North Dakota Code 26.1-18.1-07 – Requirements for group contract, individual contract, and evidence of coverage
1. a. Every group and individual contractholder is entitled to a group or individual contract.
Terms Used In North Dakota Code 26.1-18.1-07
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- Contract: A legal written agreement that becomes binding when signed.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- following: when used by way of reference to a chapter or other part of a statute means the next preceding or next following chapter or other part. See North Dakota Code 1-01-49
- Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. Source: Federal Reserve
- Individual: means a human being. See North Dakota Code 1-01-49
- Organization: includes a foreign or domestic association, business trust, corporation, enterprise, estate, joint venture, limited liability company, limited liability partnership, limited partnership, partnership, trust, or any legal or commercial entity. See North Dakota Code 1-01-49
- Person: means an individual, organization, government, political subdivision, or government agency or instrumentality. See North Dakota Code 1-01-49
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See North Dakota Code 1-01-49
b. The contract may not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by chapter 26.1-04.
c. The contract must contain a clear statement of the following:
(1) Name and address of the health maintenance organization. (2) Eligibility requirements.
(3) Benefits and services within the service area. (4) Emergency care benefits and services.
(5) Out-of-area benefits and services, if any.
(6) Copayments, deductibles, or other out-of-pocket expenses. (7) Limitations and exclusions.
(8) Enrollee termination.
(9) Enrollee reinstatement, if any. (10) Claims procedures.
(11) Enrollee grievance procedures. (12) Continuation of coverage.
(13) Conversion.
(14) Extension of benefits, if any.
(15) Coordination of benefits, if applicable. (16) Subrogation, if any.
(17) Description of the service area. (18) Entire contract provision.
(19) Term of coverage.
(20) Cancellation of group or individual contractholder. (21) Renewal.
(22) Reinstatement of group or individual contractholder, if any.
(23) Grace period.
(24) Conformity with state law.
An evidence of coverage may be filed as part of the group contract to describe the provisions required in this subdivision.
2. In addition to those provisions required in subdivision c of subsection 1, an individual contract must provide for a ten-day period to examine and return the contract and have the premium refunded. If services were received during the ten-day period, and the person returns the contract to receive a refund of the premium paid, the person must pay for the services.
3. a. Every subscriber shall receive an evidence of coverage from the group contractholder or the health maintenance organization.
b. The evidence of coverage may not contain provisions or statements which are unfair, unjust, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by chapter 26.1-04.
c. The evidence of coverage must contain a clear statement of the provisions required in subdivision c of subsection 1.
4. The commissioner may adopt rules establishing readability standards for individual contract, group contract, and evidence of coverage forms.
5. No group or individual contract, evidence of coverage, or amendment thereto may be delivered or issued for delivery in this state, unless its form has been filed with and approved by the commissioner, as provided by sections 26.1-30-19 and 26.1-30-20.
6. The provisions set forth in sections 26.1-30-20 and 26.1-30-21 govern the approval and disapproval of forms required to be filed under this section.
7. The commissioner may require the submission of whatever relevant information the commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.