§ 26.1-08-12 — Eligibility (Repealed effective December 31, 2027)

North Dakota § 26.1-08-12

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• Ch. 26.1-08: Comprehensive Health Association [Repealed]

Text

1. The association must be open for enrollment by eligible individuals. Eligible individuals
shall apply for enrollment in the association by submitting an application to the lead
carrier. The application must be completed fully and accompanied by premium and
evidence to prove eligibility.
2. Within thirty days of receipt of the application, the lead carrier shall either reject the
application for failing to comply with the requirements of this section or forward the
eligible individual a notice of acceptance and billing information.
3. At the option of the eligible individual, association coverage is effective:
a. For an eligible individual applying under subsection 10 or 11, on the signature
date of the application.
b. For an eligible individual applying under subparagraph a of paragraph 1 of
subdivision a of subsection 5 or under subparagraph a of paragraph 1 of
subdivision c of subsection 5:
(1) On the day following the date shown on the written evidence;
(2) On the signature date of the application, if it is at least one day and less
than one hundred eighty days following the date shown on the written
evidence; or
(3) On any date after the signature date of the application if the date is at least
one day and less than one hundred eighty days following the date shown on
the written evidence.
c. For an eligible individual applying under subparagraph b or c of paragraph 1 of
subdivision a of subsection 5 or under subparagraph b or c of paragraph 1 of
subdivision c of subsection 5:
(1) On the signature date of the application; or
(2) On any date after the signature date of the application but less than one
hundred eighty days following the date shown on the written evidence.
d. For an eligible individual applying under subparagraph d of paragraph 1 of
subdivision a of subsection 5, on the date the lifetime maximum occurred if the
application:
(1) Is submitted within ninety days after the date that lifetime maximum
occurred; and
(2) Is accompanied with premium for coverage retroactive to the date that
lifetime maximum occurred.
e. For an eligible individual applying under subdivision b or d of subsection 5:
(1) On the signature date of the application; or
(2) On any date after the signature date of the application, but less than
sixty-four days following termination of previous coverage.
f. For an eligible individual applying under subsection 6:
(1) On the signature date of the application; or
(2) On any date after the signature date of the application, but less than one
hundred eighty days following the date shown on the written evidence from
a medical professional.
4. An eligible individual may not purchase more than one policy from the association.
5. An individual may qualify to enroll in the association for benefit plan coverage as:
a. A traditional applicant:
(1) An individual who has been a resident of this state and continues to be a
resident of the state who has received from at least one insurance carrier
within one hundred eighty days of the date of application, one of the
following:

(a) Written evidence of rejection or refusal to issue substantially similar
insurance for health reasons by one insurer.
(b) Written evidence that a restrictive rider or a pre-existing condition
limitation, the effect of which is to reduce substantially, coverage from
that received by an individual considered a standard risk, has been
placed on the individual's policy.
(c) Written evidence that an insurer has offered to issue comparable
insurance at a rate exceeding the association benefit rate.
(d) Written evidence that the applicant has reached the lifetime maximum
coverage amount on the most recent health insurance coverage.
(2) Is not enrolled in health benefits with the state's medical assistance
program.
b. A Health Insurance Portability and Accountability Act of 1996 applicant:
(1) An individual who meets the federally defined eligibility guidelines as
follows:
(a) Has had eighteen months of qualifying previous coverage as defined
in section 26.1-36.3-01;
(b) Has applied for coverage under this chapter within sixty-three days of
the termination of the qualifying previous coverage;
(c) Is not eligible for coverage under Medicare or a group health benefit
plan as the term is defined in section 26.1-36.3-01;
(d) Does not have any other health insurance coverage;
(e) Has not had the most recent qualifying previous coverage described in
subparagraph a terminated for nonpayment of premiums or fraud; and
(f) If offered under the option, has elected continuation coverage under
the federal Consolidated Omnibus Budget Reconciliation Act [Pub. L.
99-272; 100 Stat. 82], or under a similar state program, and that
coverage has exhausted.
(2) Is and continues to be a resident of the state.
(3) Is not enrolled in health benefits with the state's medical assistance
program.
c. An applicant age sixty-five and over or disabled:
(1) An individual who is eligible for Medicare by reason of age or disability and
has been a resident of this state and continues to be a resident of this state
who has received from at least one insurance carrier within one hundred
eighty days of the date of application, one of the following:
(a) Written evidence of rejection or refusal to issue substantially similar
insurance for health reasons by one insurer.
(b) Written evidence that a restrictive rider or a pre-existing condition
limitation, the effect of which is to reduce substantially, coverage from
that received by an individual considered a standard risk, has been
placed on the individual's policy.
(c) Written evidence that an insurer has offered to issue comparable
insurance at a rate exceeding the association benefit rate.
(2) Is not enrolled in health benefits with the state's medical assistance
program.
d. A Trade Adjustment Assistance Reform Act of 2002 applicant:
(1) A trade adjustment assistance, pension benefit guarantee corporation
individual applicant who:
(a) Has three or more months of qualifying previous health insurance
coverage at the time of application;
(b) Has applied for coverage within sixty-three days of the termination of
the individual's previous health insurance coverage;
(c) Is and continues to be a resident of the state;
(d) Is not enrolled in the state's medical assistance program;
(e) Is not imprisoned under federal, state, or local authority; and

(f) Does not have health insurance coverage through:
[1] The applicant's or spouse's employer if the coverage provides for
employer contribution of fifty percent or more of the cost of
coverage of the spouse, the eligible individual, and the
dependents or the coverage is in lieu of an employer's cash or
other benefit under a cafeteria plan.
[2] A state's children's health insurance program, as defined under
section 50-29-01.
[3] A government plan.
[4] Chapter 55 of United States Code title 10 [10 U.S.C. 1071
et seq.] relating to armed forces medical and dental care.
[5] Part A or part B of title XVIII of the federal Social Security Act
[42 U.S.C. 1395 et seq.] relating to health insurance for the aged
and disabled.
(2) Coverage under this subdivision may be provided to an individual who is
eligible for health insurance coverage through the federal Consolidated
Omnibus Budget Reconciliation Act of 1985 [Pub. L. 99-272; 100 Stat. 82]; a
spouse's employer plan in which the employer contribution is less than fifty
percent; or the individual marketplace, including continuation or guaranteed
issue, but who elects to obtain coverage under this subdivision.
6. The board and lead carrier shall develop a list of medical or health conditions for which
an individual must be eligible for association coverage without applying for health
insurance coverage under subdivisions a and c of subsection 5. Individuals with
written evidence of the existence or history of any medical or health conditions on the
approved list may not be required to provide written evidence of rejection or refusal, a
rate that exceeds the association rates, substantially reduced coverage, or the lifetime
maximum amount being reached.
7. A rejection or refusal by an insurer offering only stop-loss, excess of loss, or
reinsurance coverage with respect to an applicant under subdivisions a and c of
subsection 5 is not sufficient evidence to qualify.
8. A traditional applicant, as specified under subdivision a of subsection 5, may have
insurance coverage, other than the state's medical assistance program, with an
additional commercial insurer; however, the association will reimburse eligible claim
costs as payer of last resort.
9. An individual who is eligible for association coverage as specified under subdivision c
of subsection 5 may not have more than one policy that is a supplement to part A or
part B of Medicare relating to health insurance for the aged and disabled. The
individual may obtain association coverage as a traditional applicant as specified
under subdivision a of subsection 5 which is concurrent with a supplement policy
offered by a commercial carrier. However, the association will reimburse eligible claims
as payer of last resort.
10. If an individual is enrolled in association coverage, that individual's resident dependent
is also eligible for association coverage.
11. If an individual is enrolled in association coverage, that individual's resident spouse is
also eligible for association coverage.
12. A newly born child without health insurance coverage is covered through the mother's
association benefit plan for the first thirty-one days following birth. Continued coverage
through the association for the child will be provided if the association receives an
application and the appropriate premium within thirty-one days following the birth. This
coverage is not available to an applicant under subdivision c of subsection 5.
13. Pre-existing conditions.
a. Association coverage must exclude charges or expenses incurred during the first
one hundred eighty days following the effective date of coverage for any condition
for which medical advice, diagnosis, care, or treatment was recommended or
received during the one hundred eighty days immediately preceding the signature
date of the application.

b. Association coverage must exclude charges or expenses incurred for maternity
during the first two hundred seventy days following the effective date of coverage.
c. Any individual with coverage through the association due to a catastrophic
condition or major illness who is also pregnant at the time of application is eligible
for maternity benefits after the first one hundred eighty days of coverage.
d. A pre-existing condition may not be imposed on an individual who is eligible
under subparagraph d of paragraph 1 of subdivision a of subsection 5 or
subdivision b or d of subsection 5.
14. Waiting periods do not apply:
a. To nonelective treatment or procedures for a congenital or genetic disease.
b. To an individual who has obtained coverage as a federally eligible individual as
defined in subdivision b of subsection 5.
c. To an individual who has obtained coverage as an eligible person under
subdivision a or c of subsection 5, allowing for a reduction in waiting period days
by the aggregate period of qualifying previous coverage in the same manner as
provided in subsection 3 of section 26.1-36.3-06 and provided the association
application is made within sixty-three days of termination of the qualifying
previous coverage.
d. To an individual who has obtained coverage as an eligible individual under
subdivision d of subsection 5.
e. To an individual who has obtained coverage as an eligible individual under
subparagraph d of paragraph 1 of subdivision a of subsection 5.
15. An individual is not eligible for coverage through the association if:
a. The individual is enrolled in health benefits with the state's medical assistance
program.
b. The individual has previously terminated association coverage unless twelve
months have lapsed since such termination. This limitation does not apply to an
applicant who is a federally defined eligible individual as defined under
subparagraph d of paragraph 1 of subdivision a of subsection 5 or subdivision b
of subsection 5.
c. The association has paid out one million dollars in benefits on behalf of the
individual.
d. The individual is imprisoned under federal, state, or local authority. This limitation
does not apply to an applicant who is a federally defined eligible individual as
defined under subdivision b of subsection 5.
e. The individual's premiums are paid for or reimbursed under any
government-sponsored program, government agency, health care provider,
nonprofit charitable organization, or the individual's employer. However, this
subdivision does not apply if the individual's premiums are paid for or reimbursed
under a program established under the federal Trade Adjustment Assistance
Reform Act of 2002 [Pub. L. 107-210; 116 Stat. 933].
16. A period of creditable coverage is not counted with respect to the enrollment of an
individual who seeks coverage under this chapter if after such period and before the
enrollment date, the individual experiences a significant break in coverage which is
more than sixty-three days.