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North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-05 - Board

Current through Supplement No. 393, July, 2024
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 welfare arrangement. No member may have
				more than one representative on the board, unless the multiple employer welfare
				arrangement has only two members, in which case each member must have at least
				one representative on the board. No trustee may be an employee of, or receive
				compensation from, the multiple employer welfare arrangement's service company,
				financial administrator, or insurer. A trustee may be an employee, agent, or
				representative of the sponsoring association. Trustees shall be elected by the
				membership or appointed by the sponsoring association. A majority of the
				trustees must be employees of members and be covered by the benefits provided
				by the multiple employer welfare arrangement. One trustee shall be designated
				the chairperson. The board shall meet no less than four times
				annually.
2.
Duties.
The board is responsible for operation of the multiple employer welfare
				arrangement. The board may delegate some or all of its responsibilities to the
				chairperson or other trustees between board meetings. All responsibilities of
				the multiple employer welfare arrangement not expressly delegated by the board
				or this chapter are the responsibility of the board. The board shall, at a
				minimum, have the following responsibilities:
a. Exercise fiduciary responsibility for the
				multiple employer welfare arrangement's operation and financial
				condition;
b. Select, supervise,
				and evaluate the service company, financial administrator, accountant, insurer,
				and any other contractors;
c. On
				the basis of the multiple employer welfare arrangement's overall financial
				condition, authorize changes in premium, reserve, or investment practices and
				declare assessments or dividends as appropriate;
d. Approve all reports concerning the
				multiple employer welfare arrangement's operations and status and oversee
				filing of reports with the commissioner;
e. Monitor delinquent premiums, loss
				experience, and the financial condition of individual members and authorize
				disciplinary action or expulsion as appropriate;
f. Accept or reject applications for
				membership;
g. As permitted by the
				bylaws, make or recommend changes to the bylaws for the improvement of the
				multiple employer welfare arrangement's operation and financial integrity;
				and
h. Monitor the multiple
				employer welfare arrangement's compliance with all statutes and rules governing
				its operation.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-06 - Application

Current through Supplement No. 393, July, 2024
1.
Initial
				application.
A multiple employer welfare arrangement that seeks 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 fee pursuant to North Dakota Century
				Code section 26.1-01-07 must accompany the application. An application must be
				submitted no later than sixty days prior to the requested date for authority to
				self-fund. An incomplete application must be returned to the applicant. An
				application not returned to the applicant within fourteen days of receipt must
				be acted upon within sixty days of receipt.
2.
Documents which must accompany
				application.
A multiple employer welfare arrangement shall file all of
				the following with its initial application:
a. A copy of the organizational documents of
				the multiple employer welfare arrangement, including the articles of
				incorporation and bylaws, partnership agreement, or instrument;
b. A copy of each insurance or reinsurance
				contract that purports to insure or guarantee any portion of benefits or
				coverage offered by the multiple employer welfare arrangement;
c. A copy of the benefit plan description and
				any other materials intended to be distributed to potential members;
				and
d. The names and addresses of
				all persons performing or expected to perform the functions of a financial
				administrator or service company.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-07 - Ending self-funding, runoff period, and plan dissolution

Current through Supplement No. 393, July, 2024
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 terminate. A multiple
				employer welfare arrangement may not terminate its self-funding authority less
				than ninety days prior to the end of the fund year in question. The voluntary
				termination of self-funding authority does not constitute multiple employer
				welfare arrangement dissolution under subsection 4.
2.
Revocation.
The commissioner
				shall, by order, revoke the authority of a multiple employer welfare
				arrangement to self-fund upon no less than ten days' written notice if any of
				the following events occur or conditions develop, and if the commissioner
				determines that the conditions are material:
a. Failure of the multiple employer welfare
				arrangement to comply with this chapter or with other applicable North Dakota
				laws or rules or the applicable laws and rules of any other state;
b. Failure of the multiple employer welfare
				arrangement to comply with any lawful order of the commissioner or the lawful
				order of the commissioner of another state;
c. Commission by the multiple employer
				welfare arrangement of a prohibited practice as defined by North Dakota Century
				Code chapter 26.1-04 or in related rules; or
d. A deterioration of the multiple employer
				welfare arrangement's financial integrity to the extent that its present or
				future ability to meet its obligations is or will be significantly
				impaired.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-08 - Administration

Current through Supplement No. 393, July, 2024
1.
Service
				company.
A multiple employer welfare arrangement must contract with a
				service company for services necessary to conduct the multiple employer welfare
				arrangement's day-to-day operations, except services and responsibilities
				reserved to the members, the board, individual trustees, the financial
				administrator, the accountant, or other contractors unless the multiple
				employer welfare arrangement has the staff and expertise to perform the
				day-to-day operations. The service company must have expertise in and be
				licensed for the coverages provided by the multiple employer welfare
				arrangement. Subject to the oversight of the board, the service company shall,
				directly or through subcontractors, provide all services directly related to
				the administration of coverage. These services include:
a. Accounting and recordkeeping;
b. Billing and collection of premiums and
				assessments;
c. Claims
				investigation, settlement, and reserving;
d. Claims payment, including claims wholly or
				partially subject to stop-loss insurance or member deductibles;
e. General administration;
f. Loss control, safety programs, or both;
				and
g. Underwriting.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-09 - Membership

Current through Supplement No. 393, July, 2024
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.
2.
Joining.
A new member must be
				admitted according to the standards and procedures specified in the bylaws.
				Membership is not effective until the applicant has signed a membership
				agreement affirming its commitment to comply with the bylaws and this chapter,
				including joint and several liability for the multiple employer welfare
				arrangement's obligations. The membership agreement must disclose that under
				the rules governing the multiple employer welfare arrangement, the board of
				trustees, or the commissioner, may order that an assessment be levied against
				the members if necessary to maintain the multiple employer welfare
				arrangement's sound financial condition.
3. Withdrawal. The membership agreement must
				include the procedures for withdrawing from the multiple employer welfare
				arrangement. A member must notify the multiple employer welfare arrangement of
				its desire to withdraw not less than thirty days before the date upon which it
				desires to withdraw. If the board determines that the withdrawal would cause
				the multiple employer welfare arrangement to be in violation of the minimum
				annual premium requirement or would compromise the multiple employer welfare
				arrangement's financial integrity, the multiple employer welfare arrangement
				must notify the commissioner as required under subsection 2 of section
				45-06-14-11. Withdrawal is
				prohibited and void unless:
a. The member has
				belonged to the multiple employer welfare arrangement continuously for the
				period required by the bylaws, which shall provide for a minimum of one
				complete fund year.
b. All
				outstanding premiums and assessments owed by the member have been
				paid.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-10 - Coverage

Current through Supplement No. 393, July, 2024
1.
Coverage.
A multiple employer welfare arrangement must provide coverage as
				authorized by the board.
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 members' employees.
3.
Continuing responsibility.
Notwithstanding cancellation or termination of coverage to a particular
				member, ceasing to offer a particular coverage, or termination or revocation of
				authority to self-fund, a multiple employer welfare arrangement retains
				indefinitely all responsibilities to members and other covered persons
				associated with the period while coverage was in force. This responsibility
				ceases only after a multiple employer welfare arrangement dissolves under
				subsection 4 of section
				45-06-14-07.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC 26.1-01-07.4,
					 26.1-07.1
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-11 - Premiums, cashflow, and dividends

Current through Supplement No. 393, July, 2024
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 commissioner for a reduction of
				the minimum annual premium requirement, stating the amount of reduction and the
				reasons supporting the request. The commissioner must act on the application
				within sixty days after receipt. The multiple employer welfare arrangement must
				demonstrate that the lesser premium volume would not compromise its financial
				integrity and stability.
2.
Monitoring premium volume.
A multiple employer welfare arrangement
				must monitor its premium volume. If annual premium is more than three hundred
				thousand dollars but less than four hundred thousand dollars, or less than one
				hundred thirty-three percent of the amount approved pursuant to subsection 1,
				the multiple employer welfare arrangement must notify the commissioner at
				monthly intervals of the then-current annualized premium volume, until the
				annualized volume exceeds four hundred thousand dollars. "Annualized premium
				volume" means the gross premiums written for the previous twelve months. If
				premium decreases to an annualized volume of less than three hundred thousand
				dollars, or a lesser amount if approved pursuant to subsection 1, the multiple
				employer welfare arrangement must notify the commissioner:
a. Of its intent to end its self-funding
				authority; or
b. Of its proposal
				for restoring compliance with subsection 1. If the proposal is unlikely, in the
				commissioner's judgment, to restore compliance with subsection 1 within ninety
				days, or if after ninety days the multiple employer welfare arrangement
				continues to be out of compliance, the commissioner may revoke the multiple
				employer welfare arrangement's self-funding authority.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-12 - Reserves

Current through Supplement No. 393, July, 2024
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
				  available. Accounting for reserves must be as required by the financial
				  statement forms and instructions under subsection 2 of section
				  45-06-14-16.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC 26.1-01-07.4,
					 26.1-07.1
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-13 - Stop-loss insurance

Current through Supplement No. 393, July, 2024
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 arrangement's financial integrity, the multiple
				employer welfare arrangement must notify the commissioner prior to the
				termination or modification. The multiple employer welfare arrangement must
				inform the commissioner of corrective action that will be taken to maintain the
				multiple employer welfare arrangement's financial integrity.
2.
Required stop-loss coverage.
A multiple employer welfare arrangement may not retain liability on any
				one incident of more than ten percent of its annual premium volume during the
				most recent fund year, plus twenty percent of its surplus. A multiple employer
				welfare arrangement with less than one year's experience must use the multiple
				employer welfare arrangement's estimated premium volume during the first full
				fund year. The multiple employer welfare arrangement must purchase stop-loss
				insurance for liability exposure. The stop-loss carrier must be licensed to do
				business in North Dakota.
3.
Return of liability.
Liability transferred to an insurer under
				subsection 2 may not be directly or indirectly returned to a multiple employer
				welfare arrangement or a member.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC 26.1-01-07.4,
					 26.1-07.1
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-14 - Deficit and assessments

Current through Supplement No. 393, July, 2024
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 employer welfare arrangement for three
				complete fund years after leaving the multiple employer welfare arrangement.
				After the period of continuing liability, a past member is no longer jointly
				and severally liable for the multiple employer welfare arrangement's
				liabilities and expenses, except as provided in subsection 2.
2. Runoff liability. If a multiple employer
				welfare arrangement's self-funding authority is ended under subsection 1 or 2
				of section
				45-06-14-07, members and past
				members continue to be jointly and severally liable for the multiple employer
				welfare arrangement's liabilities and expenses until final multiple employer
				welfare arrangement dissolution, as follows:
a. All members at the termination of
				self-funding authority are jointly and severally liable for all multiple
				employer welfare arrangement liabilities and expenses until the multiple
				employer welfare arrangement is dissolved; and
b. All past members that were jointly and
				severally liable under subsection 1 at the time self-funding authority is ended
				continue to be jointly and severally liable until the multiple employer welfare
				arrangement is dissolved.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-15 - Financial integrity

Current through Supplement No. 393, July, 2024
1.
Fidelity
				bond.
All contractors and individuals who handle multiple employer
				welfare arrangement funds or who will have access to multiple employer welfare
				arrangement funds, including board members, must be covered by a fidelity bond
				providing standard fidelity coverage, including coverage against dishonesty,
				theft, forgery, alteration, misplacement, or mysterious and unexplainable
				disappearance. The amount of coverage for each occurrence must be at least
				three hundred thousand dollars. The multiple employer welfare arrangement must
				purchase a fidelity bond covering the required contractors and individuals, or
				submit separate proof of coverage for all required contractors and individuals
				not covered under the plan's bond.
2.
Integrity of assets.
A
				multiple employer welfare arrangement's assets may not be:
a. Commingled with the assets of any
				member;
b. Loaned to anyone for any
				purpose or used as security for a loan, except as permitted under subsection 5
				for investments;
c. Employed for
				any purpose other than for the purposes stated in the bylaws and in compliance
				with this chapter and related statutes; or
d. Considered the property or right of any
				member or covered person, except:
(1) For
				benefits under the coverage documents;
(2) For dividends declared in accordance with
				subsection 5 of section
				45-06-14-11; and
(3) For a portion of the assets remaining
				after the plan's dissolution, in accordance with subsection 4 of section
				45-06-14-07.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-16 - Reporting

Current through Supplement No. 393, July, 2024
1.
Financial
				statements.
A multiple employer welfare arrangement must prepare annual
				financial statements containing a balance sheet; a statement of revenues,
				expenses, and surplus; a statement of changes in financial position; and a
				schedule of investments. The statements must be prepared on forms and according
				to instructions prescribed by the commissioner. The financial statements must
				be filed with the commissioner no later than one hundred eighty days after the
				end of the multiple employer welfare arrangement's fund year. For multiple
				employer welfare arrangements with annual premiums greater than two million
				dollars, the financial statements must be audited by an independent certified
				public accountant, and the auditor's report must be submitted no later than one
				hundred eighty days after the end of the multiple employer welfare
				arrangement's fund year.
2.
Quarterly reports.
If the commissioner determines that a multiple
				employer welfare arrangement's financial integrity is such that the multiple
				employer welfare arrangement's ability to meet obligations promptly and in full
				will be significantly impaired, the commissioner may require that the multiple
				employer welfare arrangement file quarterly reports with the commissioner no
				later than thirty days after the end of the first, second, and third quarters
				of each fund year. The commissioner may remove the requirement to file
				quarterly reports when the multiple employer welfare arrangement's financial
				integrity is restored. A quarterly report must contain statements of the
				multiple employer welfare arrangement's:
a.
				Current total cash on hand and on deposit, and total investment;
b. Current total reserve for unearned and
				advance premiums, and total reserve for outstanding losses reported and
				unreported;
c. Dividends declared
				and dividends paid during the quarter;
d. Gross premiums written during the
				quarter;
e. Losses paid during the
				quarter;
f. Current total members;
				and
g. Any other information that
				the commissioner requests.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-17 - Trade practices

Current through Supplement No. 393, July, 2024
Multiple employer welfare arrangements are subject to North
				  Dakota Century Code section 26.1-04-03.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC 26.1-01-07.4,
					 26.1-04-03, 26.1-07.1
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-18 - Disclosure

Current through Supplement No. 393, July, 2024
Each policy issued by a self-funded multiple employer welfare
				  arrangement must contain, in at least ten-point type on the front page and the
				  declaration page, the following notice:
NOTICE
This policy is issued by a self-funded multiple employer
				  welfare arrangement. A self-funded multiple employer welfare arrangement may
				  not be subject to all of the insurance laws and regulations of your state.
				  State insurance insolvency guaranty funds are not available for a self-funded
				  multiple employer welfare arrangement.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC 26.1-01-07.4,
					 26.1-07.1
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-14 - Multiple Employer Welfare Arrangements › Section 45-06-14-19 - Sanctions

Current through Supplement No. 393, July, 2024
The commissioner may sanction a multiple employer welfare
				  arrangement or suspend or revoke any certificate of authority issued to a
				  multiple employer welfare arrangement upon any of the following grounds:
1. Failure to comply with any provision of
				these rules or any applicable provision of the North Dakota Century
				Code;
2. Failure to comply with any
				lawful order of the commissioner of North Dakota or of any other
				state;
3. Committing an unfair or
				deceptive act or practice;
4.
				Deterioration of financial condition adversely affecting the multiple employer
				welfare arrangement's ability to pay claims;
5. A finding that the application or any
				necessary forms that have been filed with the commissioner contain fraudulent
				information or omissions; or
6. A
				finding that the multiple employer welfare arrangement or its service company
				or financial administrator has misappropriated, converted, illegally withheld,
				or refused to pay over upon proper demand any moneys that belong to a member, a
				participant, or a person otherwise entitled thereto and that have been
				entrusted to the multiple employer welfare arrangement or its service company
				or financial administrator in its fiduciary capacity.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC 26.1-01-07.4,
					 26.1-07.1
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-01 - Definition

Current through Supplement No. 393, July, 2024
"Short-term care insurance" means any insurance policy, group
				  certificate, or rider primarily advertised, marketed, offered, or designed to
				  provide coverage for less than twelve consecutive months for each covered
				  person on an expense incurred, indemnity, prepaid, or other basis, for one or
				  more necessary or medically necessary diagnostic, preventive, therapeutic,
				  rehabilitative, maintenance, or personal care services provided in a setting
				  other than an acute care unit of a hospital. Service settings may include a
				  hospital unit licensed or certified to provide skilled nursing services in a
				  skilled nursing facility, extended care facility, intermediate care facility,
				  convalescent nursing home, basic care facility, personal care facility, adult
				  day care facility, and assisted living facility. The term also includes home
				  health care and personal care services provided by a home health care agency.
				  Notwithstanding any other provision contained herein, any product advertised,
				  marketed, or offered as short-term care insurance is subject to the provisions
				  of this chapter.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-04 - Unintentional lapse

Current through Supplement No. 393, July, 2024
Each insurer offering short-term care insurance shall, as a
				  protection against unintentional lapse, comply with the following:
1.
a. Notice
				before lapse or termination. No individual short-term care policy or
				certificate shall be issued until the insurer has received from the applicant
				either a written designation of at least one person, in addition to the
				applicant, who is to receive notice of lapse or termination of the policy or
				certificate for nonpayment of premium, or a written waiver dated and signed by
				the applicant electing not to designate additional persons to receive notice.
				The applicant has the right to designate at least one person who is to receive
				the notice of termination, in addition to the insured. Designation shall not
				constitute acceptance of any liability on the third party for services provided
				to the insured. The form used for the written designation must provide space
				clearly designated for listing at least one person. The designation shall
				include each person's full name and home address. In the case of an applicant
				who elects not to designate an additional person, the waiver shall state:
				"Protection against unintended lapse. I understand that I have the right to
				designate at least one person other than myself to receive notice of lapse or
				termination of this short-term care insurance policy for nonpayment of premium.
				I understand that notice will not be given until thirty (30) days after a
				premium is due and unpaid. I elect NOT to designate a person to receive this
				notice."
The insurer shall notify the insured of the right to change
				  this written designation, no less often than once every two years.
b. When the policyholder or
				certificate holder pays premium for a short-term care insurance policy or
				certificate through a payroll or pension deduction plan, the requirements
				contained in subdivision a need not be met until sixty days after the
				policyholder or certificate holder is no longer on such a payment plan. The
				application or enrollment form for such policies or certificates shall clearly
				indicate the payment plan selected by the applicant.
c. Lapse or termination for nonpayment of
				premium. No individual short-term care policy or certificate shall lapse or be
				terminated for nonpayment of premium unless the insurer, at least thirty days
				before the effective date of the lapse or termination, has given notice to the
				insured and to those persons designated pursuant to subdivision a, at the
				address provided by the insured for purposes of receiving notice of lapse or
				termination. Notice shall be given by first-class United States mail, postage
				prepaid, and notice may not be given until thirty days after a premium is due
				and unpaid. Notice shall be deemed to have been given as of five days after the
				date of mailing.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-05 - Payment of benefits

Current through Supplement No. 393, July, 2024
A short-term care insurance policy that provides for the
				  payment of benefits based on standards described as "usual and customary",
				  "reasonable and customary", or words of similar import shall include a
				  definition of these terms and an explanation of the terms in its accompanying
				  outline of coverage.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-06 - Required disclosure of rating practices to consumers

Current through Supplement No. 393, July, 2024
1. A statement that the policy may be subject
				to rate increases in the future.
2.
				If a short-term care policy uses gender rating to determine the policy's
				premium rate, the short-term care policy must contain the following language in
				conspicuous font on the application, on the outline of coverage provided to the
				consumer at the time of solicitation, and on the front page of the insurance
				policy or certificate:
The cost for this product is based in part upon the gender of
				  the person being insured. Buying this product means you agree to allow [insert
				  Company or Agency Name Here] to determine the cost of this product based in
				  part upon the gender of the person being insured.
The individual or individuals purchasing a short-term care
				  insurance policy using gender rating to determine a policy's premium rate must
				  specifically sign, initial or otherwise acknowledge the gender rating provision
				  detailed above on the application. A copy of the acknowledged application must
				  be retained by the insurance company selling the policy.
3. An insurer shall provide notice of an
				upcoming premium rate schedule increase to all policyholders or certificate
				holders, if applicable, at least forty-five days prior to the implementation of
				the premium rate schedule increase by the insurer. The notice shall include the
				information required by this section when the rate increase is
				implemented.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-07 - Prohibition against post-claims underwriting

Current through Supplement No. 393, July, 2024
1.
a. If an
				application for short-term care insurance contains a question which asks
				whether the applicant has had medication prescribed by a physician, it shall
				also ask the applicant to list all medication that has been
				prescribed.
b. If the medications
				listed in the application were known by the insurer, or should have been known
				at the time of application, to be directly related to a medical condition for
				which coverage would otherwise be denied, then the policy or certificate shall
				not be rescinded for that condition.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-08 - Requirements for application forms and replacement coverage

Current through Supplement No. 393, July, 2024
1. The following language shall be set out
				conspicuously and in close conjunction with the applicant's signature block on
				an application for a short-term care insurance policy or certificate:
"Caution: If your answers on this application are incorrect
				  or untrue, [company] has the right to deny benefits or rescind your
				  policy."
2. Application
				forms shall include the following questions designed to elicit information as
				to whether, as of the date of the application, the applicant has another
				short-term care or long-term care insurance policy or certificate in force or
				whether a short-term care policy or certificate is intended to replace any
				other accident and sickness or short-term care policy or certificate presently
				in force. A supplementary application or other form to be signed by the
				applicant and agent, except when the coverage is sold without an agent,
				containing the questions may be used. With regard to a replacement policy
				issued to a group, the following questions may be modified only to the extent
				necessary to elicit information about health or short-term care insurance
				policies other than the group policy being replaced, provided that the
				certificate holder has been notified of the replacement.
a. Do you have another short-term care or
				long-term care insurance policy or certificate in force, including health care
				service contract, health maintenance organization contract?
b. Did you have another short-term care or
				long-term care insurance policy or certificate in force during the last twelve
				months?
(1) If so, with which
				company?
(2) If that policy lapsed,
				when did it lapse?
c.
				Are you covered by medicaid?
d. Do
				you intend to replace any of your medical or health insurance coverage with
				this policy [certificate]?
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-09 - Loss ratio

Current through Supplement No. 393, July, 2024
Benefits under short-term care insurance policies must be
				  deemed reasonable in relation to premiums provided the expected loss ratio is
				  at least seventy percent, calculated in a manner which provides for adequate
				  reserving of the insurance risk. In evaluating the expected loss ratio, due
				  consideration must be given to all relevant factors, including:
1. Statistical credibility of incurred claims
				experience and earned premiums;
2.
				The period for which rates are computed to provide coverage;
3. Experienced and projected
				trends;
4. Concentration of
				experience within early policy duration;
5. Expected claim fluctuation;
6. Experience refunds, adjustments, or
				dividends;
7. Renewability
				features;
8. All appropriate
				expense factors;
9.
				Interest;
10. Policy
				reserves;
11. Mix of business by
				risk classification; and
12.
				Product features such as elimination periods, deductibles, and maximum
				limits.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-10 - Filing requirements for advertising

Current through Supplement No. 393, July, 2024
1. Every insurer, health care service plan,
				or other entity providing short-term care insurance or benefits in this state
				shall provide a copy of any short-term care insurance advertisement intended
				for use in this state whether through written, radio, or television medium to
				the insurance commissioner of this state for review or approval by the
				commissioner to the extent it may be required under state law. In addition, all
				advertisements shall be retained by the insurer, health care service plan, or
				other entity for at least three years from the date the advertisement was first
				used.
2. The commissioner may
				exempt from these requirements any advertising form or material when, in the
				commissioner's opinion, this requirement may not be reasonably
				applied.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-11 - Standards for marketing

Current through Supplement No. 393, July, 2024
1. Display
				prominently on the first page of the outline of coverage and policy the
				following:
"Notice to buyer: This policy may not cover all of the costs
				  associated with short-term care incurred by the buyer during the period of
				  coverage. The buyer is advised to review carefully all policy
				  limitations."
2. A
				short-term care policy shall state in on the front page of the policy and
				outline of coverage the following statement:
"This is a short-term care policy that offers benefits for
				  less than twelve (12) months. This is not a long-term care
				  policy."
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-12 - Prohibition against preexisting conditions and probationary periods in replacement policies or certificates

Current through Supplement No. 393, July, 2024
If a short-term care insurance policy or certificate replaces
				  another short-term care or long-term care policy or certificate, the replacing
				  insurer shall waive any time periods applicable to preexisting conditions and
				  probationary periods in the new short-term care policy for similar benefits to
				  the extent that similar exclusions have been satisfied under the original
				  policy.
General Authority:
NDCC 28-32-02
Law Implemented:
NDCC
					 26.1-36-48
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Section 45-06-15-13 - Standards for benefit triggers

Current through Supplement No. 393, July, 2024
1. A
				short-term care insurance policy shall condition the payment of benefits on a
				determination of the insured's ability to perform activities of daily living
				and on cognitive impairment. Eligibility for the payment of benefits shall not
				be more restrictive than requiring either a deficiency in the ability to
				perform not more than three of the activities of daily living or the presence
				of cognitive impairment.
2.
a. Activities of daily living shall include
				at least the following:
(1)
				Bathing;
(2) Continence;
(3) Dressing;
(4) Eating;
(5) Toileting; and
(6) Transferring.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-15 - Short-Term Care Insurance › Appendix B - NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS, SHORT-TERM CARE OR LONG-TERM CARE INSURANCE

Current through Supplement No. 393, July, 2024
[Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to [your application] [information you have
				  furnished], you intend to lapse or otherwise terminate existing accident and
				  sickness, short-term care or long-term care insurance and replace it with the
				  long-term care insurance policy delivered herewith issued by [company name]
				  Insurance Company. Your new policy provides thirty (30) days within which you
				  may decide, without cost, whether you desire to keep the policy. For your own
				  information and protection, you should be aware of and seriously consider
				  certain factors which may affect the insurance protection available to you
				  under the new policy.
You should review this new coverage carefully, comparing it
				  with all accident and sickness, short-term care or long-term care insurance
				  coverage you now have, and terminate your present policy only if, after due
				  consideration, you find that purchase of this long-term care coverage is a wise
				  decision.
1. Health conditions which
				you may presently have (preexisting conditions), may not be immediately or
				fully covered under the new policy. This could result in denial or delay in
				payment of benefits under the new policy, whereas a similar claim might have
				been payable under your present policy.
2. State law provides that your replacement
				policy or certificate may not contain new preexisting conditions or
				probationary periods. Your insurer will waive any time periods applicable to
				preexisting conditions or probationary periods in the new policy (or coverage)
				for similar benefits to the extent such time was spent (depleted) under the
				original policy.
3. If you are
				replacing existing short-term care or long-term care insurance coverage, you
				may wish to secure the advice of your present insurer or its agent regarding
				the proposed replacement of your present policy. This is not only your right,
				but it is also in your best interest to make sure you understand all the
				relevant factors involved in replacing your present coverage.
4. [To be included only if the application is
				attached to the policy.] If, after due consideration, you still wish to
				terminate your present policy and replace it with new coverage, read the copy
				of the application attached to your new policy and be sure that all questions
				are answered fully and correctly. Omissions or misstatements in the application
				could cause an otherwise valid claim to be denied. Carefully check the
				application and write to [company name and address] within thirty (30) days if
				any information is not correct and complete, or if any past medical history has
				been left out of the application.
[Company Name]
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-16 - SHORT-TERM LIMITED-DURATION INSURANCE › Section 45-06-16-01 - Definitions

Current through Supplement No. 393, July, 2024
1. "Application" includes an application for
				individual coverage or a group enrollment form.
2. "Short-term limited-duration health
				insurance plan" means health insurance coverage provided pursuant to an
				insurance policy or group certificate of insurance that has an expiration date
				specified in the policy that is no longer than six months after the original
				effective date of the policy and, taking into account any renewals or
				extensions, has a duration of not more than twelve months in total.
General Authority:
NDCC 26.1-36-38
Law Implemented:
NDCC 26.1-36-49
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-16 - SHORT-TERM LIMITED-DURATION INSURANCE › Section 45-06-16-02 - Application requirements

Current through Supplement No. 393, July, 2024
All applications for short-term limited-duration insurance
				  policies must contain clear and unambiguous questions designed to ascertain the
				  reason for the health condition of the applicant as follows:
1. Do you have comprehensive major medical
				coverage in force as of the date of this application?
2. Are you aware that this insurance coverage
				is not comprehensive major medical coverage?
3. Why are you purchasing a short-term
				limited-duration plan? (Please check all that apply)
a. I am not eligible for Affordable Care Act
				marketplace tax subsidies.
b. I
				cannot afford an Affordable Care Act marketplace plan.
c. I do not use a lot of health care;
				therefore, I do not feel I need a comprehensive major medical plan.
d. Other.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-16 - SHORT-TERM LIMITED-DURATION INSURANCE › Section 45-06-16-03 - Disclosure requirements

Current through Supplement No. 393, July, 2024
1.
				Disclosure statement. All short-term limited-duration policies as defined under
				North Dakota Century Code section 26.1-36-49 must contain the following
				disclosure on the front cover page of the policy, the certificate of coverage,
				and the application in large print:
THIS IS NOT A COMPREHENSIVE MAJOR MEDICAL INSURANCE
				  POLICY.
THIS COVERAGE IS NOT REQUIRED TO COMPLY WITH CERTAIN FEDERAL
				  MARKET REQUIREMENTS FOR HEALTH INSURANCE, PRINCIPALLY THOSE CONTAINED IN THE
				  PATIENT PROTECTION AND AFFORDABLE CARE ACT. PLEASE CAREFULLY REVIEW THE TERMS
				  OF YOUR POLICY TO MAKE SURE YOU ARE AWARE OF ANY EXCLUSIONS OR LIMITATIONS
				  REGARDING COVERAGE OF PRE-EXISTING CONDITIONS OR HEALTH BENEFITS (SUCH AS
				  HOPITALIZATION, EMERGENCY SERVICES, MATERNITY CARE, PREVENTATIVE CARE,
				  PRESCRIPTION DRUGS, HABILITATIVE AND REHABILITATIVE CARE, AND MENTAL HEALTH AND
				  SUBSTANCE USE DISORDER SERVICES). YOUR POLICY MIGHT ALSO HAVE LIFETIME AND/OR
				  ANNUAL DOLLAR LIMITS ON HEALTH BENEFITS. IF THIS COVERAGE EXPIRES OR YOU LOSE
				  ELIGIBILITY FOR THIS COVERAGE, YOU MAY HAVE TO WAIT UNTIL AN OPEN ENROLLMENT
				  PERIOD TO OBTAIN OTHER HEAL TH INSURANCE COVERAGE.
2. Outline of coverage. The outline of
				coverage must provide the following information:
a. Types of benefits provided.
b. Cost-sharing provisions and maximum
				limits.
c. Describe how benefit
				payments are determined.
d.
				Exclusions and limitations.
e.
				Renewability provisions.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-16 - SHORT-TERM LIMITED-DURATION INSURANCE › Section 45-06-16-04 - Standards of marketing

Current through Supplement No. 393, July, 2024
An issuer through its producers, shall:
1. Provide an outline of coverage to
				applicants at the time application is presented to the prospective applicant
				and shall obtain an acknowledgment of receipt of the outline from the
				applicant.
2. Establish marketing
				procedures to assure any comparison of policies by its agents or other
				producers will be fair and accurate.
3. Establish marketing procedures to assure
				full disclosure is given to the insured.
4. Establish auditable procedures for
				verifying compliance with this section.
General Authority:
NDCC 26.1-36-38
Law Implemented:
NDCC 26.1-36-49