Section 45-06-07-05 - Prohibited practices1.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. b. A health maintenance organization may not exclude or limit services for a preexisting condition when the enrollee transfers coverage from one individual contract to another or when the enrollee converts coverage under the enrollee's conversion option, except to the extent of a preexisting condition limitation or exclusion remaining unexpired under the prior contract. Any required probationary or waiting period must be deemed to have commenced on the effective date of coverage under the prior contract. The health maintenance organization contract must disclose any preexisting condition limitations or exclusions that are applicable when an enrollee transfers from a prior health maintenance organization contract. c. A health maintenance organization shall reduce any time period applicable to a preexisting condition, for a contract by the aggregate of periods the individual was covered by qualifying previous coverage, if the qualifying previous coverage as defined in North Dakota Century Code section 26.1-36.3-01 is continuous until at least sixty-three days before the effective date of the new coverage. Any waiting period applicable to an individual for coverage under a health maintenance organization contract may not be taken into account in determining the period of continuous coverage. A health maintenance organization shall credit coverage in the same manner as provided by North Dakota Century Code section 26.1-36.3-06 and the rules adopted by the commissioner pursuant thereto. 2.Unfair discrimination. A health maintenance organization may not unfairly discriminate against any enrollee or applicant for enrollment on the basis of the age, sex, race, color, creed, national origin, ancestry, religion, marital status, or lawful occupation of an enrollee, or because of the frequency of utilization of services by an enrollee. However, a health maintenance organization is not prohibited from setting rates or establishing a schedule of charges in accordance with relevant actuarial data. 3.Prohibiting discrimination against enrollees and beneficiaries based on health status-related factors.a. A health maintenance organization may not establish rules for eligibility including continued eligibility of any individual to enroll under the terms it group contracts based on a health status-related factor, as defined in subsection 20 of North Dakota Century Code section 26.1-36.3-01. b. This section shall not be construed to: (1) Require a health maintenance organization offering group contracts to provide particular benefits other than those provided under the terms of the contract; or (2) To prevent a health maintenance organization from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled under the contract. c. A health maintenance organization offering group contracts may not require an individual as a condition of enrollment or continued enrollment under the plan to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled under the contract based on any health status-related factor, as defined in subsection 20 of North Dakota Century Code section 26.1-36.3-01. d. This subsection shall not be construed to: (1) Restrict the amount that an employer may be charged for the contract; or (2) Prevent a health maintenance organization offering group contracts from establishing premium discounts or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention. N.D. Admin Code 45-06-07-05
Effective July 1, 1994; amended effective April 1, 1996; December 1, 1997.General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1