North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-11 - Regulation on the Crediting of Qualifying Previous Coverage Toward the Reduction of Preexisting Condition Exclusion Periods › Section 45-06-11-01 - Definitions

Current through Supplement No. 393, July, 2024
As used in this chapter:
1. "Enrollment date" means the first day of coverage or, if
				  there is a waiting period, the first day of the waiting period.
2. "First day of coverage" means, in the case of an
				  individual covered for benefits under a group health plan in the group market,
				  the first day of coverage under the plan and, in the case of an individual
				  covered by health insurance coverage in the individual market, the first day of
				  coverage under the policy.
3. "Health carrier" means any entity that provides health
				  insurance in this state. For purposes of this chapter, "health carrier"
				  includes an insurance company, a prepaid limited health services corporation, a
				  fraternal benefits society, a health maintenance organization, a nonprofit
				  health services corporation, and any other entity providing a plan of health
				  insurance or health benefits subject to state insurance regulation.
4. "Late enrollee" means an individual whose enrollment in a
				  plan is a late enrollment.
5. "Late enrollment" means enrollment under a group health
				  plan other than on the earliest date on which coverage can become effective
				  under the terms of the plan, or a special enrollment date for the individual.
				  If an individual ceases to be eligible for coverage under the plan by
				  terminating employment, and then subsequently becomes eligible for coverage
				  under the plan by resuming employment, only eligibility during the individual's
				  most recent period of employment is taken into account in determining whether
				  the individual is a late enrollee under the plan with respect to the most
				  recent period of coverage. Similar rules apply if an individual again becomes
				  eligible for coverage following a suspension of coverage that applied generally
				  under the plan.
6. "Preexisting condition exclusion" means a limitation or
				  exclusion of benefits relating to a condition based on the fact that the
				  condition was present before the effective date of coverage, whether or not any
				  medical advice, diagnosis, care, or treatment was recommended or received
				  before such date.
7. "Waiting period" means the period that must pass before an
				  employee or dependent is eligible to enroll under the terms of a group health
				  plan. If an employee or dependent enrolls as a late enrollee or on a special
				  enrollment date, any period before such late or special enrollment is not a
				  waiting period. If an individual seeks and obtains coverage in the individual
				  market, any period after the date the individual files a substantially complete
				  application for coverage and before the first day of coverage is a waiting
				  period.
General Authority: NDCC 26.1-08-12(4), 26.1-36.3-06(3)(b),
					 26.1-36.4-04
Law Implemented: NDCC 26.1-08-12(4), 26.1-36.3-06(3)(b),
					 26.1-36.4-04