As used in this chapter and section 26.1-36-37.2, unless the context otherwise requires:
1. "Actuarial certification" means a written statement by a member of the American
academy of actuaries, or other individual acceptable to the insurance commissioner,
that a small employer carrier is in compliance with section 26.1-36.3-04, based upon
the person's examination of the small employer carrier, including a review of the
appropriate records and the actuarial assumptions and methods used by the small
employer carrier in establishing premium rates for applicable health benefit plans.
2. "Affiliate" or "affiliated" means any entity or person who directly or indirectly through
one or more intermediaries, controls or is controlled by, or is under common control
with, a specified entity or person.
3. "Association" means, with respect to health insurance coverage offered in this state,
an association that:
a. Has been actively in existence for at least five years;
b. Has been formed and maintained in good faith for purposes other than obtaining
insurance;
c. Does not condition membership in the association on any health status-related
factor relating to an individual, including an employee or dependent of an
employee;
d. Makes health insurance coverage offered through the association available to all
members regardless of any health status-related factor relating to the members,
or individuals eligible for coverage through a member; and
e. Does not make health insurance coverage offered through the association
available other than in connection with a member of the association.
4. "Base premium rate" means, for each class of business as to a rating period, the
lowest premium rate charged or that could have been charged under the rating system
for that class of business by the small employer carrier to small employers with similar
case characteristics for health benefit plans with the same or similar coverage.
5. "Case characteristics" means demographic or other objective characteristics of a small
employer that are considered by the small employer carrier in the determination of
premium rates for the small employer; however, claim experience, health status, and
duration of coverage are not case characteristics.
6. "Church plan" has the meaning given the term under section 3(33) of the Employee
Retirement Income Security Act of 1974 [Pub. L. 93-406; 88 Stat. 829; 29 U.S.C. 1001
et seq.].
7. "Class of business" means all or a separate grouping of small employers established
under section 26.1-36.3-03.
8. "Control" is as defined in section 26.1-10-01.
9. "Dependent" means a spouse, an unmarried child, including a dependent of an
unmarried child, under the age of twenty-two, an unmarried child who is a full-time
student under the age of twenty-six and who is financially dependent upon the
enrollee, and an unmarried child, including a dependent of an unmarried child, of any
age who is medically certified as disabled and dependent upon the enrollee as set
forth in section 26.1-36-22.
10. "Eligible employee" means an employee who works on a full-time basis and has a
normal workweek of thirty or more hours. The term includes a sole proprietor, a partner
of a partnership, and an independent contractor, if the sole proprietor, partner, or
independent contractor is included as an employee under a health benefit plan of a
small employer. The term does not include an employee who works on a part-time,
temporary, or substitute basis.
11. "Enrollee" means a person covered under a small employer health benefit plan.
12. "Established geographic service area" means a geographic area, as approved by the
insurance commissioner and based on the carrier's certificate of authority to transact
insurance in this state, within which the carrier is authorized to provide coverage.
13. "Governmental plan" means an employee welfare benefit plan as defined in
section 3(32) of the Employee Retirement Income Security Act of 1974
[Pub. L. 93-406; 88 Stat. 829; 29 U.S.C. 1001 et seq.] or any federal government plan.
14. "Group health benefit plan" means an employee welfare benefit plan as defined in
section 3(1) of the Employee Retirement Income Security Act of 1974 [Pub. L. 93-406;
88 Stat. 829; 29 U.S.C. 1001 et seq.] to the extent that the plan provides medical care
as defined in this section and including items and services paid for as medical care to
employees or their dependents as defined under the terms of the plan directly or
through insurance, reimbursement, or otherwise. For purposes of this chapter:
a. A plan, fund, or program that would not be, but for this section, an employee
welfare benefit plan and which is established or maintained by a partnership, to
the extent that the plan, fund, or program provides medical care, including items
and services paid for as medical care, to present or former partners in the
partnership, or to their dependents, as defined under the terms of the plan, fund,
or program, directly or through insurance, reimbursement, or otherwise, must be
treated as an employee welfare benefit plan which is a group health benefit plan;
b. In the case of a group health benefit plan, the term "employer" also includes the
partnership in relationship to any partner; and
c. In the case of a group health benefit plan, the term "participant" also includes:
(1) In connection with a group health benefit plan maintained by a partnership,
an individual who is a partner in relation to the partnership; or
(2) In connection with a group health benefit plan maintained by a
self-employed individual, under which one or more employees are
participants, the self-employed individual, if the individual is, or may
become, eligible to receive benefits under the plan or the beneficiaries may
be eligible to receive any benefit.
15. a. "Health benefit plan" means any hospital or medical or major medical policy,
certificate, or subscriber contract.
b. "Health benefit plan" does not include one or more, or any combination of, the
following:
(1) Coverage only for accident, or disability income insurance, or any
combination thereof;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability insurance and automobile
liability insurance;
(4) Workforce safety and insurance or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for onsite medical clinics; and
(8) Other similar insurance coverage, specified in federal regulations, under
which benefits for medical care are secondary or incidental to other
insurance.
c. "Health benefit plan" does not include the following benefits if they are provided
under a separate policy, certificate, or contract of insurance or are otherwise not
an integral part of the plan:
(1) Limited scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home health care,
community-based care, or any combination thereof; or
(3) Such other similar, limited benefits as are specified in federal regulations.
d. "Health benefit plan" does not include the following benefits if the benefits are
provided under a separate policy, certificate, or contract of insurance, there is no
coordination between the provision of the benefits, and any exclusion of benefits
under any group health benefit plan maintained by the same plan sponsor, and
the benefits are paid with respect to an event without regard to whether benefits
are provided with respect to such an event under any group health plan
maintained by the same plan sponsor:
(1) Coverage only for specified disease or illness; or
(2) Hospital indemnity or other fixed indemnity insurance.
e. "Health benefit plan" does not include the following if offered as a separate policy,
certificate, or contract of insurance:
(1) Medicare supplemental health insurance as defined under section 1882(g)
(1) of the Social Security Act;
(2) Coverage supplemental to the coverage provided under 10 U.S.C. 55; and
(3) Similar supplemental coverage provided under a group health plan.
f. A carrier offering a policy or certificate of specified disease, hospital confinement
indemnity, or limited benefit health insurance shall comply with the following:
(1) File with the insurance commissioner on or before March first of each year a
certification that contains:
(a) A statement from the carrier certifying that the policy or certificate is
being offered and marketed as supplemental health insurance and not
as a substitute for hospital or medical expense insurance or major
medical expense insurance.
(b) A summary description of the policy or certificate, including the
average annual premium rates, or range of premium rates in cases
when premiums vary by age, gender, or other factors, charged for the
policy and certificate in this state.
(2) When the policy or certificate is offered for the first time in this state on or
after August 1, 1993, file with the commissioner the information and
statement required in paragraph 1 at least thirty days before the date the
policy or certificate is issued or delivered in this state.
16. "Health carrier" or "carrier" means any entity that provides health insurance in this
state. For purposes of this chapter, health carrier includes an insurance company, a
prepaid limited health service corporation, a fraternal benefit society, a health
maintenance organization, nonprofit health service corporation, and any other entity
providing a plan of health insurance or health benefits subject to state insurance
regulation.
17. "Health status-related factor" means any of the following factors:
a. Health status;
b. Medical condition, including both physical and mental illness;
c. Claims experience;
d. Receipt of health care;
e. Medical history;
f. Genetic information;
g. Evidence of insurability, including condition arising out of acts of domestic
violence; or
h. Disability.
18. "Index rate" means, for each class of business as to a rating period for small
employers with similar case characteristics, the arithmetic average of the applicable
base premium rate and the corresponding highest premium rate.
19. "Late enrollee" means an eligible employee or dependent who requests enrollment in
a health benefit plan of a small employer following the initial enrollment period during
which the individual is entitled to enroll under the terms of the health benefit plan,
provided that the initial enrollment period is a period of at least thirty days. An eligible
employee or dependent may not be considered a late enrollee, however, if:
a. The individual:
(1) Was covered under qualifying previous coverage at the time of the initial
enrollment;
(2) Lost coverage under qualifying previous coverage as a result of termination
of employment or eligibility, the involuntary termination of the qualifying
previous coverage, death of a spouse, or divorce; and
(3) Requests enrollment within thirty days after termination of the qualifying
previous coverage.
b. The individual is employed by an employer that offers multiple health benefit
plans and the individual elects a different plan during an open enrollment period.
c. A court has ordered coverage be provided for a spouse or minor or dependent
child under a covered employee's health benefit plan and request for enrollment
is made within thirty days after issuance of the court order.
d. The individual had coverage under a Consolidated Omnibus Budget
Reconciliation Act [Pub. L. 99-272; 100 Stat. 82] continuation provision and the
coverage under that provision was exhausted.
20. "Medical care" means amounts paid for:
a. The diagnosis, care, mitigation, treatment, or prevention of disease, or amounts
paid for the purpose of affecting any structure or function of the body;
b. Transportation primarily for and essential to medical care referred to in
subdivision a; and
c. Insurance covering medical care referred to in subdivisions a and b.
21. "Network plan" means health insurance coverage offered by a health carrier under
which the financing and delivery of medical care, including items and services paid for
as medical care, are provided, in whole or in part, through a defined set of providers
under contract with the carrier.
22. "New business premium rate" means, for each class of business as to a rating period,
the lowest premium rate charged or offered, or which could have been charged or
offered, by the small employer carrier to small employers with similar case
characteristics for newly issued health benefit plans with the same or similar coverage.
23. "Plan sponsor" has the meaning given the term under section 3(16)(B) of the
Employee Retirement Income Security Act of 1974 [Pub. L. 93-406; 88 Stat. 829;
29 U.S.C. 1001 et seq.].
24. "Premium" means money paid by a small employer and eligible employees as a
condition of receiving coverage from a small employer carrier, including any fees or
other contributions associated with the health benefit plan.
25. "Producer" means insurance producer.
26. "Qualifying previous coverage" and "qualifying existing coverage" mean, with respect
to an individual, health benefits or coverage provided under any of the following:
a. A group health benefit plan;
b. A health benefit plan;
c. Medicare;
d. Medicaid;
e. Civilian health and medical program for uniformed services;
f. A medical care program of the Indian health service or of a tribal organization;
g. A state health benefit risk pool, including coverage issued under chapter 26.1-08;
h. A health plan offered under 5 U.S.C. 89;
i. A public health plan as defined in federal regulations, including a plan maintained
by a state government, the United States government, or a foreign government;
j. A health benefit plan under section 5(e) of the Peace Corps Act [Pub. L. 87-293;
75 Stat. 612; 22 U.S.C. 2504(e)]; and
k. A state's children's health insurance program funded through title XXI of the
federal Social Security Act [42 U.S.C. 1397aa et seq.].
The term "qualifying previous coverage" does not include coverage of benefits
excepted from the definition of a "health benefit plan".
27. "Rating period" means the calendar period for which premium rates established by a
small employer carrier are assumed to be in effect.
28. "Reinsuring carrier" means a small employer carrier which reinsures individuals or
groups with the program.
29. "Restricted network provision" means any provision of a health benefit plan that
conditions the payment of benefits, in whole or in part, on the use of health care
providers that have entered into a contractual arrangement with the carrier under
chapters 26.1-17, 26.1-18, and 26.1-47 to provide health care services to covered
individuals.
30. "Small employer" means, in connection with a group health plan with respect to a
calendar and a plan year, an employer who employed an average of at least two but
not more than fifty eligible employees on business days during the preceding calendar
year and who employs at least two employees on the first day of the plan year.
31. "Small employer carrier" means any carrier that offers health benefit plans covering
eligible employees of one or more small employers in this state.