavit and necessary exhibits on a form approved by the MDI;

   1. (C) Whenever reasonably necessary to determine whether a group policy is being issued by a true group, the MDI may require an affidavit on a form approved by the MDI to determine whether a group is a true group;
   2. (D) Any policy filed with the MDI under this section of this rule is a filing required by law and the filing fee, required by section 374.230(6), RSMo, must be paid; and
   3. (E) If a company violates section 376.421, RSMo or this rule with an unfiled policy, the failure to file will be evidence that the violation was willful.

4. (3) Group health policies not delivered in Missouri are subject to the following:

   1. (A) Any coverage solicited or sold in this state, whether by direct mail, agent contact, telephone contact or advertisement, must be delivered to a true group or a discretionary group;
   2. (B) Whether a group is a true group will be determined by the descriptions contained in section 376.421.1, RSMo, not by the descriptions or lack of descriptions in another state's law;
   3. (C) Whenever reasonably necessary to determine whether a group policy is being issued to a true group, the MDI may require an affidavit on a form approved by the MDI to determine whether a group is a true group;
   4. (D) The MDI shall require an affidavit with necessary exhibits on a form approved by the MDI for any policy issued to a discretionary group. This affidavit will be unnecessary only if another state having a law substantially similar to section 376.421.2(1), RSMo has approved the policy as a discretionary group policy;
   5. (E) Any policy found by the MDI to be delivered to a true group or to a discretionary group which is approved by another state under subsection (3)(D) is filed for information only. The MDI will not charge a filing fee for a policy filed for information only. Any other policy is a filing required by law for which the filing fee under section 374.230(6), RSMo must be paid; and
   6. (F) If a company violates section 376.421, RSMo or this rule with an unfiled policy, the failure to file will be evidence that the violation was willful.

AUTHORITY: section 374.045, RSMo (1986).* This rule was previously filed as 4 CSR 190-14.170. Original rule filed Oct. 5, 1989, effective May 1, 1990. *Original authority 1967. STATE OF__________________________) ) COUNTY OF_______________________) I,_________________________________________________________________ , on my oath swear that the following statements are true name to the best of my knowledge: 1. _________________________________________________________________________________ has agreed to become a policyholder name of employer of __________________________________________________________________________________ name of insurance company 2. The policy which will be issued is a group health policy with form number _____________________________ form number 3. I represent the ________________________________________________________________ in the following name of employer or employer's trust capacity:_______________________________________________ Signature:_____________________________________________________________ Type or print name: Sworn to and subscribed before me this _________ day of ___________________________ , 19_______. My commission expires _____________________________________, 19________. _______________________________________________________________________ Notary Public Affidavit 376.421.1(1) STATE OF__________________________) ) COUNTY OF_______________________) I, __________________________________________________________________, on my oath swear that the following statements are true name to the best of my knowledge: 1. ________________________________________________________________________________________________(the person) is/are a creditor, parent holding company of a creditor or a trustee or trustees or agent designated by two or more creditors. 2. The person named in statement number 1. will be the policyholder of a group health policy to insure debtors of the creditor or creditors with respect to their indebtedness. 3. The policy which will be issued is a group health policy issued by _________________________________________________________ insurance company with form number ____________________________________________. 4. I represent the person named in statement number 1. in the following capacity:_______________________________________________ Signature: __________________________________________________ Type or print name: Sworn to and subscribed before me this __________________________ day of __________________, 19________. My commission expires ____________________________, 19____________. ___________________________________________________________ Notary Public Affidavit 376.421.1(2) STATE OF__________________________) ) COUNTY OF_______________________) I, _________________________________________________________________, on my oath swear that the following statements are true name to the best of my knowledge: 1. _________________________________________________________________________________ is a labor union or similar employee organization. 2. The labor union or similar employee organization will be the policyholder of a group health policy from _______________________________________________with policy form number _______________________________. insurance company 3. I represent the labor union or similar employee organization in the following capacity:_________________________________________ _______________________________ Signature: _____________________________________________________ Type or print name: Sworn to and subscribed before me this __________ day of ___________________, 19________. My commission expires ________________________________, 19____________. ___________________________________________________________ Notary Public Affidavit 376.421.1(3) STATE OF__________________________) ) COUNTY OF_______________________) I,__________________________________________________________ , on my oath swear that the following statements are true name to the best of my knowledge: 1. ____________________________________________________________________________________is a trust, or the trustee of a fund, established or adopted by two or more employers, or by one or more labor unions or similar employee organizations, or by one or more employ ers and one or more labor unions or similar employee organizations. 2. The trust or trustee named in statement number 1. will be the policyholder of a group health policy issued by ___________________________________________________________________________ insurance company 3. I represent the trust or trustee named in statement number 1. in following capacity:___________________________________________ ______________________________________ Signature:____________________________________ Type or print name: Sworn to and subscribed before me this ____________ day of __________________, 19_________. My commission expires ____________________________, 19________. ___________________________________________________________ Notary Public Affidavit 376.421.1(4) STATE OF__________________________) ) COUNTY OF_______________________) I,_________________________________________________________________ , on my oath swear that the following statements are true name to the best of my knowledge: 1. _________________________________________________________________ is (check one): A. ~ an association B. ~ a trust or a fund established, created or maintained for the benefit of members of one or more associations. 2. (Check one of the following applicable statements) ~ The association named in statement 1. has: A. a minimum of one hundred persons; B. been organized and maintained in good faith for purposes other than that of obtaining insurance; C. been in active existence for at least two years; D. a constitution and bylaws which provide that the association shall hold regular meetings not less than annually to further the purposes of the members; E. except for credit unions, collected dues or solicited contributions from members; and F. provided the members with voting privileges and representation on the governing board and committees. ~ The association or associations making up the trust or fund named in statement 1. has or have: A. a minimum of one hundred persons; B. been organized and maintained in good faith for purposes other than that of obtaining insurance; C. been in active existence for at least two years; D. a constitution and bylaws which provide that the association or associations shall hold regular meetings not less than annually to further the purposes of the members; E. except for credit unions, collected dues or solicited contributions from members; and F. provided the members with voting representation on the governing board and committees. 3. The association, trust or fund, or the trustees of the trust or fund, named in statement 1. will be the policyholder of a group health policy issued by ____________________________________ with form number ________________________________. I represent the association, trust or fund named in statement 1. in the following capacity:_____________________________________ Signature: _______________________________________________________ Type or print name: Sworn to and subscribed before me this ___________ day of _________________, 19__________. My commission expires ____________________________, 19________________. ___________________________________________________________ Notary Public Affidavit 376.421.1(5) STATE OF__________________________) ) COUNTY OF_______________________) I,_______________________________________________________________ , on my oath swear that the following statements are true name to the best of my knowledge: 1. ___________________________________________________________________ is a credit union or is or are a trustee, trustees or agent designated by two or more credit unions. 2. I represent the credit union or trustee, trustees or agent named in statement 1. in the following capacity:__________________________ _________________________________________________________________________________________________________________ 3. The credit union or trustee, trustees or agent named in statement 1. will be the policyholder of a group health policy from _____________ __________________________________insurance company with form number _________________________________________________. Signature:__________________________________________________ Type or print name: Sworn to and subscribed before me this ______________ day of __________________, 19__________. My commission expires ________________________, 19_________________. ___________________________________________________________ Notary Public Affidavit 376.421.1(6) STATE OF__________________________) ) COUNTY OF_______________________) I,________________________________________________________________ , on my oath swear that the following statements are true name to the best of my knowledge: 1. ___________________________________________________________________________________ is a group specifically described in Missouri Revised Statutes, section 376.691. 2. The group named in statement number 1. will be the policyholder of a group health policy issued by ___________________________ ________________________________with form number_______________________________. 3. I represent the group named in statement 1. in the following capacity:______________________________________________________ Signature:_____________________________________________________ Type or print name: Sworn to and subscribed before me this _____________ day of _________________, 19________. My commission expires ____________________________, 19________. ___________________________________________________________ Notary Public Affidavit 376.421.1(7) STATE OF__________________________) ) COUNTY OF_______________________) I,___________________________________________________________________, on my oath swear that the following statements are true name to the best of my knowledge: 1. I hold the following office of the __________________________________________________ name of insurance company (the company):_________________________________________________ 2. I am authorized to execute this affidavit. 3. The company plans to issue group health policy form number _____________________________________________ (the group policy). 4. The issuance of the group policy is not contrary to the best interest of the public because:______________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ (Attach additional pages if necessary.) 5. The issuance of the group policy would result in economies of acquisition or administration described as follows:___________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ (Attach additional pages if necessary.) 6. The benefits are reasonable in relation to the premiums charged for the group policy as evidenced by the attached statement of the company's actuary. (Attach actuary's statement.) Signature:________________________________________________________ Type or print name: Sworn to and subscribed before me this ____________ day of _______________, 19______. My commission expires ___________________________, 19_______. ___________________________________________________________ Notary Public Affidavit 376.421.2.