North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-11 - Regulation on the Crediting of Qualifying Previous Coverage Toward the Reduction of Preexisting Condition Exclusion Periods › Section 45-06-11-03 - Certification of coverage in the individual market

Current through Supplement No. 393, July, 2024
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 following:
a. An automatic certificate must be provided
				within a reasonable period of time after the individual ceases to be covered
				under the policy; and
b. A
				certificate of coverage must be provided upon request if the request is made,
				by or on behalf of an individual, within twenty-four months after coverage
				ends.
c. A certificate of coverage
				issued under this section must be provided in writing. However, a written
				certificate is not required if:
(1) The
				individual is entitled to receive a certificate of coverage;
(2) The individual requests that the
				certificate be sent to another plan or health carrier instead of to the
				individual;
(3) The plan or health
				carrier agrees to accept the information through means other than a written
				certificate; and
(4) The plan or
				health carrier receives the certification within a reasonable time.
d. A certificate of coverage
				issued under this section must include the following information in a form
				similar to that shown in appendix A:
(1) The
				date on which the certificate is issued;
(2) The name of the individual or dependent
				to whom the certificate applies and any other information necessary to identify
				the individual;
(3) The name,
				address, and telephone number of the issuer of the certificate;
(4) A telephone number to call for further
				information;
(5) The date the
				qualifying previous coverage ended, unless the certificate indicates that the
				qualifying previous coverage is continuing as of the date of the certificate;
				and
(6) Either one of the
				following statements:
(a) A statement that
				the individual has at least eighteen months of qualifying previous coverage; or
(b) Both the date the individual
				first sought coverage, as evidenced by a substantially complete application,
				and the date qualifying previous coverage began.
e. If an automatic certificate is
				provided under this section, the period that must be included on the
				certificate is the last period of continuous qualifying previous coverage
				ending on the date coverage ceased.
f. If an individual requests a certificate
				under this section, a certificate must be provided for each period of
				continuous qualifying previous coverage ending within the twenty-four-month
				period ending on the date of the request. A separate certificate may be
				provided for each such period of continuous qualifying previous coverage.
g. A health carrier may provide a
				single certificate for both an individual and the individual's dependents if it
				provides all the required information for each individual and dependent, and
				separately states the information that is not identical.
h. The certificate is required to be
				provided, without charge, to each individual described in this section or an
				entity requesting the certificate on behalf of the individual. The certificate
				may be provided by first-class mail. If the certificate or certificates are
				provided to the individual and the individual's spouse at the individual's
				last-known address, the requirements of this section are satisfied with resect
				to all individuals residing and dependents at that address. If the dependent's
				last-known address is different than the individual's last-known address, a
				separate certificate is required to be provided to the dependent at the
				dependent's last-known address.
i.
				A health carrier must establish a procedure for individuals to request and
				receive certificates under this section.
j. If an automatic certificate is required to
				be provided under this section, and the individual entitled to receive the
				certificate designates another individual or entity to receive the certificate,
				the health carrier responsible for providing the certificate is permitted to
				provide the certificate to the designated party.
k. If a certificate is required to be
				provided upon request under this section and the individual entitled to receive
				the certificate designates another individual or entity to receive the
				certificate, the health carrier responsible for providing the certificate is
				required to provide the certificate to the designated party.
l. A health carrier is required to use
				reasonable efforts to determine any information needed for a certificate
				relating to the dependent coverage. In any case in which an automatic
				certificate is required to be furnished with respect to a dependent under this
				section, no individual certificate is required to be furnished until the health
				carrier knows, or making reasonable efforts should know, of the dependent's
				cessation of coverage under the plan.
m. If a certificate furnished by a health
				carrier does not provide the name of any dependent of an individual covered by
				the certificate, the individual may, if necessary, use the procedures described
				in this section for demonstrating dependent status. In addition, an individual
				may, if necessary, use these procedures to demonstrate that a child was
				enrolled within thirty days of birth, adoption, or placement for adoption.
n. A health carrier that cannot
				provide the names of dependents, or related coverage information, for purposes
				of providing a certificate of coverage for a dependent may satisfy the
				requirements of this section by providing the name of the participant covered
				by the health carrier and specifying that the type of coverage described in the
				certificate is for dependent coverage. This subdivision is in effect through
				June 30, 1998.
o. For purposes of
				certificates provided at the request of, or on behalf of, an individual in this
				section, a health carrier must make reasonable efforts to obtain and provide
				the names of any dependent covered by the certificate if such information is
				requested to be provided. If the certificate does not include the name of any
				dependent of an individual covered by the certificate, the individual may, if
				necessary, use the procedures described in this section for submitting
				documentation to establish that the qualifying previous coverage in the
				certificate applies to the dependent.
p. A health carrier providing an automatic
				certificate that does not contain the name of a dependent must furnish a
				certificate within twenty-one days after the individual ceases to be covered
				under the policy.
q. If an
				individual enrolls in a group health benefit plan with respect to which the
				plan or health carrier uses the alternative method of counting qualifying
				previous coverage described in this section, the individual provides a
				certificate of coverage under this section, and the plan or health carrier in
				which the individual enrolls so requests, the entity that issued the
				certificate, the "prior entity", is required to disclose promptly to a
				requesting plan or health carrier, the "requesting entity", the information set
				forth in this section. The prior entity furnishing the information under this
				subsection may charge the requesting entity for the reasonable cost of
				disclosing such information.
r.
				Every health carrier must allow individuals to establish qualifying previous
				coverage by means other than a certificate. The health carrier is required to
				take into account all information that it obtains or that is presented on
				behalf of an individual in making its determination, based on the relevant
				facts and circumstances, whether the individual has qualifying previous
				coverage and is entitled to offset all or a portion of any preexisting
				condition exclusion period. The health carrier shall treat the individual as
				having provided a certificate if the individual attests to the period of
				qualifying previous coverage, presents relevant corroborating evidence, and
				cooperates with the plan or health carrier's efforts to verify the coverage.
				While a health carrier may refuse to credit coverage if the individual fails to
				cooperate with efforts to verify coverage, the health carrier may not consider
				an individual's inability to obtain a certificate as evidence of the absence of
				qualifying previous coverage.