North Dakota Administrative Code

1. Description of providers. a. A health maintenance organization shall provide its subscribers with a list of the names and locations of all of its providers no later than the time of enrollment or the time the group or individual contract and evidence of coverage are issued and…

Any violation of this chapter is subject to the penalties as provided for in North Dakota Century Code title 26.1 and any other applicable law of this state. History: Effective July 1, 1994. General Authority: NDCC 26.1-18.1 14 Law Implemented: NDCC 26.1-18.1…

If any provision of this chapter or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the chapter and the application for such provision to other persons or circumstances is not affected thereby. History: Effective July …

Any health maintenance organization producer under this chapter is subject to the requirements and provisions of North Dakota Century Code chapter 26.1-26. History: Effective July 1, 1998. General Authority: NDCC 26.1-18.1-16 Law Implemented: NDCC 26.1-18.1-16 15…

These rules apply to all policies providing hospital, surgical, medical, or major medical benefits, including major medical, hospital/surgical, medical expense, and surgical expense policies. This rule does not apply to any contract or plan of insurance that provides exclusively …

Mandated loss ratio benefits under the policies specified in section 45-06-08-01 must return benefits to group policyholders in the aggregate of not less than seventy percent of premium received and to individual policyholders in the aggregate of not less than fifty-five percent …

The requirements of this chapter apply to policies issued after January 1, 1994. History: Effective July 1, 1994. 1 General Authority: NDCC 26.1-36-37.2 Law Implemented: NDCC 26.1-36-37.2 2…

The purpose of this chapter is to further improve the fairness, efficiency, and competition in the pricing and delivering of health care and health care coverage. It does so by allowing for the establishment of joint purchasing entities (purchasing cooperatives) through which eli…

This chapter applies to all health insurance purchasing cooperatives operating in this state or providing coverage to North Dakota residents. Health purchasing cooperatives are subject to the small employer employee health insurance coverage requirements contained in North Dakota…

1. "Business plan" means the plan of operation of the health insurance purchasing cooperative. 2. "Commissioner" means the insurance commissioner. 3. "Group" means a collection of small employers subject to the requirements of North Dakota Century Code chapter 26.1-36.3 who elect…

1. The commissioner has the authority to regulate the establishment and conduct of health insurance purchasing cooperatives as set forth in this chapter. 2. The commissioner has the authority to conduct financial and performance audits on health insurance purchasing cooperatives …

A health insurance purchasing cooperative shall submit a business plan for review and approval by the commissioner. The business plan must include the following information: 1. The specific steps by the health insurance purchasing cooperative to advance cost control, quality impr…

1. Health care providers or insurers offering competing products within the same service territory may not participate in a health insurance purchasing cooperative as a sponsor or administrator. 2. A health insurance purchasing cooperative sponsor or administrator may not be an e…

Repealed effective April 1, 2010.

Health insurance cooperatives collecting premiums shall provide bonding coverage for cooperative employees handling funds. Evidence of bond coverage sufficient to cover the volume of premium collected by the purchasing cooperative must be filed with the annual report required und…

For purposes of this chapter "licensed practitioner" includes dentist, chiropractor, psychologist, and optometrist. History: Effective September 1, 1994. General Authority: NDCC 26.1-01-08, 28-32-02 Law Implemented: NDCC 26.1-26.4-04

1. After an initial appeal to reverse a determination regarding hospital, medical, or other health care services is unsuccessful, a subsequent determination which may result in denial of third-party reimbursement or denial of precertification for service must include the evaluati…

As used in this chapter: 1. "Enrollment date" means the first day of coverage or, if there is a waiting period, the first day of the waiting period. 2. "First day of coverage" means, in the case of an individual covered for benefits under a group health plan in the group market, …

1. Any health carrier offering health insurance in this state must reduce any time period applicable to a preexisting condition exclusion or limitation period by the aggregate of periods the individual was covered by qualifying previous coverage, if any, if the qualifying previou…

1. This section applies to all health carriers offering health insurance coverage in the individual market. 2. A certificate of coverage must be provided, without charge, for individuals and dependents, who are or were covered under an individual health insurance policy, for the …

1. A health carrier offering group health insurance coverage under a group health benefit plan is required to provide certificates of qualifying previous coverage in accordance with this section. 2. Any entity required to provide a certificate under this section for an individual…

exclusion period. 1. A health carrier is required, within a reasonable time, to make a determination regarding the individual's qualifying previous coverage and notify the individual of the determination in accordance with this section. 2. A health carrier seeking to impose a pre…

As used in this chapter and North Dakota Century Code chapter 26.1-36.4: 1. "Preexisting condition exclusion" means a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the effective date of coverage, whether or not…

health status-related factors. 1. An insurer offering group health insurance coverage in connection with a group health benefit plan may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan based on a health…

1. An insurer offering group health insurance coverage in connection with a group health benefit plan is required to permit employees and dependents described in this section to enroll for coverage under the terms of the plan if the conditions in subsection 4 are satisfied and th…

1. A group health benefit plan that makes coverage available with respect to dependents of a participant is required to provide a special enrollment period to permit individuals described in this section to be enrolled for coverage under the terms of the plan if the enrollment is…

On or before the time an employee is offered the opportunity to enroll in a group health benefit plan, the plan is required to provided the employee with a description of the plan's special enrollment rules under this chapter. A group health benefit plan using the following model…

1996. This chapter, as well as North Dakota Century Code chapter 26.1-36.4, will be interpreted by the commissioner to conform with the requirements of the Health Insurance Portability and Accountability Act of 1996 [Pub. L. 104-191; 110 Stat. 1936; 29 U.S.C. 1181 et seq.]. Histo…

1. "Commissioner" means the insurance commissioner of North Dakota. 2. "Department" means the North Dakota insurance department. 3. "Health care services" means the following medically necessary services: preventive care, emergency care, inpatient and outpatient hospital and phys…

The commissioner shall issue a certificate of authority for the purpose of providing health care to Medicare enrollees only to a provider-sponsored organization that meets each requirement for the issuance of a certificate of authority as a health maintenance organization as in N…

The department shall take action on an application required in section 45-06-13-02 within ninety days of the date of receipt of a substantially complete application. History: Effective August 1, 2000. General Authority: NDCC 26.1-01-07.6 Law Implemented: NDCC 26.1-01-07.6

Prior to the issuance of a certificate of authority, a provider-sponsored organization must have a minimum net worth amount of: 1. At least one million five hundred thousand dollars except as provided in subsection 2. 2. No less than one million dollars based on evidence from the…

1. General rule. At the time of application under section 45-06-13-03, an applicant must submit a financial plan acceptable to the department. 2. A financial plan must include: a. A detailed marketing plan; b. Statements of revenue and expense on an accrual basis; c. Statements o…

1. A provider-sponsored organization shall have sufficient cash flow to meet its financial obligations as they become due and payable. 2. To determine whether the provider-sponsored organization meets the requirement in subsection 1, the department will examine the following: a. …

1. Insolvency deposit. a. At the time of application, an organization shall deposit one hundred thousand dollars in cash or securities, or any combination thereof, into an account in a manner that is acceptable to the department. b. The deposit must be restricted to use in the ev…

1. General policy. A provider-sponsored organization, or the legal entity of which the provider-sponsored organization is a component, may apply to the department to use the financial resources of a guarantor for the purpose of meeting the requirements in section 45-06-13-05. The…

1. "Board" means a multiple employer welfare arrangement's board of trustees. 2. "Bylaws" means the statements and organizational documents adopted by a multiple employer welfare arrangement that prescribe its purpose, government, and administration. 3. "Commissioner" means the i…

This chapter governs the formation, operation, and dissolution of a multiple employer welfare arrangement. The provisions are intended to ensure the financial integrity and the competent and equitable administration of the multiple employer welfare arrangement. History: Effective…

This chapter shall apply to all multiple employer welfare arrangements which offer or maintain an employee welfare benefit plan that is not fully insured, to or on behalf of an employer domiciled in this state or to an employer which has its principal headquarters or principal ad…

1. Content. Bylaws may contain any provision that does not conflict with this chapter. Bylaws must, at a minimum, contain the following provisions: a. The multiple employer welfare arrangement's name, purpose, fiscal year, and initial date of existence; b. Definitions of key term…

1. Structure. A multiple employer welfare arrangement must have a board of trustees consisting of at least three persons, who must be officials or employees of the members of the multiple employer welfare arrangement or of the sponsoring association of the multiple employer welfa…

1. Initial application. A multiple employer welfare arrangement seeking to offer an employee welfare benefit plan that is not fully insured shall apply for a certificate of authority. Applications must be submitted on forms prescribed by the commissioner. The appropriate filing f…

1. Termination. A multiple employer welfare arrangement may terminate its self-funded authority and cease to provide coverage effective at the end of a fund year. The multiple employer welfare arrangement must notify the commissioner within ninety days of its decision to terminat…

1. Service company. A multiple employer welfare arrangement must contract with a service company for services necessary to conduct the multiple employer welfare arrangement day-to-day operations, except services and responsibilities reserved to the members, the board, individual …

1. Availability. A multiple employer welfare arrangement must establish nondiscriminatory criteria for membership. A multiple employer welfare arrangement may reject applicants or dispel members that do not meet the multiple employer welfare arrangement's underwriting standards. …

1. Coverage. A multiple employer welfare arrangement must provide coverage as authorized by the board. 8 2. Uniform underwriting. A multiple employer welfare arrangement must offer its coverages subject to the same underwriting standards to all members and, if applicable, to all …

1. Minimum annual premium. A multiple employer welfare arrangement must have and maintain an annual premium volume of no less than three hundred thousand dollars. A multiple employer welfare arrangement or prospective multiple employer welfare arrangement may apply to the commiss…

A multiple employer welfare arrangement must establish reserves for all incurred losses, both reported and unreported, and for unearned premiums. To the extent that the amount of a loss is uncertain, the reserve must be set conservatively and adjusted as new information becomes a…

1. Purchase. A multiple employer welfare arrangement may purchase stop-loss insurance to cover a portion of its losses. If a stop-loss insurance policy is terminated or modified causing a violation of subsection 2, or otherwise compromising the multiple employer welfare arrangeme…

1. Each current member of a multiple employer welfare arrangement is jointly and severally liable for all liabilities and expenses of the multiple employer welfare arrangement. Each past member is jointly and severally liable for all liabilities and expenses of the multiple emplo…