26.1-36.4 Hospital and Medical Insurance - North Dakota Statutes

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CHAPTER 26.1-36.4HOSPITAL AND MEDICAL INSURANCE26.1-36.4-01. Application and scope. This chapter applies to all policies issued orrenewed after July 31, 1995. The provisions of chapter 26.1-36 apply when not in conflict with
this chapter.26.1-36.4-02.Definitions.As used in this chapter, the definitions in section26.1-36.3-01 apply, unless the context otherwise requires. In addition:1."Insurer" means any insurance company, nonprofit health service organization,
fraternal benefit society, or health maintenance organization that provides a plan of
health insurance or health benefits subject to state insurance regulation.2."Policy" means any health benefit plan as defined in section 26.1-36.3-01, whether
offered on a group or individual basis. The term does not include short-term major
medical policies offered in the individual market.3."Short-term", except as required by the Health Insurance Portability and
Accountability Act of 1996, means a policy or plan providing coverage for one
hundred eighty-five days or less.26.1-36.4-03. Limits on preexisting condition exclusions. An insurer may impose apreexisting condition exclusion only if:1.The exclusion relates to a condition, regardless of the cause of the condition, for
which medical diagnosis, care, or treatment was recommended or received within
the six-month period ending on the effective date of the person's coverage.2.The exclusion extends for a period of not more than twelve months after the effective
date of coverage.A group policy may impose an eighteen-month preexistingcondition to a late enrollee, as the term late enrollee is defined in section
26.1-36.3-01.26.1-36.4-03.1. Additional limits on preexisting condition exclusions. A group policymay not impose a preexisting condition exclusion that:1.Relates to pregnancy as a preexisting condition.2.Treats genetic information as a preexisting condition in the absence of a diagnosis of
a condition related to such information.26.1-36.4-04.Portability of insurance policies.An insurer shall reduce any timeperiod applicable to a preexisting condition, for a policy by the aggregate of periods the individual
was covered by qualifying previous coverage, if the qualifying previous coverage as defined in
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 benefit
plan may not be taken into account in determining the period of continuous coverage. Insurers
shall credit coverage in the same manner as provided by section 26.1-36.3-06 and the rules
adopted by the commissioner pursuant thereto.26.1-36.4-05.Renewability of health insurance coverage - Discriminationprohibited.1.An insurer issuing policies or certificates under this chapter shall provide for the
renewability or continuability of coverage unless:Page No. 1a.The individual or group has failed to pay premiums or contributions in
accordance with the terms of the health benefit plan or the insurer has not
received timely premium payments.b.The individual or group has performed an act or practice that constitutes fraud
or made an intentional misrepresentation of a material fact under the terms of
the coverage.c.Noncompliance with the insurer's minimum group participation requirements.d.Noncompliance with the insurer's employer group contribution requirements.e.A decision by the insurer to discontinue offering a particular type of health
insurance coverage in the group or individual market. A type of group health
benefit plan or individual policy may be discontinued by the insurer in that
market only if the insurer:(1)Provides advance notice of its decision under this paragraph to the
commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected
individuals,employers,participants,beneficiaries,andtothecommissioner in each state in which an affected insured is known to
reside at least ninety days prior to the nonrenewal of any health benefit
plans by the insurer. Notice to the commissioner under this subdivision
must be provided at least three working days prior to the notice to the
affected individuals, employers, participants, and beneficiaries;(3)Offers to each affected group or individual the option to purchase all
other health benefit plans or individual coverage currently being offered
by the insurer in that market; and(4)In exercising the option to discontinue the particular type of group health
benefit plan or individual coverage and in offering the option of coverage
under paragraph 3, the insurer acts uniformly without regard to claims
experience or any health status-related factor relating to any affected
individuals, participants, or beneficiaries covered or new individuals,
participants, or beneficiaries who may become eligible for such coverage.f.A decision by the insurer to discontinue offering and to nonrenew all its health
benefit plans or individual coverage delivered or issued for delivery to
employers or individuals in this state. In such a case, the insurer shall:(1)Provide advance notice of its decision under this paragraph to the
commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected
individuals, employers, participants, and beneficiaries, and to the
commissioner in each state in which an affected insured is known to
reside at least one hundred eighty days prior to the nonrenewal of any
health benefit plans by the insurer. Notice to the commissioner under
this subdivision must be provided at least three working days prior to the
noticetotheaffectedindividuals,employers,participants,andbeneficiaries; and(3)Discontinue all health insurance issued or delivered for issuance in the
state's group or individual market and not renew such health coverage in
that market.Page No. 2g.In the case of health benefit plans that are made available in the group or
individual market only through one or more associations, the membership of an
employer or individual in the association, on the basis of which the coverage is
provided, ceases, but only if the coverage is terminated under this paragraph
uniformly without regard to any health status-related factor relating to any
covered individual.h.The commissioner finds that the continuation of the coverage would not be in
the best interests of the policyholders or certificate holders or would impair the
insurer's ability to meet its contractual obligations.In this case thecommissioner shall assist affected insureds in finding replacement coverage.2.An insurer that elects not to renew a health benefit plan under subdivision f of
subsection 1 may not write new business in the applicable market in this state for a
period of five years from the date of notice to the commissioner.3.In the case of an insurer doing business in one established geographic service area
of the state, this section only applies to the insurer's operations in that service area.4.An insurer offering coverage through a network plan may not be required to offer
coverage or accept applications pursuant to subsection 1 or 2 in the case of the
following:a.To an eligible person who no longer resides, lives, or works in the service area,
or in an area for which the insurer is authorized to do business, but only if
coverage is terminated under this subdivision uniformly without regard to any
health status-related factor; orb.To an insurer that no longer has any enrollee in connection with the plan who
lives, resides, or works in the service area of the insurer, or the area for which
the insurer is authorized to do business.5.At the time of coverage renewal, an insurer may modify the health insurance
coverage for a product offered to a group or individual, if the modification is
reasonable, consistent with state law, and effective on a uniform basis. If coverage
is modified, the carrier shall:a.Provide advance notice of its decision under this subsection to the
commissioner at least three working days prior to mailing the notice to the
affected employers and participants and beneficiaries.b.Provide notice of the decision to modify health coverage to all affected
employers, participants, and beneficiaries and the commissioner sixty days
prior to the modification of health coverage by the carrier.26.1-36.4-06. Modified community rating. Premium rates for individual policies aresubject to the following:1.For any class of individuals, the premium rates charged during a rating period to the
individuals in that class for the same or similar coverage may not vary by a ratio of
more than six to one after August 1, 1995, and by a ratio of more than five to one
after August 1, 1996, when age, industry, gender, and duration of coverage of the
individuals are considered. Gender and duration of coverage may not be used as a
rating factor for policies issued after January 1, 1997.2.An insurer, in addition to the factors set forth in subsection 1, may use geography,
family composition, healthy lifestyles, and benefit variations to determine premium
rates.Page No. 33.The commissioner shall design and adopt reporting forms to be used by an insurer
to report information as to insurer's experience as to insurance provided under this
chapter on a periodic basis to determine the impact of the reforms and
implementation of modified community rating contained in this chapter.26.1-36.4-07.Health benefits package required. An insurance company, nonprofithealth service corporation, or health maintenance organization may not deliver, issue, execute,
or renew any health insurance policy, health service contract, or evidence of coverage on an
individual or group basis unless the company, corporation, or association actively offers a basic
health benefit plan and a standard health benefit plan as approved by the commissioner. The
commissioner shall design and adopt a basic health benefit plan and a standard health benefit
plan to be offered on an individual and group basis as required by this section. The basic and
standard health benefit plans must be those developed under section 26.1-36.3-06. This section
does not require a health maintenance organization to provide any benefit it is prohibited from
providing under federal law and does not excuse failure to provide benefits mandated by federal
law.26.1-36.4-08. Employer payment of employee premium. An insurer shall accept apersonal or business check from an employer as a payment method for premium payment for an
employee's individual accident and health insurance policy.This section does not apply togroups as defined under chapter 26.1-36.3.26.1-36.4-09. Health insurance utilization reports.1.Once each calendar year, any employer with fifty-one or more eligible employees or
upon termination of health insurance coverage for any employer, the employer is
entitled to a report from the insurer or administrator of that employer's employee
healthplanwhichincludesamonthlyaccountingforthemostrecenttwenty-four-month period of the total number of insured or covered employees, the
total premiums paid, and the total benefits paid on behalf of the employer's health
plan.2.Insurers shall provide the report pursuant to subsection 1 to an employer within thirty
days of receipt of a request for the information.3.The information provided pursuant to subsection 1 may not identify specific
employee claims or other confidential health care information.4.Upon notification of termination of health insurance before the end of a benefit
period, the terminated insurer, at the request of the employer and within thirty days
of the request, shall supply the succeeding or new insurer a report of all deductibles
and coinsurance payments for each employee covered by the employer's health
insurance plan for the most recent benefit period.Page No. 4Document Outlinechapter 26.1-36.4 hospital and medical insurance