North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-07 - Model Regulation to Implement Rules Regarding Contracts And Services of Health Maintenance Organizations › Section 45-06-07-03 - Definitions

Current through Supplement No. 393, July, 2024
Group or individual contract or evidence of coverage
				  delivered or issued for delivery to any person in this state by a health
				  maintenance organization required to obtain a certificate of authority in this
				  state may not contain definitions respecting the matters set forth below unless
				  such definitions comply with the requirements of this section. Definitions
				  other than those in this section may be used as appropriate, providing that
				  they do not contradict these requirements. All definitions used in the group or
				  individual contract and evidence of coverage must be in alphabetical order. As
				  used in this chapter and as used in the group or individual contract and
				  evidence of coverage:
1. "Basic health care services" means the following medically
				  necessary services: preventive care, emergency care, inpatient and outpatient
				  hospital and physician care, diagnostic laboratory, and diagnostic and
				  therapeutic radiological services. It does not include mental health services
				  or services for alcohol or drug abuse, dental or vision services, or long-term
				  rehabilitation treatment.
2. "Copayment" means the amount an enrollee must pay in order
				  to receive a specific service that is not fully prepaid.
3. "Deductible" means the amount an enrollee is responsible
				  to pay out of pocket before the health maintenance organization begins to pay
				  the costs or provide the services associated with treatment.
4. "Eligible dependent" means any member of a subscriber's
				  family who meets the eligibility requirements set forth in subsection 2 of
				  section 45-06-07-04.
5. "Emergency care services" means:
a. Within the service area: covered health care services
				  rendered by affiliated or nonaffiliated providers under unforeseen conditions
				  that require immediate medical attention. Emergency care services within the
				  service area include covered health care services from nonaffiliated providers
				  only when delay in receiving care from the health maintenance organization
				  could reasonably be expected to cause severe jeopardy to the enrollee's
				  condition.
b. Outside the service area: medically necessary health care
				  services that are immediately required because of unforeseen illness or injury
				  while the enrollee is outside the geographical limits of the health maintenance
				  organization's service area.
6. "Enrollee" means an individual who is covered by a health
				  maintenance organization.
7. "Evidence of coverage" means a statement of the essential
				  features and services of the health maintenance organization coverage which is
				  given to the subscriber by the health maintenance organization or by the group
				  contractholder.
8. "Extension of benefits" means the continuation of coverage
				  of a particular benefit provided under a group or individual contract following
				  termination with respect to an enrollee who is totally disabled on the date of
				  termination.
9. "Grievance" means a written complaint submitted in
				  accordance with the health maintenance organization's formal grievance
				  procedure by or on behalf of the enrollee regarding any aspect of the health
				  maintenance organization relative to the enrollee.
10. "Group contract" means a contract for health care
				  services which by its terms limits eligibility to enrollees of a specified
				  group. The group contract may include coverage for dependents.
11. "Group contractholder" means the person to whom a group
				  contract has been issued.
12. "Health maintenance organization" means any person who
				  undertakes to provide or arrange for the delivery of basic health care services
				  to enrollees on a prepaid basis, except for enrollee responsibility for
				  copayments or deductibles.
13. "Hospital" means a duly licensed institution that
				  provides general and specialized inpatient medical care. The term "hospital"
				  does not include a convalescent facility, nursing home, or any institution or
				  part of an institution which is used principally as a convalescent facility,
				  rest facility, nursing facility, or facility for the aged.
14. "Individual contract" means a contract for health care
				  services issued to and covering an individual. The individual contract may
				  include coverage for dependents of the subscriber.
15. "Medical necessity" or "medically necessary" means
				  appropriate and necessary services as determined by any provider affiliated
				  with the health maintenance organization which are rendered to an enrollee for
				  any condition requiring, according to generally accepted principles of good
				  medical practice, the diagnosis or direct care and treatment of an illness or
				  injury and are not provided only as a convenience. This does not preclude the
				  health maintenance organization from establishing standards by which providers
				  make their decisions as to what is medically necessary or from penalizing
				  providers for failure to meet these standards. In the case of emergency medical
				  services, the health maintenance organization has the right to make the final
				  determination of whether services should be covered.
16. "Nonbasic health care services" means any health care
				  services, other than basic health care services, that may be provided in the
				  absence of basic health care services.
17. "Out-of-area services" means the health care services
				  that a health maintenance organization covers when its enrollees are outside of
				  the service area.
18. "Participating provider" means a provider as defined in
				  this section who, under an express or implied contract with the health
				  maintenance organization or with its contractor or subcontractor, has agreed to
				  provide health care services to enrollees with an expectation of receiving
				  payment, other than copayment or deductible, directly or indirectly from the
				  health maintenance organization.
19. "Physician" means a duly licensed doctor of medicine or
				  osteopathy practicing within the scope of such a license.
20. "Primary care physician" means a physician who
				  supervises, coordinates, and provides initial and basic care to enrollees, and
				  who initiates their referral for specialist care and maintains continuity of
				  patient care.
21. "Provider" means any physician, hospital, or other person
				  licensed or otherwise authorized to furnish health care services.
22. "Replacement coverage" means the benefits provided by a
				  succeeding carrier.
23. "Service area" means the geographical area as approved by
				  the commissioner within which the health maintenance organization provides or
				  arranges for health care services that are available and accessible to
				  enrollees.
24. "Skilled nursing facility" means a facility that is
				  operated pursuant to law and is primarily engaged in providing room and board
				  accommodations and skilled nursing care under the supervision of a duly
				  licensed physician.
25. "Subscriber" means an individual whose employment or
				  other status, except family dependency, is the basis for eligibility for
				  enrollment in the health maintenance organization, or in the case of an
				  individual contract, the person in whose name the contract is issued.
26. "Supplemental health care services" means any health care
				  services that are provided in addition to basic health care services.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC
					 26.1-18.1