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<br>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,<br>fraternal benefit society, or health maintenance organization that provides a plan of<br>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<br>offered on a group or individual basis. The term does not include short-term major<br>medical policies offered in the individual market.3."Short-term", except as required by the Health Insurance Portability and<br>Accountability Act of 1996, means a policy or plan providing coverage for one<br>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<br>which medical diagnosis, care, or treatment was recommended or received within<br>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<br>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<br>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<br>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<br>was covered by qualifying previous coverage, if the qualifying previous coverage as defined in<br>section 26.1-36.3-01 is continuous until at least sixty-three days before the effective date of the<br>new coverage. Any waiting period applicable to an individual for coverage under a health benefit<br>plan may not be taken into account in determining the period of continuous coverage. Insurers<br>shall credit coverage in the same manner as provided by section 26.1-36.3-06 and the rules<br>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<br>renewability or continuability of coverage unless:Page No. 1a.The individual or group has failed to pay premiums or contributions in<br>accordance with the terms of the health benefit plan or the insurer has not<br>received timely premium payments.b.The individual or group has performed an act or practice that constitutes fraud<br>or made an intentional misrepresentation of a material fact under the terms of<br>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<br>insurance coverage in the group or individual market. A type of group health<br>benefit plan or individual policy may be discontinued by the insurer in that<br>market only if the insurer:(1)Provides advance notice of its decision under this paragraph to the<br>commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected<br>individuals,employers,participants,beneficiaries,andtothecommissioner in each state in which an affected insured is known to<br>reside at least ninety days prior to the nonrenewal of any health benefit<br>plans by the insurer. Notice to the commissioner under this subdivision<br>must be provided at least three working days prior to the notice to the<br>affected individuals, employers, participants, and beneficiaries;(3)Offers to each affected group or individual the option to purchase all<br>other health benefit plans or individual coverage currently being offered<br>by the insurer in that market; and(4)In exercising the option to discontinue the particular type of group health<br>benefit plan or individual coverage and in offering the option of coverage<br>under paragraph 3, the insurer acts uniformly without regard to claims<br>experience or any health status-related factor relating to any affected<br>individuals, participants, or beneficiaries covered or new individuals,<br>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<br>benefit plans or individual coverage delivered or issued for delivery to<br>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<br>commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected<br>individuals, employers, participants, and beneficiaries, and to the<br>commissioner in each state in which an affected insured is known to<br>reside at least one hundred eighty days prior to the nonrenewal of any<br>health benefit plans by the insurer. Notice to the commissioner under<br>this subdivision must be provided at least three working days prior to the<br>noticetotheaffectedindividuals,employers,participants,andbeneficiaries; and(3)Discontinue all health insurance issued or delivered for issuance in the<br>state's group or individual market and not renew such health coverage in<br>that market.Page No. 2g.In the case of health benefit plans that are made available in the group or<br>individual market only through one or more associations, the membership of an<br>employer or individual in the association, on the basis of which the coverage is<br>provided, ceases, but only if the coverage is terminated under this paragraph<br>uniformly without regard to any health status-related factor relating to any<br>covered individual.h.The commissioner finds that the continuation of the coverage would not be in<br>the best interests of the policyholders or certificate holders or would impair the<br>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<br>subsection 1 may not write new business in the applicable market in this state for a<br>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<br>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<br>coverage or accept applications pursuant to subsection 1 or 2 in the case of the<br>following:a.To an eligible person who no longer resides, lives, or works in the service area,<br>or in an area for which the insurer is authorized to do business, but only if<br>coverage is terminated under this subdivision uniformly without regard to any<br>health status-related factor; orb.To an insurer that no longer has any enrollee in connection with the plan who<br>lives, resides, or works in the service area of the insurer, or the area for which<br>the insurer is authorized to do business.5.At the time of coverage renewal, an insurer may modify the health insurance<br>coverage for a product offered to a group or individual, if the modification is<br>reasonable, consistent with state law, and effective on a uniform basis. If coverage<br>is modified, the carrier shall:a.Provide advance notice of its decision under this subsection to the<br>commissioner at least three working days prior to mailing the notice to the<br>affected employers and participants and beneficiaries.b.Provide notice of the decision to modify health coverage to all affected<br>employers, participants, and beneficiaries and the commissioner sixty days<br>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<br>individuals in that class for the same or similar coverage may not vary by a ratio of<br>more than six to one after August 1, 1995, and by a ratio of more than five to one<br>after August 1, 1996, when age, industry, gender, and duration of coverage of the<br>individuals are considered. Gender and duration of coverage may not be used as a<br>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,<br>family composition, healthy lifestyles, and benefit variations to determine premium<br>rates.Page No. 33.The commissioner shall design and adopt reporting forms to be used by an insurer<br>to report information as to insurer's experience as to insurance provided under this<br>chapter on a periodic basis to determine the impact of the reforms and<br>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,<br>or renew any health insurance policy, health service contract, or evidence of coverage on an<br>individual or group basis unless the company, corporation, or association actively offers a basic<br>health benefit plan and a standard health benefit plan as approved by the commissioner. The<br>commissioner shall design and adopt a basic health benefit plan and a standard health benefit<br>plan to be offered on an individual and group basis as required by this section. The basic and<br>standard health benefit plans must be those developed under section 26.1-36.3-06. This section<br>does not require a health maintenance organization to provide any benefit it is prohibited from<br>providing under federal law and does not excuse failure to provide benefits mandated by federal<br>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<br>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<br>upon termination of health insurance coverage for any employer, the employer is<br>entitled to a report from the insurer or administrator of that employer's employee<br>healthplanwhichincludesamonthlyaccountingforthemostrecenttwenty-four-month period of the total number of insured or covered employees, the<br>total premiums paid, and the total benefits paid on behalf of the employer's health<br>plan.2.Insurers shall provide the report pursuant to subsection 1 to an employer within thirty<br>days of receipt of a request for the information.3.The information provided pursuant to subsection 1 may not identify specific<br>employee claims or other confidential health care information.4.Upon notification of termination of health insurance before the end of a benefit<br>period, the terminated insurer, at the request of the employer and within thirty days<br>of the request, shall supply the succeeding or new insurer a report of all deductibles<br>and coinsurance payments for each employee covered by the employer's health<br>insurance plan for the most recent benefit period.Page No. 4Document Outlinechapter 26.1-36.4 hospital and medical insurance
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<br>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,<br>fraternal benefit society, or health maintenance organization that provides a plan of<br>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<br>offered on a group or individual basis. The term does not include short-term major<br>medical policies offered in the individual market.3."Short-term", except as required by the Health Insurance Portability and<br>Accountability Act of 1996, means a policy or plan providing coverage for one<br>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<br>which medical diagnosis, care, or treatment was recommended or received within<br>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<br>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<br>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<br>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<br>was covered by qualifying previous coverage, if the qualifying previous coverage as defined in<br>section 26.1-36.3-01 is continuous until at least sixty-three days before the effective date of the<br>new coverage. Any waiting period applicable to an individual for coverage under a health benefit<br>plan may not be taken into account in determining the period of continuous coverage. Insurers<br>shall credit coverage in the same manner as provided by section 26.1-36.3-06 and the rules<br>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<br>renewability or continuability of coverage unless:Page No. 1a.The individual or group has failed to pay premiums or contributions in<br>accordance with the terms of the health benefit plan or the insurer has not<br>received timely premium payments.b.The individual or group has performed an act or practice that constitutes fraud<br>or made an intentional misrepresentation of a material fact under the terms of<br>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<br>insurance coverage in the group or individual market. A type of group health<br>benefit plan or individual policy may be discontinued by the insurer in that<br>market only if the insurer:(1)Provides advance notice of its decision under this paragraph to the<br>commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected<br>individuals,employers,participants,beneficiaries,andtothecommissioner in each state in which an affected insured is known to<br>reside at least ninety days prior to the nonrenewal of any health benefit<br>plans by the insurer. Notice to the commissioner under this subdivision<br>must be provided at least three working days prior to the notice to the<br>affected individuals, employers, participants, and beneficiaries;(3)Offers to each affected group or individual the option to purchase all<br>other health benefit plans or individual coverage currently being offered<br>by the insurer in that market; and(4)In exercising the option to discontinue the particular type of group health<br>benefit plan or individual coverage and in offering the option of coverage<br>under paragraph 3, the insurer acts uniformly without regard to claims<br>experience or any health status-related factor relating to any affected<br>individuals, participants, or beneficiaries covered or new individuals,<br>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<br>benefit plans or individual coverage delivered or issued for delivery to<br>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<br>commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected<br>individuals, employers, participants, and beneficiaries, and to the<br>commissioner in each state in which an affected insured is known to<br>reside at least one hundred eighty days prior to the nonrenewal of any<br>health benefit plans by the insurer. Notice to the commissioner under<br>this subdivision must be provided at least three working days prior to the<br>noticetotheaffectedindividuals,employers,participants,andbeneficiaries; and(3)Discontinue all health insurance issued or delivered for issuance in the<br>state's group or individual market and not renew such health coverage in<br>that market.Page No. 2g.In the case of health benefit plans that are made available in the group or<br>individual market only through one or more associations, the membership of an<br>employer or individual in the association, on the basis of which the coverage is<br>provided, ceases, but only if the coverage is terminated under this paragraph<br>uniformly without regard to any health status-related factor relating to any<br>covered individual.h.The commissioner finds that the continuation of the coverage would not be in<br>the best interests of the policyholders or certificate holders or would impair the<br>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<br>subsection 1 may not write new business in the applicable market in this state for a<br>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<br>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<br>coverage or accept applications pursuant to subsection 1 or 2 in the case of the<br>following:a.To an eligible person who no longer resides, lives, or works in the service area,<br>or in an area for which the insurer is authorized to do business, but only if<br>coverage is terminated under this subdivision uniformly without regard to any<br>health status-related factor; orb.To an insurer that no longer has any enrollee in connection with the plan who<br>lives, resides, or works in the service area of the insurer, or the area for which<br>the insurer is authorized to do business.5.At the time of coverage renewal, an insurer may modify the health insurance<br>coverage for a product offered to a group or individual, if the modification is<br>reasonable, consistent with state law, and effective on a uniform basis. If coverage<br>is modified, the carrier shall:a.Provide advance notice of its decision under this subsection to the<br>commissioner at least three working days prior to mailing the notice to the<br>affected employers and participants and beneficiaries.b.Provide notice of the decision to modify health coverage to all affected<br>employers, participants, and beneficiaries and the commissioner sixty days<br>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<br>individuals in that class for the same or similar coverage may not vary by a ratio of<br>more than six to one after August 1, 1995, and by a ratio of more than five to one<br>after August 1, 1996, when age, industry, gender, and duration of coverage of the<br>individuals are considered. Gender and duration of coverage may not be used as a<br>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,<br>family composition, healthy lifestyles, and benefit variations to determine premium<br>rates.Page No. 33.The commissioner shall design and adopt reporting forms to be used by an insurer<br>to report information as to insurer's experience as to insurance provided under this<br>chapter on a periodic basis to determine the impact of the reforms and<br>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,<br>or renew any health insurance policy, health service contract, or evidence of coverage on an<br>individual or group basis unless the company, corporation, or association actively offers a basic<br>health benefit plan and a standard health benefit plan as approved by the commissioner. The<br>commissioner shall design and adopt a basic health benefit plan and a standard health benefit<br>plan to be offered on an individual and group basis as required by this section. The basic and<br>standard health benefit plans must be those developed under section 26.1-36.3-06. This section<br>does not require a health maintenance organization to provide any benefit it is prohibited from<br>providing under federal law and does not excuse failure to provide benefits mandated by federal<br>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<br>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<br>upon termination of health insurance coverage for any employer, the employer is<br>entitled to a report from the insurer or administrator of that employer's employee<br>healthplanwhichincludesamonthlyaccountingforthemostrecenttwenty-four-month period of the total number of insured or covered employees, the<br>total premiums paid, and the total benefits paid on behalf of the employer's health<br>plan.2.Insurers shall provide the report pursuant to subsection 1 to an employer within thirty<br>days of receipt of a request for the information.3.The information provided pursuant to subsection 1 may not identify specific<br>employee claims or other confidential health care information.4.Upon notification of termination of health insurance before the end of a benefit<br>period, the terminated insurer, at the request of the employer and within thirty days<br>of the request, shall supply the succeeding or new insurer a report of all deductibles<br>and coinsurance payments for each employee covered by the employer's health<br>insurance plan for the most recent benefit period.Page No. 4Document Outlinechapter 26.1-36.4 hospital and medical insurance
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<br>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,<br>fraternal benefit society, or health maintenance organization that provides a plan of<br>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<br>offered on a group or individual basis. The term does not include short-term major<br>medical policies offered in the individual market.3."Short-term", except as required by the Health Insurance Portability and<br>Accountability Act of 1996, means a policy or plan providing coverage for one<br>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<br>which medical diagnosis, care, or treatment was recommended or received within<br>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<br>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<br>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<br>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<br>was covered by qualifying previous coverage, if the qualifying previous coverage as defined in<br>section 26.1-36.3-01 is continuous until at least sixty-three days before the effective date of the<br>new coverage. Any waiting period applicable to an individual for coverage under a health benefit<br>plan may not be taken into account in determining the period of continuous coverage. Insurers<br>shall credit coverage in the same manner as provided by section 26.1-36.3-06 and the rules<br>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<br>renewability or continuability of coverage unless:Page No. 1a.The individual or group has failed to pay premiums or contributions in<br>accordance with the terms of the health benefit plan or the insurer has not<br>received timely premium payments.b.The individual or group has performed an act or practice that constitutes fraud<br>or made an intentional misrepresentation of a material fact under the terms of<br>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<br>insurance coverage in the group or individual market. A type of group health<br>benefit plan or individual policy may be discontinued by the insurer in that<br>market only if the insurer:(1)Provides advance notice of its decision under this paragraph to the<br>commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected<br>individuals,employers,participants,beneficiaries,andtothecommissioner in each state in which an affected insured is known to<br>reside at least ninety days prior to the nonrenewal of any health benefit<br>plans by the insurer. Notice to the commissioner under this subdivision<br>must be provided at least three working days prior to the notice to the<br>affected individuals, employers, participants, and beneficiaries;(3)Offers to each affected group or individual the option to purchase all<br>other health benefit plans or individual coverage currently being offered<br>by the insurer in that market; and(4)In exercising the option to discontinue the particular type of group health<br>benefit plan or individual coverage and in offering the option of coverage<br>under paragraph 3, the insurer acts uniformly without regard to claims<br>experience or any health status-related factor relating to any affected<br>individuals, participants, or beneficiaries covered or new individuals,<br>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<br>benefit plans or individual coverage delivered or issued for delivery to<br>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<br>commissioner in each state in which it is licensed;(2)Provides notice of the decision not to renew coverage to all affected<br>individuals, employers, participants, and beneficiaries, and to the<br>commissioner in each state in which an affected insured is known to<br>reside at least one hundred eighty days prior to the nonrenewal of any<br>health benefit plans by the insurer. Notice to the commissioner under<br>this subdivision must be provided at least three working days prior to the<br>noticetotheaffectedindividuals,employers,participants,andbeneficiaries; and(3)Discontinue all health insurance issued or delivered for issuance in the<br>state's group or individual market and not renew such health coverage in<br>that market.Page No. 2g.In the case of health benefit plans that are made available in the group or<br>individual market only through one or more associations, the membership of an<br>employer or individual in the association, on the basis of which the coverage is<br>provided, ceases, but only if the coverage is terminated under this paragraph<br>uniformly without regard to any health status-related factor relating to any<br>covered individual.h.The commissioner finds that the continuation of the coverage would not be in<br>the best interests of the policyholders or certificate holders or would impair the<br>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<br>subsection 1 may not write new business in the applicable market in this state for a<br>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<br>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<br>coverage or accept applications pursuant to subsection 1 or 2 in the case of the<br>following:a.To an eligible person who no longer resides, lives, or works in the service area,<br>or in an area for which the insurer is authorized to do business, but only if<br>coverage is terminated under this subdivision uniformly without regard to any<br>health status-related factor; orb.To an insurer that no longer has any enrollee in connection with the plan who<br>lives, resides, or works in the service area of the insurer, or the area for which<br>the insurer is authorized to do business.5.At the time of coverage renewal, an insurer may modify the health insurance<br>coverage for a product offered to a group or individual, if the modification is<br>reasonable, consistent with state law, and effective on a uniform basis. If coverage<br>is modified, the carrier shall:a.Provide advance notice of its decision under this subsection to the<br>commissioner at least three working days prior to mailing the notice to the<br>affected employers and participants and beneficiaries.b.Provide notice of the decision to modify health coverage to all affected<br>employers, participants, and beneficiaries and the commissioner sixty days<br>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<br>individuals in that class for the same or similar coverage may not vary by a ratio of<br>more than six to one after August 1, 1995, and by a ratio of more than five to one<br>after August 1, 1996, when age, industry, gender, and duration of coverage of the<br>individuals are considered. Gender and duration of coverage may not be used as a<br>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,<br>family composition, healthy lifestyles, and benefit variations to determine premium<br>rates.Page No. 33.The commissioner shall design and adopt reporting forms to be used by an insurer<br>to report information as to insurer's experience as to insurance provided under this<br>chapter on a periodic basis to determine the impact of the reforms and<br>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,<br>or renew any health insurance policy, health service contract, or evidence of coverage on an<br>individual or group basis unless the company, corporation, or association actively offers a basic<br>health benefit plan and a standard health benefit plan as approved by the commissioner. The<br>commissioner shall design and adopt a basic health benefit plan and a standard health benefit<br>plan to be offered on an individual and group basis as required by this section. The basic and<br>standard health benefit plans must be those developed under section 26.1-36.3-06. This section<br>does not require a health maintenance organization to provide any benefit it is prohibited from<br>providing under federal law and does not excuse failure to provide benefits mandated by federal<br>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<br>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<br>upon termination of health insurance coverage for any employer, the employer is<br>entitled to a report from the insurer or administrator of that employer's employee<br>healthplanwhichincludesamonthlyaccountingforthemostrecenttwenty-four-month period of the total number of insured or covered employees, the<br>total premiums paid, and the total benefits paid on behalf of the employer's health<br>plan.2.Insurers shall provide the report pursuant to subsection 1 to an employer within thirty<br>days of receipt of a request for the information.3.The information provided pursuant to subsection 1 may not identify specific<br>employee claims or other confidential health care information.4.Upon notification of termination of health insurance before the end of a benefit<br>period, the terminated insurer, at the request of the employer and within thirty days<br>of the request, shall supply the succeeding or new insurer a report of all deductibles<br>and coinsurance payments for each employee covered by the employer's health<br>insurance plan for the most recent benefit period.Page No. 4Document Outlinechapter 26.1-36.4 hospital and medical insurance
