North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-01.1 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 45-06-01.1-05 - Minimum benefit standards for prestandardized medicare supplement benefit plan policies or certificates issued for delivery prior to January 1, 1992

Current through Supplement No. 393, July, 2024
No policy or certificate may be advertised, solicited, or
				  issued for delivery in this state as a medicare supplement policy or
				  certificate unless it meets or exceeds the following minimum standards. These
				  are minimum standards and do not preclude the inclusion of other provisions or
				  benefits which are not inconsistent with these standards:
1.
General standards.
The
				following standards apply to medicare supplement policies and certificates and
				are in addition to all other requirements of this rule:
a. A medicare supplement policy or
				certificate may not exclude or limit benefits for losses incurred more than six
				months from the effective date of coverage because it involved a preexisting
				condition. The policy or certificate may not define a preexisting condition
				more restrictively than a condition for which medical advice was given or
				treatment was recommended by or received from a physician within six months
				before the effective date of coverage.
b. A medicare supplement policy or
				certificate may not indemnify against losses resulting from sickness on a
				different basis than losses resulting from accidents.
c. A medicare supplement policy or
				certificate must provide that benefits designed to cover cost-sharing amounts
				under medicare will be changed automatically to coincide with any changes in
				the applicable medicare deductible, copayment, or coinsurance amounts. Premiums
				may be modified to correspond with such changes.
d. A "noncancelable", "guaranteed renewable",
				or "noncancelable and guaranteed renewable" medicare supplement policy may not:
(1) Provide for termination of coverage of a
				spouse solely because of the occurrence of an event specified for termination
				of coverage of the insured, other than the nonpayment of premium; or
(2) Be canceled or nonrenewed by the issuer
				solely on the grounds of deterioration of health.
e.
(1)
				Except as authorized by the commissioner of this state, an issuer may neither
				cancel nor nonrenew a medicare supplement policy or certificate for any reason
				other than nonpayment of premium or material misrepresentation.
(2) If a group medicare supplement insurance
				policy is terminated by the group policyholder and not replaced as provided in
				paragraph 4, the issuer must offer certificate holders an individual medicare
				supplement policy. The issuer must offer the certificate holder at least the
				following choices:
(a) An individual medicare
				supplement policy currently offered by the issuer having comparable benefits to
				those contained in the terminated group medicare supplement policy; and
(b) An individual medicare
				supplement policy which provides only such benefits as are required to meet the
				minimum standards as defined in subsection 2 of section
				45-06-01.1-06.1.
(3) If membership in a group is
				terminated, the issuer must:
(a) Offer the
				certificate holder the conversion opportunities described in paragraph 2; or
(b) At the option of the group
				policyholder, offer the certificate holder continuation of coverage under the
				group policy.
(4) If a
				group medicare supplement policy is replaced by another group medicare
				supplement policy purchased by the same policyholder, the issuer of the
				replacement policy must offer coverage to all persons covered under the old
				group policy on its date of termination. Coverage under the new group policy
				may not result in any exclusion for preexisting conditions that would have been
				covered under the group policy being replaced.
f. Termination of a medicare supplement
				policy or certificate must be without prejudice to any continuous loss which
				commenced while the policy was in force, but the extension of benefits beyond
				the period during which the policy was in force may be predicated upon the
				continuous total disability of the insured, limited to the duration of the
				policy benefit period, if any, or to payment of the maximum benefits. Receipt
				of medicare part D benefits will not be considered in determining a continuous
				loss.
g. If a medicare supplement
				policy eliminates an outpatient prescription drug benefit as a result of
				requirements imposed by the Medicare Prescription Drug Improvement and
				Modernization Act of 2003, the modified policy shall be deemed to satisfy the
				guaranteed renewal requirements of this subsection.