# Title 45 — Insurance, Commissioner of

## Article 45-06 — Accident and Health Insurance

## Chapter 45-06-07 — Model Regulation to Implement Rules Regarding Contracts and Services of Health Maintenance Organizations

### § 45-06-07-01. Applicability and scope.

This chapter applies to all health maintenance organizations that are required to obtain a certificate
of authority in this state. In the event of conflict between the provisions of this chapter and the
provisions of any other chapter issued by the commissioner, the provisions of this chapter shall be
controlling as to health maintenance organizations.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1
### § 45-06-07-02. Effective date.

1. All group and individual contracts written or issued on or after December 31, 1993, must
conform with the provisions of these rules.
2. Group or individual contract or evidence of coverage may not be reissued, renewed,
amended, or extended in this state on or after December 31, 1993, unless it complies with this
chapter. A group or individual contract or evidence of coverage approved before
December 31, 1993, must be deemed to be reissued, renewed, amended, or extended on the
date the health maintenance organization changes the terms of the group or individual
contract or evidence of coverage or adjusts the premiums charged. Such group or individual
contracts or evidence of coverage must comply with this chapter when amended but in no
event later than June 30, 1995.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1
### § 45-06-07-03. Definitions.

Group or individual contract or evidence of coverage delivered or issued for delivery to any person
in this state by a health maintenance organization required to obtain a certificate of authority in this
state may not contain definitions respecting the matters set forth below unless such definitions comply
with the requirements of this section. Definitions other than those in this section may be used as
appropriate, providing that they do not contradict these requirements. All definitions used in the group
or individual contract and evidence of coverage must be in alphabetical order. As used in this chapter
and as used in the group or individual contract and evidence of coverage:

1. "Basic health care services" means the following medically necessary services: preventive
care, emergency care, inpatient and outpatient hospital and physician care, diagnostic
laboratory, and diagnostic and therapeutic radiological services. It does not include mental
health services or services for alcohol or drug abuse, dental or vision services, or long-term
rehabilitation treatment.
2. "Copayment" means the amount an enrollee must pay in order to receive a specific service
that is not fully prepaid.
3. "Deductible" means the amount an enrollee is responsible to pay out of pocket before the
health maintenance organization begins to pay the costs or provide the services associated
with treatment.
4. "Eligible dependent" means any member of a subscriber's family who meets the eligibility
requirements set forth in subsection 2 of section 45-06-07-04.
5. "Emergency care services" means:
a. Within the service area: covered health care services rendered by affiliated or
nonaffiliated providers under unforeseen conditions that require immediate medical
attention. Emergency care services within the service area include covered health care
services from nonaffiliated providers only when delay in receiving care from the health
maintenance organization could reasonably be expected to cause severe jeopardy to the
enrollee's condition.
b. Outside the service area: medically necessary health care services that are immediately
required because of unforeseen illness or injury while the enrollee is outside the
geographical limits of the health maintenance organization's service area.
6. "Enrollee" means an individual who is covered by a health maintenance organization.
7. "Evidence of coverage" means a statement of the essential features and services of the health
maintenance organization coverage which is given to the subscriber by the health
maintenance organization or by the group contractholder.
8. "Extension of benefits" means the continuation of coverage of a particular benefit provided
under a group or individual contract following termination with respect to an enrollee who is
totally disabled on the date of termination.
9. "Grievance" means a written complaint submitted in accordance with the health maintenance
organization's formal grievance procedure by or on behalf of the enrollee regarding any aspect
of the health maintenance organization relative to the enrollee.
10. "Group contract" means a contract for health care services which by its terms limits eligibility
to enrollees of a specified group. The group contract may include coverage for dependents.
11. "Group contractholder" means the person to whom a group contract has been issued.
12. "Health maintenance organization" means any person who undertakes to provide or arrange
for the delivery of basic health care services to enrollees on a prepaid basis, except for
enrollee responsibility for copayments or deductibles.
13. "Hospital" means a duly licensed institution that provides general and specialized inpatient
medical care. The term "hospital" does not include a convalescent facility, nursing home, or
any institution or part of an institution which is used principally as a convalescent facility, rest
facility, nursing facility, or facility for the aged.

14. "Individual contract" means a contract for health care services issued to and covering an
individual. The individual contract may include coverage for dependents of the subscriber.
15. "Medical necessity" or "medically necessary" means appropriate and necessary services as
determined by any provider affiliated with the health maintenance organization which are
rendered to an enrollee for any condition requiring, according to generally accepted principles
of good medical practice, the diagnosis or direct care and treatment of an illness or injury and
are not provided only as a convenience. This does not preclude the health maintenance
organization from establishing standards by which providers make their decisions as to what is
medically necessary or from penalizing providers for failure to meet these standards. In the
case of emergency medical services, the health maintenance organization has the right to
make the final determination of whether services should be covered.
16. "Nonbasic health care services" means any health care services, other than basic health care
services, that may be provided in the absence of basic health care services.
17. "Out-of-area services" means the health care services that a health maintenance organization
covers when its enrollees are outside of the service area.
18. "Participating provider" means a provider as defined in this section who, under an express or
implied contract with the health maintenance organization or with its contractor or
subcontractor, has agreed to provide health care services to enrollees with an expectation of
receiving payment, other than copayment or deductible, directly or indirectly from the health
maintenance organization.
19. "Physician" means a duly licensed doctor of medicine or osteopathy practicing within the
scope of such a license.
20. "Primary care physician" means a physician who supervises, coordinates, and provides initial
and basic care to enrollees, and who initiates their referral for specialist care and maintains
continuity of patient care.
21. "Provider" means any physician, hospital, or other person licensed or otherwise authorized to
furnish health care services.
22. "Replacement coverage" means the benefits provided by a succeeding carrier.
23. "Service area" means the geographical area as approved by the commissioner within which
the health maintenance organization provides or arranges for health care services that are
available and accessible to enrollees.
24. "Skilled nursing facility" means a facility that is operated pursuant to law and is primarily
engaged in providing room and board accommodations and skilled nursing care under the
supervision of a duly licensed physician.
25. "Subscriber" means an individual whose employment or other status, except family
dependency, is the basis for eligibility for enrollment in the health maintenance organization, or
in the case of an individual contract, the person in whose name the contract is issued.
26. "Supplemental health care services" means any health care services that are provided in
addition to basic health care services.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1

### § 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
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.
History: Effective July 1, 1994; amended effective April 1, 1996.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1
### § 45-06-07-05. Prohibited practices.

1. 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.
History: 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
### § 45-06-07-06. Services.

1. Access to care.
a. A health maintenance organization shall establish and maintain adequate arrangements
to provide health services for its enrollees, including:
(1) Reasonable proximity to the business or personal residences of the enrollees so as
not to result in unreasonable barriers to accessibility;
(2) Reasonable hours of operation and after-hours services;
(3) Emergency care services available and accessible within the service area
twenty-four hours a day, seven days a week; and
(4) Sufficient providers, personnel, administrators, and support staff to assure that all
services contracted for will be accessible to enrollees on an appropriate basis
without delays detrimental to the health of enrollees.

b. A health maintenance organization shall make available to each enrollee a primary care
physician and provide accessibility to medically necessary specialists through staffing,
contracting, or referral. A health maintenance organization shall provide for continuity of
care for enrollees referred to specialists.
c. A health maintenance organization shall have written procedures governing the
availability of services utilized by enrollees, including at least the following:
(1) Well-patient examinations and immunizations;
(2) Emergency telephone consultation on a twenty-four hours per day, seven days per
week basis;
(3) Treatment of emergencies;
(4) Treatment of minor illness; and
(5) Treatment of chronic illnesses.
2. Basic health care services. A health maintenance organization shall provide, or arrange for
the provision of, as a minimum, basic health care services that must include the following:
a. Emergency care services, as defined in subsection 5 of section 45-06-06-03.
b. Inpatient hospital services, meaning medically necessary hospital services including
room and board; general nursing care; special diets when medically necessary; use of
operating room and related facilities; use of intensive care units and services; x-ray,
laboratory, and other diagnostic tests; drugs, medications, biologicals, anesthesia, and
oxygen services; special nursing when medically necessary; physical therapy, radiation
therapy, and inhalation therapy; administration of whole blood and blood plasma; and
short-term rehabilitation services.
c. Inpatient physician care services, meaning medically necessary health care services
performed, prescribed, or supervised by physicians or other providers including
diagnostic, therapeutic, medical, surgical, preventive, referral, and consultative health
care services.
d. Outpatient medical services, meaning preventive and medically necessary health care
services provided in a physician's office, a nonhospital-based health care facility, or at a
hospital. Outpatient medical services must include diagnostic services; treatment
services; laboratory services; x-ray services; referral services; and physical therapy,
radiation therapy, and inhalation therapy. Outpatient services must also include
preventive health services that must include at least a broad range of voluntary family
planning services, well-child care from birth, periodic health evaluations for adults,
screening to determine the need for vision and hearing correction, and pediatric and
adult immunizations in accordance with accepted medical practice.
3. Out-of-area services and benefits.
a. Out-of-area services are subject to the same copayment requirements set forth in
subsection 6 of section 45-06-07-04.
b. When an enrollee is traveling or temporarily residing out of a health maintenance
organization's service area, a health maintenance organization shall provide benefits for
reimbursement for emergency care services and transportation which is medically
necessary and appropriate under the circumstances to return the enrollee to a health
maintenance organization provider, subject to the following conditions:

(1) The condition could not reasonably have been foreseen;
(2) The enrollee could not reasonably arrange to return to the service area to receive
treatment from the health maintenance organization's provider;
(3) The travel or temporary residence must be for some purpose other than the receipt
of medical treatments; and
(4) The health maintenance organization is notified by telephone within twenty-four
hours of the commencement of such care unless it is shown that it was not
reasonably possible to communicate with the health maintenance organization in
such time limits.
c. Services received by an enrollee outside of the health maintenance organization's
service area will be covered only so long as it is unreasonable to return the enrollee to
the service area.
4. Supplemental health care services. In addition to the basic health care services required to
be provided in subsection 2, a health maintenance organization may offer to its enrollees any
supplemental health care services it chooses to provide. Limitations as to time and cost may
vary from those applicable to basic health care services.
5. Nonbasic health care services. A health maintenance organization may offer nonbasic
health care services to any group or individual on a prepaid basis, subject to the same
conditions as for supplemental health care services, as described in subsection 4, except that
the health maintenance organization need not provide basic health care services as a
condition to providing nonbasic health care services.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1
### § 45-06-07-07. Other requirements.

1. Description of providers.
a. A health maintenance organization shall provide its subscribers with a list of the names
and locations of all of its providers no later than the time of enrollment or the time the
group or individual contract and evidence of coverage are issued and upon reenrollment.
If a provider is no longer affiliated with a health maintenance organization, the health
maintenance organization shall provide notice of such change to its affected subscribers
within thirty days. Subject to the approval of the commissioner, a health maintenance
organization may provide its subscribers with a list of providers or provider groups for a
segment of the service area. However, a list of all providers must be made available to
subscribers upon request.
b. Any list of providers must contain a notice regarding the availability of the listed primary
care physicians. Such notice must be in not less than twelve-point type and be placed in
a prominent place on the list of providers. The notice must contain the following or similar
language:
Enrolling in [name of health maintenance organization] does not guarantee services
by a particular provider on this list. If you wish to receive care from specific
providers listed, you should contact those providers to be sure that they are
accepting additional patients for [name of health maintenance organization].

2. Description of the services area. A health maintenance organization shall provide its
subscribers with a description of its service area no later than the time of enrollment or the
time the group or individual contract and evidence of coverage is issued and upon request
thereafter. If the description of the service area is changed, the health maintenance
organization shall provide at such time a new description of the service area to its subscribers.
3. Copayments and deductibles. A health maintenance organization may require copayments
or deductibles of enrollees as a condition for the receipt of specific health care services.
Copayments for basic health care services must be shown in the group or individual contract
and evidence of coverage as a specified dollar amount. Copayments and deductibles must be
the only allowable charge, other than premiums, assessed to subscribers for basic,
supplemental, and nonbasic health care services.
4. Grievance procedure.
a. A grievance procedure must be established and maintained by a health maintenance
organization to provide reasonable procedures for the prompt and effective resolution of
written grievances.
b. A health maintenance organization shall provide grievance forms to be given to enrollees
who wish to register written grievances. Such forms must include the address and
telephone number to which grievances must be directed and must also specify any
required time limits imposed by the health maintenance organization.
c. The grievance procedure must provide for written acknowledgment of grievances and
grievances to be resolved or to have a final determination of the grievance by the health
maintenance organization within a reasonable period of time, but not more than ninety
days from the date the grievance is received. This period may be extended in the event
of a delay in obtaining the documents or records necessary for the resolution of the
grievance, or by the mutual written agreement of the health maintenance organization
and the enrollee.
d. Prior to the resolution of a grievance filed by a subscriber or enrollee, coverage may not
be terminated for any reason which is the subject of the written grievance, except if the
health maintenance organization has, in good faith, made a reasonable effort to resolve
the written grievance through its grievance procedure and coverage is being terminated
as provided for in subsection 8 of section 45-06-07-04.
e. If enrollee's grievances may be resolved through a specified arbitration agreement, the
enrollee must be advised in writing of the enrollee's rights and duties under the
agreement at the time the grievance is registered. Any such agreement must be
accompanied by a statement setting forth in writing the terms and conditions of binding
arbitration. Any health maintenance organization that makes such binding arbitration a
condition of enrollment must fully disclose this requirement to its enrollees in the group or
individual contract and evidence of coverage.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1
### § 45-06-07-08. Penalties.

Any violation of this chapter is subject to the penalties as provided for in North Dakota Century
Code title 26.1 and any other applicable law of this state.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1

Law Implemented: NDCC 26.1-18.1
### § 45-06-07-09. Severability.

If any provision of this chapter or the application thereof to any person or circumstances is for any
reason held to be invalid, the remainder of the chapter and the application for such provision to other
persons or circumstances is not affected thereby.
History: Effective July 1, 1994.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1
### § 45-06-07-10. Producer compliance.

Any health maintenance organization producer under this chapter is subject to the requirements
and provisions of North Dakota Century Code chapter 26.1-26.
History: Effective July 1, 1998.
General Authority: NDCC 26.1-18.1-16
Law Implemented: NDCC 26.1-18.1-16
