North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Section 45-08-01.2-01 - Definitions

Current through Supplement No. 393, July, 2024
As used in this chapter, these words and terms have the
				  following meanings, unless the context clearly indicates otherwise:
1.
a."Allowable expense", except as set forth below or when a
				  statute requires a different definition, means any health care expense,
				  including coinsurance or copayments and without reduction for any applicable
				  deductible, that is covered in full or in part by any of the plans covering the
				  person.
b. If a plan is advised by a covered person that all plans
				  covering the person are high-deductible health plans and the person intends to
				  contribute to a health savings account established in accordance with section
				  223 of the Internal Revenue Code of 1986, the primary high-deductible health
				  plan's deductible is not an allowable expense, except for any health care
				  expense incurred that may not be subject to the deductible as described in
				  section 223(c)(2)(C) of the Internal Revenue Code of 1986.
c. An expense or a portion of an expense that is not covered
				  by any of the plans is not an allowable expense.
d. Any expense that a provider by law or in accordance with a
				  contractual agreement is prohibited from charging a covered person is not an
				  allowable expense.
e. The following are examples of expenses that are not
				  allowable expenses:
(1) If a person is confined in a private hospital room, the
				  difference between the cost of a semiprivate room in the hospital and the
				  private room is not an allowable expense, unless one of the plans provides
				  coverage for private hospital room expenses.
(2) If a person is covered by two or more plans that compute
				  their benefit payments on the basis of usual and customary fees or relative
				  value schedule reimbursement or other similar reimbursement methodology, any
				  amount charged by the provider in excess of the highest reimbursement amount
				  for a specified benefit is not an allowable expense.
(3) If a person is covered by two or more plans that provide
				  benefits or services on the basis of negotiated fees, any amount in excess of
				  the highest of the negotiated fees is not an allowable expense.
(4) If a person is covered by one plan that calculates its
				  benefits or services on the basis of usual and customary fees or relative value
				  schedule reimbursement or other similar reimbursement methodology and another
				  plan that provides its benefits or services on the basis of negotiated fees,
				  the primary plan's payment arrangement shall be the allowable expense for all
				  plans. However, If the provider has contracted with the secondary plan to
				  provide the benefit or service for a specific negotiated fee or payment amount
				  that is different than the primary plan's payment arrangement and if the
				  provider's contract permits, that negotiated fee or payment shall be the
				  allowable expense used by the secondary plan to determine its benefits.
f. The definition of "allowable expense" may exclude certain
				  types of coverage or benefits such as dental care, vision care, prescription
				  drugs, or hearing aids. A plan that limits the application of coordination of
				  benefits to certain coverages or benefits may limit the definition of allowable
				  expense in its contract to expenses that are similar to the expenses that it
				  provides. When coordination of benefits is restricted to specific coverages or
				  benefits in a contract, the definition of allowable expense shall include
				  similar expenses to which coordination of benefits applies.
g. When a plan provides benefits in the form of services, the
				  reasonable cash value of each service will be considered an allowable expense
				  and a benefit paid.
h. The amount of the reduction may be excluded from allowable
				  expense when a covered person's benefits are reduced under a primary plan:
(1) Because the covered person does not comply with the plan
				  provisions concerning second surgical opinions or precertification of
				  admissions or services; or
(2) Because the covered person has a lower benefit because
				  the covered person did not use a preferred provider.
2. "Birthday" refers only to month and day in a calendar year
				  and does not include the year in which the individual is born.
3. "Claim" means a request that benefits of a plan be
				  provided or paid. The benefits claimed may be in the form of:
a. Services, including supplies;
b. Payment for all or a portion of the expenses incurred;
c. A combination of subdivisions a and b; or
d. An indemnification.
4. "Closed panel plan" means a plan that provides health
				  benefits to covered persons primarily in the form of services through a panel
				  of providers that have contracted with or are employed by the plan, and that
				  excludes benefits for services provided by other providers, except in cases of
				  emergency or referral by a panel member.
5. "Consolidated Omnibus Budget Reconciliation Act of 1985"
				  or "COBRA" means coverage provided under a right of continuation pursuant to
				  federal law.
6. "Coordination of benefits" or "COB" means a provision
				  establishing an order in which plans pay their claims, and permitting secondary
				  plans to reduce their benefits so that the combined benefits of all plans do
				  not exceed total allowable expenses.
7. "Custodial parent" means:
a. The parent awarded custody of a child by a court decree;
				  or
b. In the absence of a court decree, the parent with whom the
				  child resides more than one-half of the calendar year without regard to any
				  temporary visitation.
8.
a. "Group-type contract" means a contract that is not
				  available to the
general public and is obtained and maintained only because
				  of membership in or a connection with a particular organization or group,
				  including blanket coverage.
b. "Group-type contract" does not include an individually
				  underwritten and issued guaranteed renewable policy even if the policy is
				  purchased through payroll deduction at a premium savings to the insured since
				  the insured would have the right to maintain or renew the policy independently
				  of continued employment with the employer.
9. "High-deductible health plan" has the meaning given the
				  term under section 223 of the internal Revenue Code of 1986, as amended by the
				  Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
10.
a."Hospital indemnity benefits" means benefits not related to
				  expenses incurred.
b. "Hospital indemnity benefits" does not include
				  reimbursement-type benefits even if they are designed or administered to give
				  the insured the right to elect indemnity-type benefits at the time of claim.
11.
a. "Plan" means a form of coverage with which coordination is
				  allowed. Separate parts of a plan for members of a group that are provided
				  through alternative contracts that are intended to be part of a coordinated
				  package of benefits are considered one plan and there is no coordination of
				  benefits among the separate parts of the plan.
b. If a plan coordinates benefits, its contract shall state
				  the types of coverage that will be considered in applying the coordination of
				  benefits provision of that contract. Whether the contract uses the term "plan"
				  or some other term such as "program", the contractual definition may be no
				  broader than the definition of "plan" in this subsection. The definition of
				  "plan" in the model coordination of benefits provision in appendix A is an
				  example.
c. "Plan" includes:
(1) Group and nongroup insurance contracts and subscriber
				  contracts;
(2) Uninsured arrangements of group or group-type coverage;
(3) Group and nongroup coverage through closed panel plans;
(4) Group-type contracts;
(5) The medical care components of long-term care contracts,
				  such as skilled nursing care;
(6) The medical benefits coverage in automobile "no-fault"
				  and traditional automobile "fault" type contracts subject to the provisions of
				  the North Dakota no-fault coordination of benefits provisions as set forth in
				  subsection 3 of section 26.1-41-13; and
(7) Medicare or other governmental benefits, as permitted by
				  law, except as provided in paragraph 8 of subdivision d. That part of the
				  definition of plan may be limited to the hospital, medical, and surgical
				  benefits of the governmental program.
d. "Plan" does not include:
(1) Hospital indemnity coverage benefits or other fixed
				  indemnity coverage;
(2) Accident only coverage;
(3) Specified disease or specified accident coverage;
(4) Limited benefit health coverage;
(5) School accident-type coverages that cover students for
				  accidents only, including athletic injuries, either on a twenty-four-hour basis
				  or on a "to and from school" basis;
(6) Benefits provided in long-term care insurance policies
				  for nonmedical services, for example, personal care, adult day care, homemaker
				  services, assistance with activities of daily living, respite care, and
				  custodial care or for contracts that pay a fixed daily benefit without regard
				  to expenses incurred or the receipt of services;
(7) Medicare supplement policies;
(8) A state plan under medicaid; or
(9) A governmental plan, which by law, provides benefits that
				  are in excess of those of any private insurance plan or other nongovernmental
				  plan.
12. "Policyholder" means the primary insured named in a
				  nongroup insurance policy.
13. "Primary plan" means a plan whose benefits for a person's
				  health care coverage must be determined without taking the existence of any
				  other plan into consideration. A plan is a primary plan if:
a. The plan either has no order of benefit determination
				  rules, or its rules differ from those permitted by this regulation; or
b. All plans that cover the person use the order of benefit
				  determination rules required by this regulation, and under those rules the plan
				  determines its benefits first.
14. "Secondary plan" means a plan that is not a primary plan.
General Authority: NDCC 26.1-36-38
Law Implemented: NDCC 26.1-36-10, 26.1-36-29,
					 26.1-41-13