§ 26.1-47-03 — Health benefits plans

1. Health care insurers may issue policies or subscriber agreements which provide for
incentives for covered persons to use the health care services of preferred providers.
These policies or subscriber agreements must contain all of the following provisions:
a. A provision that if a covered person receives emergency care and cannot
reasonably reach a preferred provider that care will be reimbursed as though the
covered person had been treated by a preferred provider.
b. A provision that if covered services are not available through a preferred provider,
reimbursement for those services will be made as though the covered person had
been treated by a preferred provider.
c. A provision which clearly discloses differentials between benefit levels for health
care services of preferred providers and benefit levels for health care services of
other providers.
d. A provision that entitles the covered person, if any health care services covered
under the health benefit plan are not available through a preferred provider within
fifty miles [80.47 kilometers] of the policyholder's legal residence, to the provision
of those covered services under the health benefit plan by a health care provider
not under contract with the health care insurer and located within fifty miles [80.47
kilometers] of the policyholder's legal residence. For the covered person to be
eligible for benefits under this subdivision, the health care provider not under

contract with the health care insurer must furnish the health care services at the
same cost or less that would have been incurred had the covered person secured
the health care services through a preferred provider.
2. If the policy or subscriber agreement provides differences in benefit levels payable to
preferred providers compared to other providers, the differences may not unfairly deny
payment for covered services and may be no greater than necessary to provide a
reasonable incentive for covered persons to use the preferred provider.