§ 26.1-08-06 — Comprehensive benefit plan (Repealed effective December 31, 2027)

North Dakota § 26.1-08-06

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-08: Comprehensive Health Association [Repealed]

Text

1. The benefit plan must offer comprehensive health care coverage to every eligible
individual. The coverage to be issued by the association, its schedule of benefits,
exclusions, and other limitations must be established by the lead carrier and subject to
the approval of the board.
2. In establishing the benefit plan coverage, the board shall take into consideration the
levels of health insurance coverage provided in the state and medical economic
factors as may be deemed appropriate. Benefit levels, deductibles, coinsurance
factors, copayments, exclusions, and limitations may be applied as determined to be
generally reflective of health insurance coverage provided in the state.
3. The coverage may include deductibles of not less than five hundred dollars per
individual per benefit period.
4. The coverage must include a limitation of not less than three thousand dollars per
individual on the total annual out-of-pocket expenses for services covered under this
section.
5. Any coverage or combination of coverages through the association may not exceed a
lifetime maximum benefit of one million dollars for an individual.
6. The coverage may include cost-containment measures and requirements, including
preadmission screening, second surgical opinion, concurrent utilization review, and
individual case management for the purpose of making the benefit plan more
cost-effective.
7. The coverage may include preferred provider organizations, health maintenance
organizations, and other limited network provider arrangements.
8. Coverage must include oral surgery for partially or completely unerupted impacted
teeth, a tooth root without the extraction of the entire tooth, or the gums and tissues of
the mouth when not performed in connection with the extraction or repair of teeth.
9. Coverage must include substance abuse and mental disorders as outlined in sections
26.1-36-08 and 26.1-36-09.
10. Covered expenses must include, at the option of the eligible individual, professional
services rendered by a chiropractor and for services and articles prescribed by a
chiropractor for which an additional premium may be charged.
11. The coverage must include organ transplants as approved by the board.
12. The association must be payer of last resort of benefits whenever any other benefit or
source of third-party payment is available. Benefits otherwise payable under an
association benefit plan must be reduced by all amounts paid or payable through any
other health insurance coverage and by all hospital and medical expense benefits paid

or payable under any workforce safety and insurance coverage, automobile medical
payment or liability insurance whether provided on the basis of fault or no fault, and by
any hospital or medical benefits paid or payable under or provided pursuant to any
state or federal law or program. The association must have a cause of action against
an eligible individual for the recovery of the amount of benefits paid that are not for
covered expenses. Benefits due from the association may be reduced or refused as a
setoff against any amount recoverable under this subsection.