§ 26.1-17.1-01 — Definitions

North Dakota § 26.1-17.1-01

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-17.1: Prepaid Limited Health Service Organizations

Text

As used in this chapter, unless otherwise defined in this chapter:
1. "Enrollee" means an individual, including dependents, who is entitled to limited health
services pursuant to a contract with an entity authorized to provide or arrange for such
services under this chapter.
2. "Evidence of coverage" means the certificate, agreement, or contract issued pursuant
to section 26.1-17.1-08 setting forth the coverage to which an enrollee is entitled.
3. "Limited health service" means dental care services, vision care services, mental
health services, substance abuse services, pharmaceutical services, podiatric care
services, and such other services as may be determined by the commissioner to be
limited health services. Limited health service may not include hospital, medical,
surgical, or emergency services except as such services are provided incident to the
limited health services set forth in the preceding sentence.
4. "Net equity" means the excess of total assets over total liabilities, excluding liabilities
which have been subordinated in a manner acceptable to the commissioner.
5. "Prepaid limited health service organization" means any corporation, partnership, or
other entity which, in return for a prepayment, undertakes to provide or arrange for the
provision of one or more limited health services to enrollees. Prepaid limited health
service organization does not include:
a. An entity otherwise authorized pursuant to the laws of this state either to provide
any limited health service on a prepayment or other basis or to indemnify for any
limited health service;
b. An entity that meets the requirements of section 26.1-17.1-06; or
c. A provider or entity when providing or arranging for the provision of limited health
services pursuant to a contract with a prepaid limited health service organization
or with an entity described in subdivision a or b.
6. "Provider" means any physician, dentist, health facility, or other person or institution
which is duly licensed or otherwise authorized to deliver or furnish limited health
services.
7. "Subscriber" means the person whose employment or other status, except for family
dependency, is the basis for entitlement to limited health services pursuant to a
contract with an entity authorized to provide or arrange for such services under this
chapter.
8. "Tangible net equity" means net equity reduced by the value assigned to intangible
assets including goodwill; going-concern value; organizational expense; startup costs;
long-term prepayments of deferred charges; nonreturnable deposits; and obligations of
officers, directors, owners, or affiliates, except short-term obligations of affiliates for
goods or services arising in the normal course of business which are payable on the
same terms as equivalent transactions with nonaffiliates and which are not past-due.
9. "Uncovered expense" means the cost of health care services that are the obligation of
a prepaid limited health services organization for which an enrollee may be liable in
the event of the insolvency of the organization and for which alternative arrangements
acceptable to the commissioner have not been made to cover the costs. Costs
incurred by a provider who has agreed in writing not to bill enrollees, except for
permissible supplemental charges, must be considered a covered expense.