reglab/statecodes huggingface dataset:
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-01 - Definitions

Current through Supplement No. 393, July, 2024
1. "Board" means the public employees
				retirement system board created by North Dakota Century Code section
				54-52-03.
2. "Commissioner" means
				the insurance commissioner.
3.
				"Fiscal year" means a self-insurance health plan's twelve-month fiscal
				year.
4. "Runoff self-insurance
				health plan" means a self-insurance health plan that no longer has authority to
				self-fund but which continues to exist for the purpose of paying claims,
				preparing reports, and administering transactions associated with the period
				when the self-insurance health plan provided coverage.
5. "Self-insurance health plan" has the same
				meaning as provided under North Dakota Century Code section
				54-52.1-01.
6. "Service company"
				means an entity licensed under North Dakota Century Code chapter 26.1-27 as an
				administrator of an entity licensed under North Dakota Century Code title 26.1
				as an insurance company, health maintenance organization, or nonprofit health
				service corporation.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-02 - Purpose

Current through Supplement No. 393, July, 2024
The provisions in this chapter are intended to ensure the
				  financial integrity and the competent and equitable administration of the
				  self-insurance health plan.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-03 - Scope

Current through Supplement No. 393, July, 2024
This chapter applies to all self-insurance health plans
				  established by the board as set forth in North Dakota Century Code chapter
				  54-52.1.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-04 - Ending self-insurance health plan

Current through Supplement No. 393, July, 2024
1.
Termination.
The board may terminate its self-insurance health
				plan as set forth in North Dakota Century Code chapter 54-52.1. The board shall
				notify the commissioner of its decision to terminate within ninety days of its
				decision to terminate.
2.
Runoff self-insurance health plan.
A self-insurance health plan
				must continue to exist as a runoff self-insurance health plan after its
				authority to self-fund has ended, for the purpose of paying claims, preparing
				reports, and administering transactions associated with the period during which
				the self-insurance health plan provided coverage. A runoff self-insurance
				health plan must continue to comply with this chapter and with other applicable
				North Dakota laws and rules.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-05 - Administration

Current through Supplement No. 393, July, 2024
1.
Service company.
The board
				may contract with one or more service companies for services necessary to
				conduct the day-to-day operations of the self-insurance health plan. The
				service company or companies must have expertise in and be licensed for the
				services provided to the self-insurance health plan. Subject to the oversight
				of the board, the service company or companies may provide, directly or through
				subcontractors, services directly related to the administration of
				coverage.
2.
Record keeping
				and examination authority.
A self-insurance health plan must maintain
				all records necessary to verify the accuracy and completeness of all reports
				submitted to the commissioner under section 45-06-17-07. The commissioner may
				examine the self-insurance health plan's records in order to verify the
				self-insurance health plan's compliance with this chapter and with other
				statutes and rules. The provisions of North Dakota Century Code chapter 26.1-03
				apply to the commissioner's examination. All records concerning claims,
				reserves, financial transactions, and other matters necessary for the
				self-insurance health plan's operations are the self-insurance health plan's
				property and must be retained for the current year plus the previous five
				years.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-06 - Reserves

Current through Supplement No. 393, July, 2024
A reserve must be established for all charges, claims, costs,
				  and expenses of the self-insurance health plan. This reserve must be set at a
				  level to cover between two and four months of expected charges, claims, costs,
				  and expenses. The reserve must be adjusted as new information becomes
				  available.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-07 - Reporting

Current through Supplement No. 393, July, 2024
1. Financial statements. A self-insurance
				health plan 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 self-insurance health plan's fiscal
				year. In lieu of self-prepared financial statements, a self-insurance health
				plan may submit audited financial statements prepared by an independent
				certified public accountant. The auditor's report must be submitted no later
				than thirty days after completion of the audit.
2. Quarterly reports. If the commissioner
				determines a self-insurance health plan's financial integrity is such that the
				self-insurance health plan's ability to meet obligations promptly and in full
				will be significantly impaired, the commissioner may require the self-insurance
				health plan to file quarterly reports with the commissioner no later than
				thirty days after the end of the first, second, and third quarters of each
				fiscal year. The commissioner may remove the requirement to file quarterly
				reports when the self-insurance health plan's financial integrity is restored.
				A quarterly report must contain statements of the self-insurance health plan's:
a. Current total cash on hand and on deposit,
				and total investment;
b. Current
				total reserve for outstanding losses reported and unreported;
c. Gross premiums written during the
				quarter;
d. Losses paid during the
				quarter;
e. Current total members;
				and
f. Any other information that
				the commissioner requests.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-08 - Trade practices

Current through Supplement No. 393, July, 2024
Self-insurance health plans are subject to the provisions of
				  the unfair trade practices act found at North Dakota Century Code section
				  26.1-04-03.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-17 - SELF-INSURANCE HEALTH PLANS › Section 45-06-17-09 - Disclosure

Current through Supplement No. 393, July, 2024
Each policy issued by a self-insurance health plan must
				  contain, in at least ten-point type on the front page and declaration page, the
				  following notice:
NOTICE
This policy is issued by a self-insurance health plan. A
				  self-insurance health plan 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-insurance health plan.
General Authority:
NDCC 26.1-36.6
Law Implemented:
NDCC
					 26.1-36.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-01 - Definitions

Current through Supplement No. 393, July, 2024
As used in this chapter:
1. "Affiliate" has the same meaning as defined in North
				  Dakota Century Code section 26.1-10-01.
2. "Control" has the same meaning as defined in North Dakota
				  Century Code section 26.1-10-01.
3. "Evidence of individual insurability" means a statement
				  furnished by the debtor, as a condition of insurance becoming effective, that
				  relates specifically to the health status or to the health or medical history
				  of the debtor.
4. "Loss ratio" means incurred claims divided by earned
				  premiums.
5. "Preexisting condition" means any condition for which the
				  insured debtor received medical advice, consultation, or treatment within six
				  months before the effective date of coverage.
General Authority: NDCC 26.1-37-15
Law Implemented: NDCC
					 26.1-37
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-02 - Rights and treatment of debtors

Current through Supplement No. 393, July, 2024
1.
Termination of group consumer credit insurance policy.
a. If a debtor is covered by a group consumer
				credit insurance policy providing for the payment of single premiums to the
				insurer, or any other premium payment method which prepays coverage beyond one
				month, then provision shall be made by the insurer that in the event of
				termination of the policy for any reason, insurance coverage with respect to
				any debtor insured under the policy shall be continued for the entire period
				for which the premium has been paid.
b. If a debtor is covered by a group consumer
				credit insurance policy providing for the payment of premiums to the insurer on
				a monthly basis, then the policy shall provide that, in the event of
				termination of the policy, termination notice shall be given to the insured
				debtor at least thirty days prior to the effective date of termination except
				when replacement of the coverage by the same or another insurer in the same or
				greater amount takes place without lapse of coverage. The insurer shall provide
				or cause to be provided this required information to the debtor.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-03 - Determination of reasonableness of benefits in relation to premium charge

Current through Supplement No. 393, July, 2024
1. Benefits provided by consumer credit
				insurance policies must be reasonable in relation to the premium charged.
				Premium rates charged for credit life or disability satisfy this requirement if
				the premium rate charged develops or may reasonably be expected to develop a
				loss ratio of not less than forty-five percent. With the exception of
				deviations approved under section
				45-07-01.1-10, the rates shown in
				sections 45-07-01.1-04 and
				45-07-01.1-05, as adjusted
				pursuant to section
				45-07-01.1-09, shall be presumed
				to satisfy this standard. Anticipated losses that develop or are expected to
				develop a loss ratio of not less than forty-five percent shall be presumed
				reasonable. Any insurer filing a deviation in accordance with section
				45-07-01.1-10 must satisfy the
				sixty percent loss ratio standard on its total consumer credit insurance
				business, including that of affiliated insurers, for each type of insurance
				defined in North Dakota Century Code section 26.1-37-02 for which the deviation
				is being filed.
2. Premium rates
				charged for credit unemployment or credit property satisfy this requirement if
				anticipated losses are expected to develop a loss ratio of no less than
				forty-five percent.
3. Nonstandard
				coverage. If any insurer files for approval of any form providing coverage
				different than that described in sections
				45-07-01.1-04 through
				45-07-01.1-06, the insurer shall
				demonstrate to the satisfaction of the commissioner that the premium rates to
				be charged for such coverage are:
a.
				Reasonably expected to develop a loss ratio of not less than sixty percent; or
b. Actuarially consistent with the
				rates used for standard coverages.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-04 - Credit life insurance rates

Current through Supplement No. 393, July, 2024
1.
Premium rate.
Subject to the conditions and requirements in
				subsection 2 and section 45-07-01.1-10, the prima facie rates shown below are
				considered to meet the requirements of section 45-07-01.1-03 and may be used
				without filing additional actuarial support.
a. Monthly outstanding balance basis:
				Sixty-two cents per month per one thousand dollars of outstanding insured debt
				on single life insurance and one dollar five cents per month per one thousand
				dollars of outstanding insured debt on joint life insurance if premiums are
				payable on a monthly outstanding balance basis.
b. Single premium basis: If the premium is
				charged on a single premium basis, the rate shall be computed according to the
				following formula or according to a formula approved by the commissioner which
				produces rates substantially the same as those produced by the following
				formula:
Click
				  here to view Image
Sp = Single premium per one hundred
				  dollars of initial consumer credit life insurance coverage.
Op = Sixty-two cents, the prima facie
				  consumer credit life insurance premium rate for monthly outstanding balance
				  coverage from subdivision a.
It = The scheduled amount of insurance
				  for month t.
Ii = Initial amount of insurance. For
				  a net insurance policy, Ii equals the initial principal
				  balance of the loan.
dis = .0028, representing an annual discount rate of three
				  percent for interest plus four-tenths percent for mortality.
n = The number of months in the term of the insurance.
c. If the benefits provided are
				other than those described in the introduction to this subsection, premium
				rates for such benefits shall be actuarially consistent with the rates provided
				in subdivisions a and b.
d. If life
				coverage is sold on a joint basis involving two people, the factor for
				calculating the rate is 1.7.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-05 - Credit accident and health insurance rates

Current through Supplement No. 393, July, 2024
1. Premium rate. Subject to the conditions
				and requirements in subsection 5 and section 45-07-01.1-10, the prima facie
				rates shown below are considered to meet the requirements of section
				45-07-01.1-03 and may be used without filing additional actuarial support.
a. If premiums are payable on a single
				premium basis for the duration of the coverage, the prima facie rate per one
				hundred dollars of initial insured debt for single accident and health
				insurance is as set forth in the table below (rates for monthly periods other
				than those listed shall be interpolated or extrapolated):
Number of Equal Monthly Installments
After
Fourteenth Day of Disability, Retroactive to Fire
								Day of Disability
After
Fourteenth Day of Disability
After Thirtieth Day of Disability, Retroactive to
								First Day of Disability
After
Thirtieth Day of Disability
6
$1.31
$.83
$1.05
$.55
12
1.88
1.30
1.51
.94
24
2.54
1.85
2.03
1.39
36
3.01
2.23
2.38
1.70
48
3.40
2.56
2.65
1.94
60
3.74
2.83
2.89
2.16
72
4.00
3.06
3.06
2.32
84
4.17
3.24
3.18
2.43
96
4.30
3.38
3.27
2.51
108
4.40
3.50
3.34
2.58
120
4.47
3.60
3.40
2.62
b.
				If premiums are paid on the basis of a premium rate per month per thousand of
				outstanding insured gross debt, these premiums shall be computed according to
				the following formula or according to a formula approved by the commissioner
				which produces rates actuarially consistent with the single premium rates in
				subdivision a of subsection 1:
Click
				  here to view Image
Where SPn = Single
				premium rate per one hundred dollars of initial insured debt repayable in n
				equal monthly installments as shown in subdivision a.
OPn = Monthly outstanding balance
				  premium rate per one thousand dollars.
n = The number of months in the term of the insurance.
dis = .0025, representing an annual discount rate of three
				  percent for interest.
c. If
				the coverage provided is a constant maximum indemnity for a given period of
				time, the actuarial equivalent of subdivisions a and b shall be used.
d. If the coverage provided is a combination
				of a constant maximum indemnity for a given period of time after which the
				maximum indemnity begins to decrease in even amounts per month, an appropriate
				combination of the premium rate for a constant maximum indemnity for a given
				period of time and the premium rate for a maximum indemnity which decreases in
				even amounts per month shall be used.
e. The outstanding balance rate for credit
				accident and health insurance may be either a term-specified rate or may be a
				single composite term outstanding balance rate.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-06 - Credit unemployment insurance rates

Current through Supplement No. 393, July, 2024
1. Each insurer filing rates for credit
				unemployment insurance shall include in its rate filing with the commissioner
				the appropriate rate formula upon which its rates are based, including a
				provision for anticipated losses. Anticipated losses that develop or are
				expected to develop a loss ratio of not less than forty-five percent shall be
				presumed reasonable. Anticipated losses may include an amount for fluctuation
				in loss due to catastrophe based on the experience of at least the latest nine
				policy years or as long as the company has been writing this line of business.
				If coverage is sold on a joint basis involving two people, the factor for
				calculating the rate is 1.8.
2.
				Credit unemployment insurance policies must contain benefits at least as
				favorable to insureds as the provisions below:
a. Coverage for unemployment for any reason,
				except that coverage may be excluded for:
(1)
				Voluntary forfeiture of salary, wage, or other employment income;
(2) Resignation;
(3) Retirement;
(4) General strike;
(5) Illegal walkout;
(6) War;
(7) Separation from the military;
(8) Willful misconduct or criminal misconduct
				or unlawful behavior; and
(9)
				Disability caused by injury, sickness, or pregnancy.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-07 - Credit property insurance rates

Current through Supplement No. 393, July, 2024
1.
				Each insurer filing rates for credit property insurance shall include in its
				rate filing with the commissioner the appropriate rate formula upon which its
				rates are based, including a provision for anticipated losses. Anticipated
				losses that develop or are expected to develop a loss ratio of no less than
				forty-five percent shall be presumed to be reasonable. Anticipated losses may
				include an amount for fluctuation in loss due to catastrophe.
2. Credit property rates must provide for at
				a minimum the following coverages found in the standard fire policy and
				extended coverage endorsement: fire, lightning, riot, riot attending a strike,
				civil commotion, smoke, aircraft and vehicle damage, windstorm, hail, and
				explosion.
General Authority: NDCC 26.1-37-15
Law Implemented: NDCC
					 26.1-37
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-08 - Refund formulas

Current through Supplement No. 393, July, 2024
1. In the event of
				termination, no charge for consumer credit insurance may be made for the first
				fifteen days of a month and a full month may be charged for sixteen days or
				more of a month.
2. The
				requirements of the consumer credit insurance law that refund formulas be filed
				with the commissioner shall be considered fulfilled if the refund formulas are
				set forth in the individual policy or group certificate filed with the
				commissioner.
3. No refund of five
				dollars or less need be made.
General Authority: NDCC 26.1-37-15
Law Implemented: NDCC
					 26.1-37
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-09 - Experience reports and adjustment of prima facie rates

Current through Supplement No. 393, July, 2024
1. The commissioner will, on a triennial
				basis, beginning January 1, 2006, review the loss ratio standards set forth in
				section 45-07-01.1-03 and the prima facie
				rates set forth in sections
				45-07-01.1-04 and
				45-07-01.1-05 and determine
				therefrom the rate of expected claims on a statewide basis, compare such rate
				of expected claims with the rate of actual claims for the preceding three years
				determined from the incurred claims and earned premiums at prima facie rates
				reported in the annual statement supplement or other available source, and
				publish the adjusted actual statewide prima facie rates to be used by insurers
				during the next triennium. The rates will reflect the difference between:
a. Actual claims based on experience; and
b. Expected claims based on the
				loss ratio standards set forth in section
				45-07-01.1-03 applied to the prima
				facie rates set forth in sections
				45-07-01.1-04 and
				45-07-01.1-05.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-10 - Use of rates

Current through Supplement No. 393, July, 2024
1.
Use of
				prima facie rates.
An insurer that files rates or has rates on file that
				are equivalent to the prima facie rates shown in sections
				45-07-01.1-04 and
				45-07-01.1-05, to the extent
				adjusted pursuant to section
				45-07-01.1-09, may use those rates
				without further proof of their reasonableness.
2.
Use of rates higher than prima facie
				rates.
An insurer may file for approval of and use rates that are higher
				than the prima facie rates shown in sections
				45-07-01.1-04 and
				45-07-01.1-05, to the extent
				adjusted pursuant to section
				45-07-01.1-09, as long as the
				filed rates are consistent with the provisions of section
				45-07-01.1-03.
If rates higher than the prima facie rates shown in sections
				  45-07-01.1-04 and
				  45-07-01.1-05, to the extent
				  adjusted pursuant to section
				  45-07-01.1-09, are filed for
				  approval, the filing shall specify the account or accounts to which the rates
				  apply. The rates may be:
a. Applied
				uniformly to all accounts of the insurer;
b. Applied on an equitable basis approved by
				the commissioner to only one or more accounts of the insurer for which the
				experience has been less favorable than expected; or
c. Applied according to a case-rating
				procedure on file with the commissioner.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-11 - Supervision of consumer credit insurance operations

Current through Supplement No. 393, July, 2024
1. Each insurer transacting credit insurance
				in this state shall be responsible for conducting a thorough periodic triennial
				review of creditors with respect to their credit insurance business with such
				creditors to assure compliance with the insurance laws of this state and the
				regulation promulgated by the commissioner.
2. Written records of such reviews shall be
				maintained by the insurer for review by the commissioner.
General Authority: NDCC 26.1-37-15
Law Implemented: NDCC
					 26.1-37
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-12 - Prohibited transactions

Current through Supplement No. 393, July, 2024
The following practices, when engaged in by insurers in
				  connection with the sale or placement of credit insurance, or as an inducement
				  thereto, shall constitute unfair methods of competition and shall be subject to
				  the Unfair Trade Practices Act of this state.
1. The offer or grant by an insurer to a
				creditor of any special advantage or any service not set out in either the
				group insurance contract or in the agency contract, other than the payment of
				agent's commissions;
2. Agreement
				by an insurer to deposit with a bank or financial institution money or
				securities of the insurer with the design or intent that the same shall affect
				or take the place of a deposit of money or securities which otherwise would be
				required of the creditor by the bank or financial institution as a compensating
				balance or offsetting deposit for a loan or other advancement; and
3. Deposit by an insurer of money or
				securities without interest or at a lesser rate of interest than is currently
				being paid by the creditor, bank, or financial institution to other depositors
				of like amounts for similar durations. This subsection shall not be construed
				to prohibit the maintenance by an insurer of such demand deposits or premium
				deposit accounts as are reasonably necessary for use in the ordinary course of
				the insurer's business.
General Authority: NDCC 26.1-37-15
Law Implemented: NDCC
					 26.1-37
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-07 - Credit Insurance › Chapter 45-07-01.1 - Consumer Credit Insurance › Section 45-07-01.1-13 - Severability

Current through Supplement No. 393, July, 2024
If any provision or clause of this chapter or the
				  application thereof to any person or situation is held invalid, such invalidity
				  shall not affect any other provision or application of the chapter which can be
				  given effect without the invalid provision or application, and to this end the
				  provisions of this chapter are declared severable.
General Authority: NDCC 26.1-37-15
Law Implemented: NDCC
					 26.1-37
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-02 - Applicability and scope

Current through Supplement No. 393, July, 2024
This chapter applies to all plans that are issued on or
				  after the effective date of this chapter.
General Authority: NDCC 26.1-36-38
Law Implemented: NDCC 26.1-36-10, 26.1-36-29,
					 26.1-41-13
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-03 - Use of model coordination of benefits contract provisions

Current through Supplement No. 393, July, 2024
1. Appendix A contains a model coordination
				of benefits provision for use in contracts. The use of this model coordination
				of benefits provision is subject to the provisions of subsections 2, 3, and 4
				and to the provisions of section
				45-08-01.2-04.
2. Appendix B is a plain language description
				of the coordination of benefits process that explains to the covered person how
				health plans will implement coordination of benefits. It is not intended to
				replace or change the provisions that are set forth in the contract. Its
				purpose is to explain the process by which the two or more plans will pay for
				or provide benefits.
3. The
				coordination of benefits provision contained in appendix A and the plain
				language explanation in appendix B do not have to use the specific words and
				format shown in appendix A or appendix B. Changes may be made to fit the
				language and style of the rest of the contract or to reflect differences among
				plans that provide services, that pay benefits for expenses incurred, and that
				indemnify. No substantive changes are permitted.
4. A coordination of benefits provision may
				not be used that permits a plan to reduce its benefits on the basis that:
a. Another plan exists and the covered person
				did not enroll in that plan;
b. A
				person is or could have been covered under another plan, except with respect to
				part B of medicare; or
c. A person
				has elected an option under another plan providing a lower level of benefits
				than another option that could have been elected.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-04 - Rules for coordination of benefits

Current through Supplement No. 393, July, 2024
When a person is covered by two or more plans, the rules for
				  determining the order of benefit payments are as follows:
1.
a. The
				primary plan shall pay or provide its benefits as if the secondary plan or
				plans did not exist.
b. If the
				primary plan is a closed panel plan and the secondary plan is not a closed
				panel plan, the secondary plan shall pay or provide benefits as if it were the
				primary plan when a covered person uses a nonpanel provider, except for
				emergency services or authorized referrals that are paid or provided by the
				primary plan.
c. When multiple
				contracts providing coordinated coverage are treated as a single plan under
				this chapter, this section applies only to the plan as a whole, and
				coordination among the component contracts is governed by the terms of the
				contracts. If more than one carrier pays or provides benefits under the plan,
				the carrier designated as primary within the plan shall be responsible for the
				plan's compliance with this regulation.
d. If a person is covered by more than one
				secondary plan, the order of benefit determination rules of this chapter decide
				the order in which secondary plans benefits are determined in relation to each
				other. Each secondary plan shall take into consideration the benefits of the
				primary plan or plans and the benefits of any other plan, which under the rules
				of this chapter, has its benefits determined before those of that secondary
				plan.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-05 - Procedure to be followed by secondary plan to calculate benefits and pay a claim

Current through Supplement No. 393, July, 2024
In determining the amount to be paid by the secondary plan
				  on a claim, should the plan wish to coordinate benefits, the secondary plan
				  shall calculate the benefits it would have paid on the claim in the absence of
				  other health care coverage and apply that calculated amount to any allowable
				  expense under its plan that is unpaid by the primary plan. The secondary plan
				  may reduce its payment by the amount so that, when combined with the amount
				  paid by the primary plan, the total benefits paid or provided by all plans for
				  the claim do not exceed one hundred percent of the total allowable expense for
				  that claim. In addition, the secondary plan shall credit to its plan deductible
				  any amounts it would have credited to its deductible in the absence of other
				  health care coverage.
General Authority: NDCC 26.1-36-38
Law Implemented: NDCC 26.1-36-10, 26.1-36-29,
					 26.1-41-13
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-06 - Miscellaneous provisions

Current through Supplement No. 393, July, 2024
1. A secondary plan
				that provides benefits in the form of services may recover the reasonable cash
				value of the services from the primary plan, to the extent that benefits for
				the services are covered by the primary plan and have not already been paid or
				provided by the primary plan. Nothing in this provision shall be interpreted to
				require a plan to reimburse a covered person in cash for the value of services
				provided by a plan that provides benefits in the form of services.
2.
a. A
				plan with order of benefits determination rules that comply with this chapter
				(complying plan) may coordinate its benefits with a plan that is "excess" or
				"always secondary" or that uses order of benefits determination rules that are
				inconsistent with those contained in this chapter (noncomplying plan) on the
				following basis:
(1) If the complying plan is
				the primary plan, it shall pay or provide its benefits first;
(2) If the complying plan is the secondary
				plan, it shall pay or provide its benefits first, but the amount of the
				benefits payable shall be determined as if the complying plan were the
				secondary plan. In such a situation, the payment shall be the limit of the
				complying plan's liability; and
(3) If the noncomplying plan does not provide
				the information needed by the complying plan to determine its benefits within a
				reasonable time after it is requested to do so, the complying plan shall assume
				that the benefits of the noncomplying plan are identical to its own, and shall
				pay its benefits accordingly. If within two years of payment the complying plan
				receives information as to the actual benefits of the noncomplying plan, it
				shall adjust payments accordingly.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-07 - Effective date for existing contracts

Current through Supplement No. 393, July, 2024
1.
				A contract that provides health care benefits and that was issued before the
				effective date of this chapter shall be brought into compliance with this
				regulation by the later of:
a. The next
				anniversary date or renewal date of the contract;
b. Twelve months following the effective date
				of these rules; or
c. The
				expiration of any applicable collectively bargained contract pursuant to which
				it was written.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Appendix A

Current through Supplement No. 393, July, 2024
MODEL COB CONTRACT PROVISIONS
COORDINATION OF THIS CONTRACT'S BENEFITS WITH OTHER
				  BENEFITS
The coordination of benefits (COB) provision applies when a
				  person has health care coverage under more than one plan. Plan is defined
				  below.
The order of benefits determination rules govern the order
				  in which each plan will pay a claim for benefits. The plan that pays first is
				  called the primary plan. The primary plan must pay benefits in accordance with
				  its policy terms without regard to the possibility that another plan may cover
				  some expenses. The plan that pays after the primary plan is the secondary plan.
				  The secondary plan may reduce the benefits it pays so that payments from all
				  plans does not exceed 100% of the total allowable expense.
DEFINITIONS
A. A
				plan is any of the following that provides benefits or services for medical or
				dental care or treatment. If separate contracts are used to provide coordinated
				coverage for members of a group, the separate contracts are considered parts of
				the same plan and there is no COB among those separate contracts.
(1) Plan includes: group and nongroup
				insurance contracts, health maintenance organization (HMO) contracts, closed
				panel plans or other forms of group or group type coverage (whether insured or
				uninsured); medical care components of long-term care contracts, such as
				skilled nursing care; medical benefits under group or individual automobile
				contracts; and medicare or any other federal governmental plan, as permitted by
				law.
(2) Plan does not include:
				hospital indemnity coverage or other fixed indemnity coverage; accident-only
				coverage; specified disease or specified accident coverage; limited benefit
				health coverage, as defined by state law; school accident-type coverage;
				benefits for nonmedical components of long-term care policies; medicare
				supplement policies; medicaid policies; or coverage under other federal
				governmental plans, unless permitted by law.
Each contract for coverage under (1) or (2) is a separate
				  plan. If a plan has two parts and COB rules apply only to one of the two, each
				  of the parts is treated as a separate plan.
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 45-08-02-01 - Scope

Current through Supplement No. 393, July, 2024
This chapter is applicable to all insurance policies and
				  certificates and subscriber contracts issued or provided by an insurance
				  company, health maintenance organization, or a nonprofit service corporation on
				  a group or group-type basis covering persons as employees of employers or as
				  members of unions or associations.
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
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 45-08-02-03 - Unfair discrimination in group health insurance coverage transfers

Current through Supplement No. 393, July, 2024
Group coverage of accident and health insurance benefits
				  transferred from one carrier to another must guaranty transfer of coverage for
				  all eligible persons covered under the existing group insurance program and the
				  transfer of such coverage must be negotiated on the basis of all eligible
				  persons being covered under the group insurance program of the new carrier,
				  irrespective of the current state of health of such persons, provided all such
				  persons are currently covered under the present carrier's group insurance
				  program. Violation of this section by an insurance company or agent constitutes
				  unfair discrimination and is a prohibited practice as defined in subsection 7
				  of North Dakota Century Code section 26.1-04-03.
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
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 45-08-02-04 - Effective date of discontinuance for nonpayment of premium or subscription charges

Current through Supplement No. 393, July, 2024
1. If a policy or
				contract or certificate subject to these rules provides for automatic
				discontinuance of the coverage after a premium or subscription charge has
				remained unpaid through the grace period allowed for such payment, the carrier
				is liable for valid claims for covered losses incurred prior to the end of the
				grace period.
2. If the actions of
				the carrier after the end of the grace period indicate that it considers the
				coverage as continuing in force beyond the end of the grace period (such as, by
				continuing to recognize claims subsequently incurred), the carrier is liable
				for valid claims for losses beginning prior to the effective date of written
				notice of discontinuance to the policyholder or other entity responsible for
				making payments or submitting subscription charges to the carrier. The
				effective date of discontinuance shall not be prior to midnight at the end of
				the third scheduled workday after the date upon which the notice is delivered.
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
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 45-08-02-05 - Requirements for notice of discontinuance

Current through Supplement No. 393, July, 2024
1. Any notice of discontinuance so given by
				the carrier must include a request to the group policyholder or other entity
				involved to notify employees covered under the policy or subscriber contract of
				the date as of which the group policy or contract will discontinue and to
				advise that, unless otherwise provided in the policy, certificate, or contract,
				the carrier shall not be liable for claims for losses incurred after such date.
				Such notice of discontinuance must also advise, in any instance in which the
				plan involves employee contributions, that if the policyholder or in any
				instance in which the plan involves employee contributions, that if the
				policyholder or other entity continues to collect contributions for the
				coverage beyond the date of discontinuance, the policyholder or other entity
				may be held solely liable for the benefits with respect to which the
				contributions have been collected.
2. The carrier will prepare and furnish to
				the policyholder or other entity at the same time a supply of a notice form to
				be distributed to the employees or members concerned indicating such
				discontinuance and the effective date thereof, and urging the employees or
				members to refer to their certificates or contracts in order to determine what
				rights, if any, are available to them upon such discontinuance.
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
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 45-08-02-06 - Extension of benefits

Current through Supplement No. 393, July, 2024
1. Every group
				policy or certificate or other contract subject to these rules hereafter
				issued, or under which the level of benefits is hereafter altered, modified, or
				amended, must provide a reasonable provision for extension of benefits in the
				event of total disability at the date of discontinuance of the group coverage,
				as required by the following subsections.
2. In the case of a group life plan which
				contains a disability benefit extension of any type (e.g., premium waiver
				extension, extended death benefit in event of total disability, or payment of
				income for a specified period during total disability), the discontinuance of
				the group policy does not operate to terminate such extension.
3. In the case of a group plan providing
				benefits for loss of time from work or specific indemnity during hospital
				confinement, discontinuance of the policy during a disability has no effect on
				benefits payable for that disability or confinement.
4. In the case of hospital or medical expense
				coverages other than dental and maternity expense, a reasonable extension of
				benefits or accrued liability provision is required. Such a provision will be
				considered "reasonable" if it provides an extension of at least twelve months
				under "major medical" and "comprehensive medical" type coverages, and under
				other types of hospital or medical expense coverages provides either an
				extension of at least ninety days or an accrued liability for expenses incurred
				during a period of disability or during a period of at least ninety days
				starting with a specific event which occurred while coverage was in force
				(e.g., an accident).
5. Any
				applicable extension of benefits or accrued liability must be described in any
				policy or contract involved as well as in group insurance certificates. The
				benefits payable during any period of extension or accrued liability may be
				subject to the policy's or contract's regular benefit limits (e.g., benefits
				ceasing at exhaustion of a benefit period or of maximum benefits). For hospital
				or medical expense coverages, the benefit payments may be limited to payments
				applicable to the disabling condition only.
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