Section 45-06-07-04 - Requirements for contracts and evidence of coverage 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. 3.Benefits and services within the service area. The group or individual contract and evidence of coverage must contain a specific description of benefits and services available within the service area. 4.Emergency care benefits and services. The group or individual contract and evidence of coverage must contain a specific description of benefits and services available for emergencies twenty-four hours a day, seven days a week, including disclosure of any restrictions on emergency care services. A group or individual contract or evidence of coverage may not limit the coverage of emergency services within the service area to affiliated providers only. 5.Out-of-area benefits and services. The group or individual contract and evidence of coverage must contain a specific description of benefits and services available out of the service area. 6.Copayments and deductibles. The group or individual contract and evidence of coverage must contain a description of any copayments or deductibles that must be paid by enrollees. 7.Limitations and exclusions. The group or individual contract and evidence of coverage must contain a description of any limitations or exclusions on the services, kind of services, benefits, or kind of benefits including any limitations or exclusions due to preexisting conditions, waiting periods, or an enrollee's refusal of treatment. 8.Enrollee termination.a. A health maintenance organization may not cancel or terminate coverage of services provided an enrollee under a health maintenance organization group or individual contract except for one or more of the following reasons: (1) Failure to pay the amounts due under the group or individual contract. (2) Fraud or material misrepresentation in enrollment or in the use of services or facilities. (3) Material violation of the terms of the group or individual contract. (4) Failure to meet the eligibility requirements under a group contract. (5) Termination of the group contract under which the enrollee was covered. (6) Failure of the enrollee and the primary care physician to establish a satisfactory patient-physician relationship if: (a) It is shown that the health maintenance organization has, in good faith, provided the enrollee with the opportunity to select an alternative primary care physician; (b) The enrollee has repeatedly refused to follow the plan of treatment ordered by the physician; and (c) The enrollee is notified in writing at least thirty days in advance that the health maintenance organization considers the patient-physician relationship to be unsatisfactory and specific changes are necessary in order to avoid termination. (7) Such other good cause agreed upon in the group or individual contract and approved by the commissioner. However, coverage may not be canceled or terminated on the basis of the status of the enrollee's health or because the enrollee has exercised the enrollee's rights under the health maintenance organization's grievance procedure by registering a grievance against the health maintenance organization.
b. A health maintenance organization may not cancel or terminate an enrollee's coverage for services provided under a health maintenance organization group or individual contract without giving the enrollee at least fifteen days' written notice of such termination. Notice will be considered given on the date of mailing or, if not mailed, on the date of delivery. This notice must include the reason for termination. If termination is due to nonpayment of premium, the grace period required in subsection 23 of section 45-06-07-04 applies. Advance notice of termination is not required to be given for termination due to nonpayment of premium. c. A health maintenance organization may not terminate coverage of a dependent child upon attainment of the limiting age if the child is and continues to be both: (1) Incapable of self-support because of mental retardation, mental illness, or physical incapacity; and (2) Chiefly dependent upon the subscriber for support and maintenance. Proof of such incapacity and dependency must be furnished to the health maintenance organization by the subscriber within thirty-one days of the child's attainment of the limiting age and subsequently as reasonably required by the health maintenance organization.
9.Enrollee reinstatement. If a health maintenance organization permits reinstatement of an enrollee's coverage, the group or individual contract and evidence of coverage must include any terms and conditions concerning reinstatement. The contract and evidence of coverage may state that all reinstatements are at the option of the health maintenance organization and that the health maintenance organization is not obligated to reinstate any terminated coverage. 10.Claims procedures. The group or individual contract and evidence of coverage must contain procedures for filing claims that include: a. Any required notice to the health maintenance organization. b. If any claim forms are required, how, when, and where to obtain and submit them. c. Any requirements for filing proper proofs of loss. d. Any time limit of payment of claims. e. Notice of any provisions for resolving disputed claims, including arbitration. f. A statement of restrictions, if any, on assignment of sums payable to the enrollee by the health maintenance organization. 11.Enrollee grievance procedures and arbitration. In compliance with subsection 4 of section 45-06-07-09, the group or individual contract and evidence of coverage must contain a description of the health maintenance organization's method for resolving enrollee grievances, including procedures to be followed by the enrollee in the event any dispute arises under the contract, including any provisions for arbitration. 12.Continuation of coverage. A group contract and evidence of coverage must contain a provision that any enrollee who is an inpatient in a hospital or a skilled nursing facility on the date of discontinuance of the group contract must be covered in accordance with the terms of the group contract until discharged from such hospital or skilled nursing facility. The enrollee may be charged the appropriate premium for coverage that was in effect prior to discontinuance of the group contract. 13.Conversion of coverage.a. The group or individual contract and evidence of coverage must contain a conversion provision that provides that each enrollee has the right to convert coverage to an individual health maintenance organization contract in the following circumstances: (1) Upon termination of eligibility for coverage under a group or individual contract; or (2) Upon termination of the group contract. To obtain the conversion contract, an enrollee shall submit a written application and the applicable premium payment to the health maintenance organization within thirty-one days after the date the enrollee's eligibility for coverage terminates.
b. A conversion contract is not required to be made available if: (1) The enrollee's termination of coverage occurred for any of the reasons listed in paragraphs 1, 2, 3, 6, and 7 of subdivision a of subsection 8 of section 45-06-07-04; (2) The enrollee is covered by or is eligible for benefits under Title XVIII of the United States Social Security Act (medicare); (3) The enrollee is covered by or is eligible for similar hospital, medical, or surgical benefits under state or federal law; (4) The enrollee is covered by or is eligible for similar hospital, medical, or surgical benefits under any arrangement of coverage for individuals in a group; (5) The enrollee is covered for similar benefits by an individual policy or contract; or (6) The enrollee has not been continuously covered during the three-month period immediately preceding that person's termination of coverage. c. The conversion contract must provide basic health care services to its enrollees as a minimum. d. The conversion contract must begin coverage of the enrollee formerly covered under the group or individual contract on the date of termination from such group or individual contract. e. Coverage must be provided without requiring evidence of insurability and may not impose any preexisting condition limitations or exclusions as described in subsection 1 of section 45-06-07-05 other than those remaining unexpired under the contract from which conversion is exercised. Any probationary or waiting period set forth in the conversion contract must be deemed to commence on the effective date of the enrollee's coverage under the prior group or individual contract. f. If a health maintenance organization does not issue individual or conversion contracts, the health maintenance organization may use a noncancelable group contract to provide coverage for enrollees who are eligible for conversion coverage. 14.Extension of benefits for total disability.a. Each group contract issued by a health maintenance organization must contain a reasonable extension of benefits upon discontinuance of the group contract with respect to enrollees who become totally disabled while enrolled under the contract and who continue to be totally disabled at the date of discontinuance of the contract. b. Upon payment of premium at the current group rate, coverage must remain in full force and effect until the first of the following to occur: (1) The end of a period of twelve months starting with the date of termination of the group contract; (2) The date the enrollee is no longer totally disabled; or (3) The date a succeeding carrier provides replacement coverage to that enrollee without limitation as to the disabling condition. c. Upon termination of the extension of benefits, the enrollee must have the right to convert coverage as provided in subsection 13. 15.Coordination of benefits. The group or individual contract and evidence of coverage may contain a provision for coordination of benefits that is consistent with that applicable to other carriers in the jurisdiction. Any provisions or rules for coordination of benefits established by a health maintenance organization may not relieve a health maintenance organization of its duty to provide or arrange for a covered health care service to any enrollee because the enrollee is entitled to coverage under any other contract, policy, or plan, including coverage provided under government programs. The health maintenance organization is required to provide covered health care services first and then, at its option, seek coordination of benefits. 16.Subrogation for injuries caused by third parties. The group or individual contract and evidence of coverage may not contain any provisions concerning subrogation for injuries caused by third parties unless the wording has been approved by the commissioner. 17.Description of the service area. The group or individual contract and evidence of coverage must contain a description of the approved service area. 18.Entire contract provision. The group or individual contract must contain a statement that the contract, all applications, and any amendments constitute the entire agreement between the parties. A portion of the charter, bylaws, or other document of the health maintenance organization may not be part of such a contract unless set forth in full in the contract or attached to the contract. However, the evidence of coverage may be attached to and made a part of the group contract. 19.Term of coverage. The group or individual contract and evidence of coverage must contain the time and date or occurrence upon which coverage takes effect, including any applicable waiting periods, or describe how the time and date or occurrence upon which coverage takes effect is determined. The contract and evidence of coverage must also contain the time and date or occurrence upon which coverage will terminate. 20.Cancellation or termination. The group or individual contract must contain the conditions upon which cancellation or termination may be effected by the health maintenance organization, the group contractholder, or the subscriber. 21.Renewal. The group or individual contract and evidence of coverage must contain the conditions for, and any restrictions upon, the subscriber's right to renewal. 22.Reinstatement of group or individual contractholder. If a health maintenance organization permits reinstatement of a group or individual, the contract and evidence of coverage must include any terms and conditions concerning reinstatement. The contract and evidence of coverage may state that all reinstatements are at the option of the health maintenance organization and that the health maintenance organization is not obligated to reinstate any terminated contract. 23.Grace period.a. The group or individual contract must provide for a grace period of not less than thirty-one days for the payment of any premium except the first, during which time the coverage must remain in effect if payment is made during the grace period. The evidence of coverage must include notice that a grace period exists under the group contract and that coverage continues in force during the grace period. b. During the grace period: (1) The health maintenance organization remains liable for providing the services and benefits contracted for; (2) The contractholder remains liable for the payment of premium for coverage during the grace period; and (3) The subscriber remains liable for any copayments and deductibles. c. If the premium is not paid during the grace period, coverage is automatically terminated at the end of the grace period. Following the effective date of such termination, the health maintenance organization shall deliver written notice of termination to the contractholder. 24.Conformity with state law. Any group or individual contract and evidence of coverage delivered or issued for delivery in this state must include a provision that states that any provision not in conformity with North Dakota Century Code chapter 26.1-18.1, this chapter, or any other applicable law or rule in this state may not be rendered invalid but be must construed and applied as if it were in full compliance with the applicable laws and rules of this state. 25.Right to examine contract. An individual contract must contain a provision stating that a person who has entered into an individual contract with a health maintenance organization must be permitted to return the contract within ten days of receiving it and to receive a refund of the premium paid if the person is not satisfied with the contract for any reason. If the contract is returned to the health maintenance organization or to the agent through whom it was purchased, it is considered void from the beginning. However, if services are rendered or claims are paid for such person by the health maintenance organization during the ten-day examination period and the person returns the contract to receive a refund of the premium paid, the person must be required to pay for such services. N.D. Admin Code 45-06-07-04
Effective July 1, 1994; amended effective April 1, 1996.General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1