North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-02 - Group Coverage Discontinuance and Replacement Model Regulation › Section 45-08-02-02 - Definitions

Current through Supplement No. 393, July, 2024
For purposes of this chapter:
1. "Carrier" means a person or an entity that offers or
				  provides a policy, contract, or certificate of insurance coverage in this
				  state. "Carrier" includes an insurer, a health maintenance organization, a
				  nonprofit service corporation, or any other person or entity providing a
				  policy, contract, or certificate of insurance coverage subject to state
				  insurance regulation.
2. "Group-type basis" means a benefit plan, other than
				  "salary budget" plans utilizing individual insurance policies, certificates, or
				  subscriber contracts, which meets the following conditions:
a. Coverage is provided through insurance policies,
				  certificates, or subscriber contracts to classes of employees or members
				  defined in terms of conditions pertaining to employment or membership.
b. The coverage is not available to the general public and
				  can be obtained and maintained only because of the covered person's membership
				  in or connection with the particular organization or group, including bank
				  depositor groups.
c. There are arrangements for bulk payment of premiums or
				  subscription charges to the insurer or nonprofit service corporation.
d. There is sponsorship of the plan by the employer, union,
				  bank, or association.
3.
a. "Health insurance coverage" means a hospital and medical
				  expense incurred policy, a nonprofit health care service plan contract, a
				  health maintenance organization subscriber contract, or any other health care
				  plan or arrangement that pays for or furnishes medical or health care services
				  whether by insurance or otherwise.
b. "Health insurance coverage" shall not include one or more,
				  or any combination of, the following:
(1) Coverage only for accident, or disability income
				  insurance, or any combination thereof;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability
				  insurance and automobile liability insurance;
(4) Workers' compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for onsite medical clinics; and
(8) Other similar insurance coverage, specified in federal
				  regulations issued pursuant to the Health Insurance Portability and
				  Accountability Act of 1996 (HIPAA) [
				  Pub. L. No.
				  104-191 ], under which benefits for medical care
				  are secondary or incidental to other insurance benefits.
c. "Health insurance coverage" shall not include the
				  following benefits if they are provided under a separate policy, certificate or
				  contract of insurance or are otherwise not an integral part of the coverage:
(1) Limited scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home
				  health care, community-based care, or any combination thereof; or
(3) Other similar, limited benefits specified in federal
				  regulations issued pursuant to HIPAA.
d. "Health insurance coverage" shall not include the
				  following benefits if the benefits are provided under a separate policy,
				  certificate or contract of insurance, there is no coordination between the
				  provision of the benefits and any exclusion of benefits under any group health
				  plan maintained by the same plan sponsor, and the benefits are paid with
				  respect to an event without regard to whether benefits are provided with
				  respect to such an event under any group health plan maintained by the same
				  plan sponsor:
(1) Coverage only for a specified disease or illness; or
(2) Hospital indemnity or other fixed indemnity insurance.
e. "Health insurance coverage" shall not include the
				  following if offered as a separate policy, certificate, or contract of
				  insurance:
(1) Medicare supplemental health insurance as defined under
				  section 1882(g)(1) of the Social Security Act;
(2) Coverage supplemental to the coverage provided under
				  chapter 55 of title 10, United States Code; or
(3) Similar supplemental coverage provided to coverage under
				  a group health plan.
General Authority: NDCC 26.1-04-08, 28-32-02
Law Implemented: NDCC 26.1-04-03(7), 26.1-30-19,
					 26.1-33-11, 26.1-33-12, 26.1-36-22, 26.1-36-23,
					 26.1-36-23.1