For purposes of these rules, in addition to the definitions in 33-22-1107, MCA, the following definitions apply:

1. (1) "Benefit trigger," for the purposes of independent review, means a contractual provision in the insured's policy of long-term care insurance conditioning the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. For purposes of a tax-qualified long-term care insurance contract, as defined in Section 770B of the Internal Revenue Code of 1986, as amended, "benefit trigger" shall include a determination by a licensed health care practitioner that an insured is a chronically ill individual.
2. (2) "Commissioner" means the Montana State Auditor and Ex Officio Commissioner of Insurance.

3. (3) "Exceptional increase" means a premium rate increase filed by an insurer as exceptional; and

   1. (a) for which the commissioner determines the need for a rate increase to be justified:

      1. (i) due to a change in laws or rules applicable to long-term care coverage in this state; or
      2. (ii) due to increased and unexpected utilization that affects the majority of insurers of similar products.
   2. (b) except as provided in ARM 6.6.3124, exceptional increases are subject to the same requirements as other premium rate increases;
   3. (c) the commissioner may request a review of the basis for the exceptional increase by an independent actuary or a professional actuarial body;
   4. (d) the commissioner, in determining whether there is a necessary basis for an exceptional increase, shall also determine any potential offsets to higher claims costs.
4. (4) "Incidental" means that the value of the long-term care benefits provided is less than 10% of the total value of the benefits provided over the life of the policy. These values shall be measured as of the date of issue.
5. (5) "Independent review organization" has the same meaning as in 33-32-402, MCA.
6. (6) "Insurer" or "issuer" means an insurance company, health service corporation, health maintenance organization, or other entity providing long-term care insurance or benefits in Montana.
7. (7) "Licensed health care professional" means an individual qualified by education and experience in an appropriate field to determine, by record review, an insured's actual functional or cognitive impairment.
8. (8) "Qualified actuary" means a member in good standing of the American Academy of Actuaries.

Authorizing statute(s): 33-1-313, 33-22-1121, MCA

Implementing statute(s): 33-22-1101, 33-22-1102, 33-22-1103, 33-22-1107, 33-22-1108, 33-22-1111, 33-22-1112, 33-22-1113, 33-22-1114, 33-22-1115, 33-22-1116, 33-22-1117, 33-22-1119, 33-22-1120, 33-22-1121, MCA

History: NEW, 1991 MAR p. 119, Eff. 2/1/91; AMD, 2008 MAR p. 615, Eff. 10/1/08; AMD, 2019 MAR p. 126, Eff. 1/26/19.