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 45-06-07-04 - Requirements for contracts and evidence of coverage

Current through Supplement No. 393, July, 2024
Each subscriber is entitled to receive an individual
				  contract or evidence of coverage in a form that has been approved by the
				  commissioner. Each group contractholder is entitled to receive a group contract
				  as approved by the commissioner. Group contracts, individual contracts, and
				  evidences of coverage must be delivered or issued for delivery to subscribers
				  or group contractholders within a reasonable time after enrollment, but not
				  more than fifteen days from the later of the effective date of coverage or the
				  date on which the health maintenance organization is notified of enrollment.
1.
Health maintenance
				organization information.
The group or individual contract and evidence
				of coverage must contain the name, address, and telephone number of the health
				maintenance organization, and where and in what manner information is available
				as to how services may be obtained. A telephone number within the service area
				for calls, without charge to members, to the health maintenance organization's
				administrative office must be made available and disseminated to enrollees to
				adequately provide telephone access for enrollee services, problems, or
				questions. A health maintenance organization shall provide a method by which
				the enrollee may contact the health maintenance organization at no cost to the
				enrollee. This may be done through the use of toll-free or collect telephone
				calls. The enrollee must be informed of the method by notice in the handbook,
				newsletter, or flyer. The group or individual contract or evidence of coverage
				may indicate the manner in which the number will be disseminated rather than
				list the number itself.
2.
Eligibility requirements.
a. The
				group or individual contract and evidence of coverage must contain eligibility
				requirements indicating the conditions that must be met to enroll as a
				subscriber or eligible dependent, the limiting age for subscribers and eligible
				dependents including the effects of medicare eligibility, and a clear statement
				regarding coverage of newbornand adopted children.
b. A group or individual contract or evidence
				of coverage may not contain any provision excluding or limiting coverage for a
				newborn child or adopted child. Medically diagnosed congenital defects and
				birth abnormalities must be treated the same as any other illness or injury for
				which coverage is provided. The group or individual contract and evidence of
				coverage may require that notification of birth of a newborn childor the
				placement for adoption of a child and payment of any required premium must be
				furnished to the health maintenance organization within thirty-one days after
				the date of birthor placement for adoption in order to have coverage continue
				beyond such thirty-one-day period. The health maintenance organization is
				entitled to premium for the first thirty-one days of coverage, unless the
				coverage is rejected by the subscriber prior to the birthor placement for
				adoption of the child.
c. The
				definition of an eligible dependent must include:
(1) The spouse of the subscriber.
(2) An unmarried dependent child of the
				subscriber, including a dependent of an unmarried child who:
(a) Has not reached age twenty-two;
(b) Has reached age sixteen
				through age twenty-six who is attending a recognized college or university,
				trade school, or secondary school on a full-time basis; or
(c) Has reached agetwenty-two but who is
				incapable of self-support because of mental retardation, mental illness, or
				physical incapacity which began before the child reached age twenty-two, and
				who is chiefly dependent upon the subscriber for support and maintenance.
d. The
				definition of a dependent child of a subscriber must include a child who:
(1) Is related to the subscriber as a natural
				child, a child placed for adoption, or a stepchild;
(2) Resides in the subscriber's household and
				who qualifies as a dependent of the subscriber or the subscriber's spouse under
				the United States Internal Revenue Code and the federal tax regulations; or
(3) Is eligible by virtue of a
				court order making the subscriber responsible for health care services for the
				dependent child.