§ 26.1-36.9-03 — Dental insurer rates - Approval (Effective after June 30, 2027)

North Dakota § 26.1-36.9-03

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-36.9: Dental Benefit Plans

Text

1. The commissioner may deem a proposed plan rate of a dental insurer to be excessive
and disapprove the proposed plan rate if the dental insurer files a rate change and the:
a. Administrative expense component, not including taxes and assessments,
increases from the previous year's rate filing by more than four percent;
b. Reported contribution to surplus exceeds two percent of total revenue; or
c. Dental loss ratio for the plan is less than seventy-five percent.
2. a. If the annual dental loss ratio for a dental benefit plan is less than seventy-five
percent, the dental insurer offering the plan shall refund the excess premium to
covered individuals and groups. As used in this section, "dental loss ratio" means
the ratio used to determine the minimum percentage of all premium funds
collected by a dental insurer each year which must be spent on actual patient

care rather than overhead costs. This minimum required percentage that dental
benefit plans must meet for the portion of patient premiums must be dedicated to
patient care rather than administrative and overhead costs or the difference must
be refunded as provided in this section.
b. A dental insurer shall provide notice to all individuals and groups that were
covered under the plan during the applicable twelve-month period that such
individuals and groups are entitled to a refund on the premium, or if the individual
or group remains covered by the dental insurer, that the individual or group is
eligible for a credit on the premium for the following twelve-month period.
c. The total of all refunds issued under this subsection must equal the amount of the
dental insurer's earned premium which exceeds the amount necessary to achieve
a dental loss ratio of seventy-five percent, calculated using data reported by the
dental insurer.
d. The dental loss ratio is calculated by dividing the numerator by the denominator
as follows:
(1) The numerator is the amount spent on care, which must include:
(a) The amount expended for clinical dental services that are services
within the code on dental procedures and nomenclature, provided to
enrollees which includes payments under capitation contracts with
dental providers, whose services are covered by the contract for
dental clinical services or supplies covered by the contract;
(b) Unpaid claim reserves; and
(c) Any claim payment recovered by insurers from providers or enrollees
using utilization management efforts, which are deducted from
incurred claims amounts.
(2) Any overpayment received from a provider may not be reported as a paid
claim. Overpayment recoveries received from a provider must be deducted
from incurred claims amounts.
(3) The calculation of the numerator does not include:
(a) All administrative costs, including infrastructure, personnel costs, or
broker payments;
(b) Amounts paid to third-party vendors for secondary network savings;
(c) Amounts paid to third-party vendors for network development,
administrative fees, claims processing, and utilization management; or
(d) Amounts paid to providers for professional or administrative services
that do not represent compensation or reimbursement for covered
services provided to an enrollee, including dental record copying
costs, attorney fees, subrogation vendor fees, and compensation to
paraprofessionals, janitors, quality assurance analysts, administrative
supervisors, secretaries to dental personnel, and dental record clerks.
(4) (a) The denominator is calculated using insurer revenue.
(b) The earned premium is all moneys paid by a policyholder or
subscriber as a condition of receiving coverage from the issuer,
including any fees or other contributions associated with the dental
benefit plan.
(c) The denominator is the total amount of the earned premium revenues,
excluding federal and state taxes and licensing and regulatory fees
paid after accounting for any payments pursuant to federal law.
3. The commissioner may:
a. Authorize a waiver or adjustment of the refund requirements in this section only if
it is determined by the commissioner that issuing refunds would result in financial
impairment for the dental insurer.
b. Adopt rules to implement and administer this section.
4. This section does not apply to a dental insurer with one thousand enrollees or less
cumulative of all plans based on a three-year average.