Montana Code 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:
Terms Used In Montana Code 33-22-1315
- Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
- 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. See Montana Code 33-22-1303
- Benefit year: means the calendar year for which an eligible health insurer provides coverage through an individual health insurance policy. See Montana Code 33-22-1303
- Board: means the association's board of directors provided for in 33-22-1306. See Montana Code 33-22-1303
- 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. See Montana Code 33-22-1303
- 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. See Montana Code 33-22-1303
- 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. See Montana Code 33-22-1303
- Reinsurance payments: means an amount paid by the association to an eligible health insurer under the program. See Montana Code 33-22-1303
(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.