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North Dakota Century Code Title 26.1. Insurance § 26.1-08-01. Definitions

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In this chapter, unless the context otherwise requires:

1. “Association” means the comprehensive health association of North Dakota.

2. “Benefit plan” means insurance policy coverage offered by the association through the lead carrier.

3. “Benefit plan premium” means the charge for the benefit plan based on the benefits provided in section 26.1-08-06 and determined pursuant to section 26.1-08-08.

4. “Board” means the association board of directors.

5. “ Church plan” means a plan as defined under section 3(33) of the federal Employee Retirement Income Security Act of 1974.

6. “Creditable coverage” has the same meaning as “qualifying previous coverage” as defined under section 26.1-36.3-01.

7. “Eligible individual” means an individual eligible for association benefit plan coverage as specified under section 26.1-08-12.

8. “Governmental plan” has the same meaning as provided under section 3(32) of the federal Employee Retirement Income Security Act of 1974 [Pub. L. 93-406;  88 Stat. 833;  29 U.S.C. 1002] and as may be provided under any federal governmental plan.

9. “Group health plan” has the same meaning as employee welfare benefit plan as provided under section 3(1) of the federal Employee Retirement Income Security Act of 1974 [Pub. L. 93-406;  88 Stat. 833;  29 U.S.C. 1002] to the extent that the plan provides medical care, and including items and service paid for as medical care to employees or the employees' dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.

10. “Health insurance coverage” means any hospital and medical expense-incurred policy, nonprofit health care service plan contract, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes benefits that pay the costs of or provide medical, surgical, or hospital care or, if selected by the eligible individual, chiropractic care.

a. Health insurance coverage does not include any one or more of the following:

(1) Coverage only for accident, disability income insurance, or any combination of the two;

(2) Coverage issued as a supplement to liability insurance;

(3) Liability insurance, including general liability insurance and automobile liability insurance;

(4) Workforce safety and insurance or similar insurance;

(5) Automobile medical payment insurance;

(6) Credit-only insurance;

(7) Coverage for onsite medical clinics;  and

(8) Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

b. Health insurance coverage does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:

(1) Limited scope dental or vision benefits;

(2) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of this care;  and

(3) Other similar limited benefits specified under federal regulations issued under the Health Insurance Portability and Accountability Act of 1996 [Pub. L. 104-191;  110 Stat. 1936;  29 U.S.C. 1181 et seq.].

c. Health insurance coverage does not include any of the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance;  there is no coordination between the provision of the benefits;  any exclusion of benefits under any group health insurance coverage maintained by the same plan sponsor;  and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same sponsor:

(1) Coverage only for specified disease or illness;  and

(2) Hospital indemnity or other fixed indemnity insurance.

d. Health insurance coverage does not include the following if offered as a separate policy, certificate, or contract of insurance:

(1) Coverage supplemental to the coverage provided under chapter 55 of United States Code title 10 [10 U.S.C. 1071 et seq.] relating to armed forces medical and dental care;  and

(2) Similar supplemental coverage provided under a group health plan.

11. “Insurer” means any insurance company, nonprofit health service organization, fraternal benefit society, health maintenance organization, and any other entity providing or selling health insurance coverage or health benefits that are subject to state insurance regulation.

12. “Lead carrier” means the insurance company selected by the board to administer the association benefit plans.

13. “Medicare” means coverage under both parts A and B of title XVIII of the federal Social Security Act [Pub. L. 89-97;  79 Stat. 291;  42 U.S.C. 1395 et seq.].

14. “Participating member” means any insurer that is licensed in this state which has an annual earned premium volume of health insurance coverage, including Medicare supplemental health insurances as defined under section 1882(g)(1) of the federal Social Security Act [42 U.S.C. 1395ss(g)(1)], derived from or on behalf of residents in the previous calendar year of at least one hundred thousand dollars.

15. “Resident” means an individual who has been a legal resident of this state for a minimum of one hundred eighty-three days, determined by applying section 54-01-26.  However, for a federally defined eligible individual as defined under subdivision b of subsection 5 of section 26.1-08-12, there is no minimum residency requirement.  The board may waive the residency requirement upon a showing of good cause.

16. “Significant break in coverage” means a period of sixty-three or more consecutive days during all of which the individual does not have creditable coverage.  Neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage.

17. “Trade adjustment assistance, pension benefit guarantee corporation individual” means an individual who is certified as eligible for federal trade adjustment assistance or federal pension benefit guarantee corporation assistance as provided by the federal Trade Adjustment Assistance Reform Act of 2002 [Pub. L. 107-210;  116 Stat. 933], the spouse of such an individual, or a dependent of such an individual as provided under the federal Internal Revenue Code.

Cite this article: - North Dakota Century Code Title 26.1. Insurance § 26.1-08-01. Definitions - last updated January 01, 2020 |

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