reglab/statecodes huggingface dataset:
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-13 - Restoration of coverage

Current through Supplement No. 393, July, 2024
1.
a. Except as provided in subdivision b, a
				small employer carrier shall, as a condition of continuing to transact business
				in this state with small employers, offer to provide a health benefit plan as
				described in subsection 3 to any small employer whose coverage was terminated
				or not renewed by such small employer carrier after January 1, 1994.
b. The offer required under subdivision a
				shall not be required with respect to a health benefit plan that was not
				renewed if:
(1) The health benefit plan was
				not renewed for reasons permitted in subsection 1 of North Dakota Century Code
				section 26.1-36.3-05; or
(2) The
				nonrenewal was a result of the small employer voluntarily electing coverage
				under a different health benefit plan.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-14 - Special enrollment periods

Current through Supplement No. 393, July, 2024
1. Employees
				losing other coverage. A group health plan shall permit an employee who is
				eligible, but not enrolled, for coverage (or a dependent of the employee if the
				dependent is eligible, but not enrolled) to enroll for coverage under the terms
				of the plan if each of the following conditions is met:
a. The employee or dependent was covered
				under a group health plan at the time coverage was previously offered to the
				employee or dependent.
b. The
				employee stated in writing at the time coverage was previously offered that
				coverage under a group health plan was the reason for declining enrollment, but
				only if the plan required such a statement at the time and provided the
				employee with notice of the requirement and its consequences.
c. The employee's or dependent's coverage:
(1) Was under a Consolidated Omnibus Budget
				Reconciliation Act continuation provision and the coverage was exhausted; or
(2) If not under a Consolidated
				Omnibus Budget Reconciliation Act continuation provision, the coverage was
				terminated as a result of loss of eligibility for the coverage or because
				employer contributions toward the coverage were terminated.
d. Under the terms of the plan,
				the employee requests enrollment not later than thirty days after the date of
				termination of the coverage or employer contribution.
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 45-06-07-01 - Applicability and scope

Current through Supplement No. 393, July, 2024
This chapter applies to all health maintenance organizations
				  that are required to obtain a certificate of authority in this state. In the
				  event of conflict between the provisions of this chapter and the provisions of
				  any other chapter issued by the commissioner, the provisions of this chapter
				  shall be controlling as to health maintenance organizations.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC
					 26.1-18.1
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 45-06-07-02 - Effective date

Current through Supplement No. 393, July, 2024
1. All group and
				individual contracts written or issued on or after December 31, 1993, must
				conform with the provisions of these rules.
2. Group or individual contract or evidence
				of coverage may not be reissued, renewed, amended, or extended in this state on
				or after December 31, 1993, unless it complies with this chapter. A group or
				individual contract or evidence of coverage approved before December 31, 1993,
				must be deemed to be reissued, renewed, amended, or extended on the date the
				health maintenance organization changes the terms of the group or individual
				contract or evidence of coverage or adjusts the premiums charged. Such group or
				individual contracts or evidence of coverage must comply with this chapter when
				amended but in no event later than June 30, 1995.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC
					 26.1-18.1
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 45-06-07-05 - Prohibited practices

Current through Supplement No. 393, July, 2024
1.
Preexisting conditions.
a. A
				health maintenance organization may impose a preexisting condition exclusion
				only if:
(1) The exclusion relates to a
				condition, regardless of the cause of the condition, for which medical advice,
				diagnosis, care, or treatment was recommended or received within the six-month
				period immediately preceding the effective date of coverage;
(2) The exclusion extends for a period of not
				more than twelve months, or eighteen months in the case of a late enrollee for
				coverage offered to a small employer pursuant to North Dakota Century Code
				chapter 26.1-36.3, after the effective date of coverage;
(3) In the case of group contracts, the
				exclusion does not relate to pregnancy as a preexisting condition; and
(4) In the case of group
				contracts, the exclusion does not relate to genetic information as a
				preexisting condition in the absence of a diagnosis of a condition related to
				such information.
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 45-06-07-06 - Services

Current through Supplement No. 393, July, 2024
1.
Access to care.
a. A health maintenance organization shall
				establish and maintain adequate arrangements to provide health services for its
				enrollees, including:
(1) Reasonable
				proximity to the business or personal residences of the enrollees so as not to
				result in unreasonable barriers to accessibility;
(2) Reasonable hours of operation and
				after-hours services;
(3)
				Emergency care services available and accessible within the service area
				twenty-four hours a day, seven days a week; and
(4) Sufficient providers, personnel,
				administrators, and support staff to assure that all services contracted for
				will be accessible to enrollees on an appropriate basis without delays
				detrimental to the health of enrollees.
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 45-06-07-07 - Other requirements

Current through Supplement No. 393, July, 2024
1.
Description of providers.
a. A
				health maintenance organization shall provide its subscribers with a list of
				the names and locations of all of its providers no later than the time of
				enrollment or the time the group or individual contract and evidence of
				coverage are issued and upon reenrollment. If a provider is no longer
				affiliated with a health maintenance organization, the health maintenance
				organization shall provide notice of such change to its affected subscribers
				within thirty days. Subject to the approval of the commissioner, a health
				maintenance organization may provide its subscribers with a list of providers
				or provider groups for a segment of the service area. However, a list of all
				providers must be made available to subscribers upon request.
b. Any list of providers must contain a
				notice regarding the availability of the listed primary care physicians. Such
				notice must be in not less than twelve-point type and be placed in a prominent
				place on the list of providers. The notice must contain the following or
				similar language:
Enrolling in [name of health maintenance organization] does
				  not guarantee services by a particular provider on this list. If you wish to
				  receive care from specific providers listed, you should contact those providers
				  to be sure that they are accepting additional patients for [name of health
				  maintenance organization].
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 45-06-07-08 - Penalties

Current through Supplement No. 393, July, 2024
Any violation of this chapter is subject to the penalties as
				  provided for in North Dakota Century Code title 26.1 and any other applicable
				  law of this state.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC
					 26.1-18.1
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 45-06-07-09 - Severability

Current through Supplement No. 393, July, 2024
If any provision of this chapter or the application thereof
				  to any person or circumstances is for any reason held to be invalid, the
				  remainder of the chapter and the application for such provision to other
				  persons or circumstances is not affected thereby.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC
					 26.1-18.1
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 45-06-07-10 - Producer compliance

Current through Supplement No. 393, July, 2024
Any health maintenance organization producer under this
				  chapter is subject to the requirements and provisions of North Dakota Century
				  Code chapter 26.1-26.
General Authority: NDCC 26.1-18.1-16
Law Implemented: NDCC
					 26.1-18.1-16
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-08 - Loss Ratios › Section 45-06-08-01 - Scope

Current through Supplement No. 393, July, 2024
These rules apply to all policies providing hospital,
				  surgical, medical, or major medical benefits, including major medical,
				  hospital/surgical, medical expense, and surgical expense policies. This rule
				  does not apply to any contract or plan of insurance that provides exclusively
				  for accident, disability income insurance, specified disease, hospital
				  confinement indemnity, or other limited benefit health insurance.
General Authority: NDCC 26.1-36-37.2
Law Implemented: NDCC
					 26.1-36-37.2
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-08 - Loss Ratios › Section 45-06-08-02 - Mandated loss ratios - Factors to be considered

Current through Supplement No. 393, July, 2024
Mandated loss ratio benefits under the policies specified in
				  section 45-06-08-01 must return benefits
				  to group policyholders in the aggregate of not less than seventy percent of
				  premium received and to individual policyholders in the aggregate of not less
				  than fifty-five percent of premium received. Association group business which
				  is marketed to individuals and individually underwritten and issued is
				  considered individual coverage for loss ratio purposes. These minimum standards
				  must be on the basis of incurred claims experienced and earned premiums for the
				  entire period for which rates are computed to provide coverage in accordance
				  with accepted actuarial principles and practices. In evaluating the experienced
				  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. Interest; and
9. Policy reserves.
General Authority: NDCC 26.1-36-37.2
Law Implemented: NDCC
					 26.1-36-37.2
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-08 - Loss Ratios › Section 45-06-08-03 - Compliance

Current through Supplement No. 393, July, 2024
The requirements of this chapter apply to policies issued
				  after January 1, 1994.
General Authority: NDCC 26.1-36-37.2
Law Implemented: NDCC
					 26.1-36-37.2
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-01 - Purpose and intent

Current through Supplement No. 393, July, 2024
The purpose of this chapter is to further improve the
				  fairness, efficiency, and competition in the pricing and delivering of health
				  care and health care coverage. It does so by allowing for the establishment of
				  joint purchasing entities (purchasing cooperatives) through which eligible
				  small employers can purchase health coverage for their employees.
General Authority: NDCC 26.1-01-07.4
Law Implemented: NDCC
					 26.1-01-07.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-02 - Applicability and scope

Current through Supplement No. 393, July, 2024
This chapter applies to all health insurance purchasing
				  cooperatives operating in this state or providing coverage to North Dakota
				  residents. Health purchasing cooperatives are subject to the small employer
				  employee health insurance coverage requirements contained in North Dakota
				  Century Code chapter 26.1-36.3. This chapter does not apply to any other health
				  insurance or health care buying or marketing mechanism otherwise permitted by
				  law.
General Authority: NDCC 26.1-01-07.4
Law Implemented: NDCC
					 26.1-01-07.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-03 - Definitions

Current through Supplement No. 393, July, 2024
1. "Business plan" means the plan of operation of the health
				  insurance purchasing cooperative.
2. "Commissioner" means the insurance commissioner.
3. "Group" means a collection of small employers subject to
				  the requirements of North Dakota Century Code chapter 26.1-36.3 who elect to
				  join together to form a group health insurance purchasing cooperative. It does
				  not include an industrywide trade association meeting the exemption
				  requirements outlined in subsection 15 of North Dakota Century Code section
				  26.1-36.3-07 or any other insurance purchasing group arrangements in existence
				  prior to August 1, 1994.
4. "Health insurance purchasing cooperative" means a group of
				  small employers who join together to purchase health insurance.
General Authority: NDCC 26.1-01-07.4
Law Implemented: NDCC
					 26.1-01-07.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-04 - Commissioner duties - Filing requirements - Audits and examinations

Current through Supplement No. 393, July, 2024
1. The commissioner has the authority to
				regulate the establishment and conduct of health insurance purchasing
				cooperatives as set forth in this chapter.
2. The commissioner has the authority to
				conduct financial and performance audits on health insurance purchasing
				cooperatives operating in the state. The costs of such audits shall be the
				responsibility of the purchasing cooperative.
3. Each health insurance purchasing
				cooperative doing business in the state shall file with the commissioner the
				following information or documents:
3- A business plan for approval by the commissioner.
b. Annual reports identifying the number of
				individuals insured through the cooperative, the names of insurance companies
				providing coverage to cooperative members and rates charged for insurance
				policies provided through the cooperative, and any proposed changes in the
				business plan of the cooperative.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-05 - Business plan

Current through Supplement No. 393, July, 2024
A health insurance purchasing cooperative shall submit a
				  business plan for review and approval by the commissioner. The business plan
				  must include the following information:
1. The specific steps by the health insurance
				purchasing cooperative to advance cost control, quality improvement, and
				improved access to health insurance and health care services.
2. The scope of health insurance purchasing
				cooperative services to be offered in the service territory and the resources
				and expertise to be used to implement and administer the plan.
3. The corporate chart, bylaws, and other
				business operation documents of the health insurance purchasing cooperative.
4. A list of officers and
				directors of the health insurance purchasing cooperative and the contract
				administrator if one is employed.
5. Evidence of adequate security and prudence
				in the accounting, deposit, collection, handling, and transfer of moneys.
6. Any other information required
				by the commissioner to verify the purchasing group is qualified to administer
				the benefit plan.
General Authority: NDCC 26.1-01-07.4
Law Implemented: NDCC
					 26.1-01-07.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-06 - Conflict of interest

Current through Supplement No. 393, July, 2024
1. Health care
				providers or insurers offering competing products within the same service
				territory may not participate in a health insurance purchasing cooperative as a
				sponsor or administrator.
2. A
				health insurance purchasing cooperative sponsor or administrator may not be an
				employee or a subsidiary of a health care provider or insurer offering
				competing products within the same service territory.
3. The employees of a health care provider or
				insurer may receive services through a health insurance purchasing cooperative.
				The employer may vote in corporate governance elections for officers and
				directors. A health care provider, insurer, or an employee of a health care
				provider or insurer may not serve as an officer or director of a health
				insurance purchasing cooperative.
General Authority: NDCC 26.1-01-07.4
Law Implemented: NDCC
					 26.1-01-07.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-09 - Group Health Insurance Purchasing Cooperatives › Section 45-06-09-08 - Bonding protection

Current through Supplement No. 393, July, 2024
Health insurance cooperatives collecting premiums shall
				  provide bonding coverage for cooperative employees handling funds. Evidence of
				  bond coverage sufficient to cover the volume of premium collected by the
				  purchasing cooperative must be filed with the annual report required under
				  subdivision b of subsection 3 of section
				  45-06-09-04.
General Authority: NDCC 26.1-01-07.4
Law Implemented: NDCC
					 26.1-01-07.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-10 - Utilization Review › Section 45-06-10-01 - Definition

Current through Supplement No. 393, July, 2024
For purposes of this chapter "licensed practitioner"
				  includes dentist, chiropractor, psychologist, and optometrist.
General Authority: NDCC 26.1-01-08, 28-32-02
Law Implemented: NDCC
					 26.1-26.4-04
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-10 - Utilization Review › Section 45-06-10-02 - Subsequent determination after initial appeal

Current through Supplement No. 393, July, 2024
1. After an initial appeal to reverse a
				determination regarding hospital, medical, or other health care services is
				unsuccessful, a subsequent determination which may result in denial of
				third-party reimbursement or denial of precertification for service must
				include the evaluation, findings, and concurrence of a physician or licensed
				practitioner trained in the relevant specialty to make a final determination
				that care provided or to be provided was, is, or may be medically
				inappropriate.
2. A physician or
				licensed practitioner must hold a valid, current professional license issued by
				an appropriate professional board.
3. Compensation of a physician or licensed
				practitioner giving an opinion in regard to any determination under subsection
				1 may not be dependent in any way upon the result of the final determination.
General Authority: NDCC 26.1-01-08, 28-32-02
Law Implemented: NDCC
					 26.1-26.4-04
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 45-06-11-05 - Notification of qualifying previous coverage and preexisting condition exclusion period

Current through Supplement No. 393, July, 2024
1. A health carrier
				is required, within a reasonable time, to make a determination regarding the
				individual's qualifying previous coverage and notify the individual of the
				determination in accordance with this section.
2. A health carrier seeking to impose a
				preexisting condition exclusion is required to disclose to the individual in
				writing its determination of any preexisting condition exclusion period that
				applies to the individual and the basis for such determination, including the
				source and substance of any information on which the health carrier relied. In
				addition, the health carrier is required to provide the individual with a
				written explanation of any appeal procedures established by the issuer and with
				a reasonable opportunity to submit additional evidence of coverage. Nothing in
				this section prevents a health carrier from modifying an initial determination
				qualifying previous coverage if it determines that the individual did not have
				the claimed qualifying previous coverage, provided that:
a. A notice of reconsideration is provided to
				the individual; and
b. Until the
				final determination is made, the health carrier, for purposes of approving
				access to medical services, acts in a manner consistent with the initial
				determination.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-12 - Regulation to Implement North Dakota Century Code Chapter 26.1-36.4, Relating to Hospital and Medical Insurance › Section 45-06-12-01 - Definitions

Current through Supplement No. 393, July, 2024
As used in this chapter and North Dakota Century Code
				  chapter 26.1-36.4:
1. "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.
2. "Waiting period" means, with respect to a health benefit
				  plan, whether offered on a group or individual basis, and an individual who is
				  a potential participant or beneficiary in the plan, the period that must pass
				  with respect to the individual before the individual is eligible to be covered
				  for benefits under the terms of the plan.
General Authority: NDCC 28-32-02(1)
Law Implemented: NDCC
					 26.1-36.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-12 - Regulation to Implement North Dakota Century Code Chapter 26.1-36.4, Relating to Hospital and Medical Insurance › Section 45-06-12-02 - Prohibiting discrimination against participants and beneficiaries based on health status-related factors

Current through Supplement No. 393, July, 2024
1. An
				insurer offering group health insurance coverage in connection with a group
				health benefit plan may not establish rules for eligibility, including
				continued eligibility, of any individual to enroll under the terms of the plan
				based on a health status-related factor, as defined in subsection 20 of North
				Dakota Century Code section 26.1-36.3-01.
2. Subsection 1 shall not be construed to:
a. Require an insurer to provide particular
				benefits other than those provided under the terms of the plan or coverage; or
b. Prevent the insurer from
				establishing limitations or restrictions on the amount, level, extent, or
				nature of the benefits or coverage for similarly situated individuals enrolled
				in the plan or coverage.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-12 - Regulation to Implement North Dakota Century Code Chapter 26.1-36.4, Relating to Hospital and Medical Insurance › Section 45-06-12-03 - Special enrollments for certain individuals who losecoverage

Current through Supplement No. 393, July, 2024
1. An insurer offering group health insurance
				coverage in connection with a group health benefit plan is required to permit
				employees and dependents described in this section to enroll for coverage under
				the terms of the plan if the conditions in subsection 4 are satisfied and the
				enrollment is requested within the period described in subsection 5.
2. An employee is described in this section
				if:
a. The employee is eligible, but not
				enrolled, for coverage under the terms of the plan; and
b. When enrollment was previously offered to
				the employee under the plan and was declined by the employee, the employee was
				covered under another group health benefit plan or had other health insurance
				coverage.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-12 - Regulation to Implement North Dakota Century Code Chapter 26.1-36.4, Relating to Hospital and Medical Insurance › Section 45-06-12-04 - Special enrollment periods for certain dependent beneficiaries

Current through Supplement No. 393, July, 2024
1. A group health benefit plan that makes
				coverage available with respect to dependents of a participant is required to
				provide a special enrollment period to permit individuals described in this
				section to be enrolled for coverage under the terms of the plan if the
				enrollment is requested within the time period described in subsection 7. The
				enrollment is effective at the time described in subsection 8. The special
				enrollment rights under this section apply without regard to the dates on which
				an individual would otherwise be able to enroll under the plan.
2. An individual is described in this section
				if:
a. The individual is an employee who is
				eligible, but not enrolled, in the plan;
b. The individual would be a participant but
				for a prior election by the individual not to enroll in the plan during a
				previous enrollment period; and
c.
				A person becomes a dependent of the individual through marriage, birth,
				adoption, or placement for adoption.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-12 - Regulation to Implement North Dakota Century Code Chapter 26.1-36.4, Relating to Hospital and Medical Insurance › Section 45-06-12-05 - Notice of enrollment rights

Current through Supplement No. 393, July, 2024
On or before the time an employee is offered the opportunity
				  to enroll in a group health benefit plan, the plan is required to provided the
				  employee with a description of the plan's special enrollment rules under this
				  chapter. A group health benefit plan using the following model description of
				  the special enrollment rules is deemed to be in compliance with this section:
If you decline enrollment for yourself or your dependents,
				  including your spouse, because of other health insurance coverage, you may in
				  the future be able to enroll yourself or your dependents in this plan, provided
				  that you request enrollment within thirty days after your other coverage ends.
				  In addition, if you have a new dependent as a result of marriage, birth,
				  adoption, or placement for adoption, you may be able to enroll yourself or your
				  dependents, provided that you request enrollment within thirty days after the
				  marriage, birth, adoption, or placement for adoption.
General Authority: NDCC 28-32-02(1)
Law Implemented: NDCC
					 26.1-36.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-12 - Regulation to Implement North Dakota Century Code Chapter 26.1-36.4, Relating to Hospital and Medical Insurance › Section 45-06-12-06 - Conformance with the Health Insurance Portability and Accountability Act of 1996

Current through Supplement No. 393, July, 2024
This chapter, as well as North Dakota Century Code chapter
				  26.1-36.4, will be interpreted by the commissioner to conform with the
				  requirements of the Health Insurance Portability and Accountability Act of 1996
				  [ Pub. L.
				  104-191; 110 Stat. 1936;
				  29 U.S.C.
				  1181 et seq.].
General Authority: NDCC 28-32-02(1)
Law Implemented: NDCC
					 26.1-36.4
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-01 - Definitions

Current through Supplement No. 393, July, 2024
1. "Commissioner" means the insurance commissioner of North
				  Dakota.
2. "Department" means the North Dakota insurance department.
3. "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.
4. "Medicare+choice program" means the criteria developed by
				  the Balanced Budget Act of 1997 [
				  Pub. L.
				  105-33; 111 Stat. 312; 42 U.S.C. 1345 et seq.],
				  whereby risk-bearing organizations are permitted to offer health insurance or
				  health benefits coverage to medicare-eligible enrollees through a
				  medicare+choice plan.
5. "Provider" means any physician, hospital, or other person
				  licensed or otherwise authorized to furnish health care services.
6. "Provider-sponsored organization" means a public or
				  private entity that:
a. Is established or organized, and operated, by a health
				  care provider, or group of affiliated health care providers;
b. Provides a substantial proportion of the health care items
				  and services under the medicare+choice program directly through the provider or
				  affiliated group of providers; and
c. With respect to which the affiliated providers share,
				  directly or indirectly, substantial financial risk with respect to the
				  provision of such items and services and have at least a majority financial
				  interest in the entity.
General Authority: NDCC 26.1-01-07.6
Law Implemented: NDCC
					 26.1-01-07.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-02 - General

Current through Supplement No. 393, July, 2024
The commissioner shall issue a certificate of authority for
				  the purpose of providing health care to medicare enrollees only to a
				  provider-sponsored organization that meets each requirement for the issuance of
				  a certificate of authority as a health maintenance organization as in North
				  Dakota Century Code chapter 26.1-18.1 and other applicable insurance laws and
				  regulations of this state except when preempted by federal law.
General Authority: NDCC 26.1-01-07.6
Law Implemented: NDCC
					 26.1-01-07.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-03 - Action

Current through Supplement No. 393, July, 2024
The department shall take action on an application required
				  in section
				  45-06-13-02 within ninety days of
				  the date of receipt of a substantially complete application.
General Authority: NDCC 26.1-01-07.6
Law Implemented: NDCC
					 26.1-01-07.6
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-04 - Minimum net worth requirements

Current through Supplement No. 393, July, 2024
Prior to the issuance of a certificate of authority, a
				  provider-sponsored organization must have a minimum net worth amount of:
1. At least one million five hundred
				thousand dollars except as provided in subsection 2.
2. No less than one million dollars based on
				evidence from the organization's financial plan demonstrating to the
				department's satisfaction that the organization has available to it an
				administrative infrastructure that the department considers appropriate to
				reduce, control, or eliminate startup administrative costs.
a. After the effective date of a
				provider-sponsored organization's certificate of authority, a
				provider-sponsored organization shall maintain a minimum net worth amount equal
				to the greater of:
(1) One million dollars;
(2) Two percent of annual premium
				revenues as reported on the most recent annual financial statement filed with
				the department for up to and including the first one hundred fifty million
				dollars of annual premiums and one percent of annual premium revenues on
				premiums in excess of one hundred fifty million dollars;
(3) An amount equal to the sum of three
				months of uncovered health care expenditures as reported on the most recent
				financial statement filed with the department; or
(4) Using the most recent annual financial
				statement filed with the department, an amount equal to the sum of:
(a) Eight percent of annual health care
				expenditures paid on a noncapitated basis to nonaffiliated providers;
(b) Four percent of annual health
				care expenditures paid on a capitated basis to nonaffiliated providers plus
				annual health care expenditures paid on a noncapitated basis to affiliated
				providers; and
(c) Annual health
				care expenditures that are paid on a capitated basis to affiliated providers
				are not included in the calculation of the net worth requirement under
				subsection 1 and this paragraph.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-05 - Financial plan requirements

Current through Supplement No. 393, July, 2024
1. General
				rule. At the time of application under section
				45-06-13-03, an applicant must
				submit a financial plan acceptable to the department.
2. A financial plan must include:
a. A detailed marketing plan;
b. Statements of revenue and expense on an
				accrual basis;
c. Statements of
				sources and uses of funds;
d.
				Balance sheets;
e. Detailed
				justifications and assumptions in support of the financial plan including, when
				appropriate, certification of reserves and actuarial liabilities by a qualified
				health maintenance organization actuary; and
f. If applicable, statements of the
				availability of financial resources to meet projected losses.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-06 - Liquidity

Current through Supplement No. 393, July, 2024
1. A provider-sponsored organization shall
				have sufficient cash flow to meet its financial obligations as they become due
				and payable.
2. To determine
				whether the provider-sponsored organization meets the requirement in subsection
				1, the department will examine the following:
a. The provider-sponsored organization's
				timelilness in meeting current obligations;
b. The extent to which the provider-sponsored
				organization's current ratio of assets to liabilities is maintained at a one to
				one ratio including whether there is a declining trend in the current ratio
				over time; and
c. The availability
				of outside financial resources to the provider-sponsored organization.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-07 - Deposits

Current through Supplement No. 393, July, 2024
1.
Insolvency deposit.
a. At the time of application, an
				organization shall deposit one hundred thousand dollars in cash or securities,
				or any combination thereof, into an account in a manner that is acceptable to
				the department.
b. The deposit
				must be restricted to use in the event of insolvency to help assure
				continuation of services or pay costs associated with receivership or
				liquidation.
c. At the time of the
				provider-sponsored organization's application for a certification of authority,
				and, thereafter, upon the department's request, a provider-sponsored
				organization shall provide the department with proof of the insolvency deposit,
				such proof to be in a form that the department considers appropriate.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-13 - Provider-Sponsored Organizations › Section 45-06-13-08 - Guarantees

Current through Supplement No. 393, July, 2024
1.
General policy.
A
				provider-sponsored organization, or the legal entity of which the
				provider-sponsored organization is a component, may apply to the department to
				use the financial resources of a guarantor for the purpose of meeting the
				requirements in section
				45-06-13-05. The department has
				the discretion to approve or deny approval of the use of a guarantor.
2.
Request to use a
				guarantor.
To apply to use the financial resources of a guarantor, a
				provider-sponsored organization must submit to the department the following
				material:
a. Documentation that the guarantor
				meets the requirements for a guarantor under subsection 3; and
b. The guarantor's independently audited
				financial statements for the current year-to-date and for the two most recent
				fiscal years. The financial statements must include the guarantor's balance
				sheets, the profit and loss statements, and cash flow statements.
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 45-06-14-01 - Definitions

Current through Supplement No. 393, July, 2024
1. "Board" means a
				multiple employer welfare arrangement's board of trustees.
2. "Bylaws" means the statements and
				organizational documents adopted by a multiple employer welfare arrangement
				that prescribe its purpose, government, and administration.
3. "Commissioner" means the insurance
				commissioner.
4. "Coverage" means
				the right of a covered person or entity to benefits or indemnification provided
				directly or indirectly by a multiple employer welfare arrangement, by virtue of
				the coverage document.
5. "Coverage
				document" means the document specifying the characteristics and duration of
				coverage provided through a multiple employer welfare arrangement.
				Characteristics of coverage include the kind of loss or benefit that the
				multiple employer welfare arrangement will reimburse, subject to specific
				exclusions, limitations, or deductibles.
6. "Days" means calendar days.
7. "Employee welfare benefit plan" means an
				employee welfare benefit plan as defined by
				29 U.S.C. section
				1002.
8. "Financial administrator" means an entity
				employing persons trained and experienced in money management and investments,
				and possessing no less than five years' experience as an organization in money
				management and investments with demonstrated competence.
9. "Fully insured" means that for the health
				care benefits or coverage provided or offered by or through a multiple employer
				welfare arrangement:
a. An admitted insurer
				is directly obligated by contract to each participant to provide all of the
				coverage under the plan or arrangement; and
b. The liability and responsibility of the
				admitted insurer to provide covered services or to pay benefits is not
				contingent, and is provided directly to the individual employee, member, or
				dependent.
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 45-06-14-02 - Purpose

Current through Supplement No. 393, July, 2024
This chapter governs the formation, operation, and
				  dissolution of a multiple employer welfare arrangement. The provisions are
				  intended to ensure the financial integrity and the competent and equitable
				  administration of the 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 45-06-14-03 - Scope

Current through Supplement No. 393, July, 2024
This chapter applies to all multiple employer welfare
				  arrangements that offer or maintain an employee welfare benefit plan that is
				  not fully insured, to or on behalf of an employer domiciled in this state or to
				  an employer that has its principal headquarters or principal administrative
				  offices in this state and to all service companies that provide services to the
				  employee welfare benefit plan or 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 45-06-14-04 - Bylaws

Current through Supplement No. 393, July, 2024
1.
Content.
Bylaws may contain any provision that does not conflict with this
				chapter. Bylaws must, at a minimum, contain the following provisions:
a. The multiple employer welfare
				arrangement's name, purpose, fiscal year, and initial date of
				existence;
b. Definitions of key
				terms;
c. A statement of the
				powers, duties, and responsibilities assigned to the board, the service
				company, the financial administrator, and reserved by the membership;
d. The number, term of office, and method of
				selection and replacement of the members of the board;
e. The procedure for calling board
				meetings;
f. The method of periodic
				selection and review of the service company and financial
				administrator;
g. The procedure for
				amending the bylaws;
h. The
				procedure for resolving disputes among members, which must not include
				submitting disputes to the commissioner;
i. The criteria for membership in the
				multiple employer welfare arrangement, including standards of financial
				integrity and loss experience;
j.
				The procedure for admitting new members to the multiple employer welfare
				arrangement;
k. The criteria for
				expelling members from the multiple employer welfare arrangement for reasons,
				including nonpayment of premiums;
l. The procedure for withdrawal and expulsion
				of members from the multiple employer welfare arrangement, including the
				minimum required period of membership;
m. A statement of the coverages to be
				provided by the multiple employer welfare arrangement;
n. The procedure for including and excluding
				a member's participation in a particular coverage;
o. The proposed initial premium payments by
				members and, if applicable, by the members' employees;
p. The procedure for changing premium
				rates;
q. The procedure for levying
				and collecting an assessment;
r. A
				statement identifying those with access to multiple employer welfare
				arrangement funds and the purposes for which multiple employer welfare
				arrangement funds may be spent;
s.
				The procedure for distributing dividends, and the eligibility of past members
				and past covered employees for dividends; and
t. The procedure for distributing any assets
				remaining upon the multiple employer welfare arrangement's
				dissolution.