Title 58 — INSURANCE

No long - term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in subdivision 58-17B-2(4)(a): (1) Shall use a definition of "preexisting condition" which is more restrictive than the following: Preexisting condition …

No long - term care insurance policy may be delivered or issued for delivery in this state if the policy: (1) Conditions eligibility for any benefits on a prior hospitalization requirement; (2) Conditions eligibility for benefits provided in an institutional care setting on the r…

The director may adopt rules, pursuant to chapter 1-26 , establishing loss ratio standards for long - term care insurance policies provided that a specific reference to long - term insurance policies is contained in the regulation. Source: SL 1989, ch 440 , § 9.

Long - term care insurance policyholders shall have the right to return the policy within thirty days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason. Long - term care insurance policies shall …

[Repealed or reserved.]

Terms used in this chapter mean: (1) "Utilization review," a review of health care services provided or to be provided to an individual to assist in the determination of the nature of the injury or condition, or the appropriateness of the treatment provided or to be provided; (2)…

A utilization review organization that conducts utilization reviews solely for property and casualty insurers in this state pursuant to policies issued in this state is not subject to chapters 58-17F , 58-17G , 58-17H , and 58-17I except that any such utilization review organizat…

Any property and casualty insurer seeking utilization review with respect to an insurance contract issued in this state may only use a utilization review organization registered pursuant to this chapter. Source: SL 2002, ch 231 , § 3.

Any utilization review pursuant to this chapter shall be administered by a qualified licensed health care professional. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care professional. Any utilization review evaluation s…

No utilization review organization may base its fees or charges on any recommendation for reduction in payment under an insurance contract or on a percentage of claim savings. Source: SL 2002, ch 231 , § 5.

An insurer that denies, in whole or in part, a policyholder's claim after consideration of a utilization review shall provide the policyholder with an opportunity to request reconsideration and to submit additional information relating to the claim. Source: SL 2002, ch 231 , § 6.

Nothing in this chapter is intended to create or abrogate any cause of action as a result of a violation of the standards in this chapter. Source: SL 2002, ch 231 , § 7.

For the purposes of this chapter, the term, affiliate, means a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified. For the purposes of this section, the term, control, or con…

After the receipt of an application filed pursuant to § 58-17E-9 , the director shall review the application and notify the applicant of any deficiencies in the application. Source: SL 2006, ch 257 , § 9.

Prior to registration by the director, each discount medical plan organization shall establish an internet website in order to conform to the requirements of §

Any registration is effective for one year, unless prior to its expiration the registration is renewed in accordance with this section or suspended or revoked in accordance with §

The director shall renew the registration of each holder that meets the requirements of this chapter. Source: SL 2006, ch 257 , § 12.

The director may suspend the authority of a discount medical plan organization to enroll new members or refuse to renew or revoke a discount medical plan organization's registration if the director finds that any of the following conditions exist: (1) The discount medical plan or…

If the director has cause to believe that grounds for the nonrenewal, suspension, or revocation of a registration exists, the director shall notify the discount medical plan organization in writing specifically stating the grounds for the refusal to renew or suspension or revocat…

If the registration of a discount medical plan organization is surrendered, revoked, or not renewed, the discount medical plan organization shall proceed, immediately following the effective date of the order of revocation or, in the case of a nonrenewal, the date of expiration o…

The director shall, in its order suspending the authority of the discount medical plan organization to enroll new members, specify the period during which the suspension is to be in effect and the conditions, if any, that shall be met by the discount medical plan organization pri…

In lieu of suspending or revoking a discount medical plan organization's registration pursuant to § 58-17E-14 , if the discount medical plan organization has been found to have violated any provision of this chapter, the director may enter into a consent order pursuant to §

A provider who provides discounts to the provider's own patients without any cost or fee of any kind to the patient is not required to obtain and maintain a registration under this chapter as a discount medical plan organization. Source: SL 2006, ch 257 , § 18.

For the purposes of this chapter, the term, discount medical plan, means a business arrangement or contract in which a person, in exchange for fees, dues, charges, or other consideration, offers access for its members to providers of medical or ancillary services and the right to…

Each registered discount medical plan organization shall maintain in force a surety bond in its own name in an amount not less than twenty thousand dollars and shall be in favor of any person and the director of the Division of Insurance for the benefit of any person who is damag…

In lieu of the bond required by § 58-17E-20 , a registered discount medical plan organization may deposit and maintain deposited with the director, or at the discretion of the director, with any organization or trustee acceptable to the director through which a custodial or contr…

Except for the director, the assets or securities held in this state as a deposit pursuant to §§ 58-17E-20 and 58-17E-21 are not subject to levy by a judgment creditor or other claimant of the discount medical plan organization. Source: SL 2006, ch 257 , § 22.

The director may examine or investigate the business and affairs of any discount medical plan organization to protect the interests of the residents of this state based on the following reasons, including complaint indices, recent complaints, information from other states, or as …

If the discount medical plan organization cancels a membership for any reason other than nonpayment of fees by the member, the discount medical plan organization shall make a pro rata reimbursement of all periodic charges to the member. Source: SL 2006, ch 257 , § 24.

A discount medical plan organization shall prepare written materials for its members that specifies the benefits a member is to receive under the discount medical plan and that complies with §§ 58-17E-38 , 58-17E-40 , and 58-17E-42 to 58-17E-44 , inclusive. Source: SL 2006, ch 25…

Any provider offering medical or ancillary services to members shall provide the services in accordance with a written agreement entered into directly by the provider or indirectly by a provider network to which the provider belongs. Source: SL 2006, ch 257 , § 26.

A provider agreement between a discount medical plan organization and a provider shall provide the following: (1) A list of the medical or ancillary services and products to be provided at a discount; (2) The amount or amounts of the discounts or, alternatively, a fee schedule th…

A provider agreement between a discount medical plan organization and a provider network shall require that the provider network have written agreements with its providers that: (1) Contain the provisions described in § 58-17E-27 ; (2) Authorize the provider network to contract w…

A provider agreement between a discount medical plan organization and an entity that contracts with a provider network shall require that the entity, in its contracts with the provider network, require the provider network to have written agreements with its providers that comply…

For the purposes of this chapter, the term, discount prescription drug plan, means a business arrangement or contract in which a person, in exchange for fees, dues, charges, or other consideration provides access for its plan members to providers of pharmacy services and the righ…

The discount medical plan organization shall maintain a copy of each active provider agreement into which it has entered. Source: SL 2006, ch 257 , § 30.

Each discount medical plan organization shall maintain on an internet website page an up-to-date list of the names and addresses of the providers with which it has contracted directly or through a provider network. The internet website address shall be prominently displayed on al…

The provisions of §§ 58-17E-26 to 58-17E-31 , inclusive, apply to those providers with which the discount medical plan organization has contracted with directly or indirectly as well as those providers that are members of a provider network with which the discount medical plan or…

A discount medical plan organization may market directly or contract with other marketers for the distribution of its product. The discount medical plan organization shall have an executed written agreement with a marketer prior to the marketer's marketing, promoting, selling, or…

The agreement between the discount medical plan organization and the marketer shall prohibit the marketer from using advertising, marketing materials, brochures, and discount medical plan cards without the discount medical plan organization's approval in writing. Source: SL 2006,…

The discount medical plan organization shall be bound by and is responsible for the activities of a marketer that are within the scope of the marketer's contract with the organization, or are otherwise approved by or under the direction and control of the organization. Source: SL…

A discount medical plan organization shall approve in writing any advertisement, marketing material, brochure, or discount card used by marketers to market, promote, sell, or distribute the discount medical plan prior to their use. Source: SL 2006, ch 257 , § 36.

Upon request, a discount medical plan organization shall submit to the director any advertising, marketing material, or brochure regarding a discount medical plan. Source: SL 2006, ch 257 , § 37.

Any advertisement of a discount medical plan organization shall be truthful and not misleading in fact or in implication. An advertisement is misleading if it has a capacity or tendency to mislead or deceive based on the overall impression that the advertisement is reasonably exp…

Any person subject to registration pursuant to § 58-17E-9 shall prominently and boldly disclose that the product is not insurance. Any advertisements or solicitations made by such a person are subject to the provisions of §§ 58-33A-2 to 58-33A-4 , inclusive, and §§ 58-33A-7 to 58…

For the purposes of this chapter, discount medical plan organization, means an entity that, in exchange for fees, dues, charges, or other consideration, provides access for discount medical plan members to providers of medical or ancillary services and the right to receive medica…

No discount medical plan organization may: (1) Except as otherwise provided in this chapter or as a disclaimer of any relationship between discount medical plan benefits and insurance, or as a description of an insurance product connected with a discount medical plan, use the ter…

No person subject to registration pursuant to § 58-17E-9 may receive personal information, money, or other consideration for enrollment in a plan or program until the consumer has signed a contract or agreement with the person and no later than at the time the contract is signed,…

If the initial contact with a prospective member is by telephone, the disclosures required by § 58-17E-41 shall be made orally and included in the initial written materials that describe the benefits under the discount medical plan provided to the prospective or new member. Sourc…

In addition to the general disclosures required by § 58-17E-41 , each discount medical plan organization shall provide to each new member a copy of the terms of the discount medical plan in written materials. Source: SL 2006, ch 257 , § 41.